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In Thailand more than 9,000 HIV-infected children receive free antiretroviral therapy (ART) through the public health system. This pioneering public health programme has received international acclaim but to date there has been no comprehensive evaluation of the various elements that have contributed to its scale-up in the paediatric population. Using a definition of the continuum of paediatric HIV treatment and care that starts at transmission of HIV and ends with transition of adolescents to adult services this thesis analyses it on three levels: policy, provider and service-user. It examines HIV policies and the Children's ART Network (CAN) model; the delivery of paediatric services; and service-users' ability to access treatment services consistently. It aims to document these perspectives to learn lessons of relevance to policy makers and service-providers in Thailand and beyond. The objectives were met using a multi-method approach comprising predominantly qualitative research techniques, supported by quantitative data and triangulation. In order to represent the range of experiences data were collected from sites in two provinces representing each type of service-provider: university, provincial and district hospitals, and two HIV orphanages. The fieldwork took place over 14 months (March 2008-May 2009) and comprised a review of ART policy; interviews with policy "actors" (n=27); focus-group discussions with HIV service-providers (n=3); interviews with HIV-positive adolescents and caregivers (prior and current) of HIV-positive children (n=45); quantitative analysis of hospital and orphanage registry data (n=498); and, a questionnaire survey of service-users (n=252). Evaluation of health policy made clear the importance of pro-poor health reforms in the 1990s and early 2000s that have entitled Thais to free health-care, including H IV services for eligible individuals. The government programme for HIV positive children was designed to address their diagnostic, treatment and support needs in a holistic way. These far reaching measures contributed to the Thai HIV treatment programme being recognised as global leaders of the public health approach to HIV treatment. However, some health-systems and policy gaps have emerged. Policy interviews showed that policy development slowed, partly due to altered financial priorities within the health sector, but also to divisions between the health-financing department and the co-ordinating body of the national AIDS programme. Policies relating to paediatric HIV are fragmented, sometimes poorly implemented and some child-specific elements have been neglected. There are other areas of concern too: HIV incidence - including among pregnant women - have shown indications that it will increase, infant prevention strategies (through PMTCT) have reduced transmission rates but HIV- infected mothers seem less likely to receive antenatal care; children continue to present late for HIV services; and skilled support for adolescents and their transition to adult services is limited. Focus-group discussions revealed highly motivated peer-support volunteers operating in hospitals and the community who provide support to health workers and HIV-affected families throughout the continuum. They would benefit from a more secure funding mechanism and accreditation. Well-trained, dedicated healthcare providers struggle to deliver the standard of service they feel HIV-infected children need. The government programme is scaling-up the 'CAN' model through which children are referred back to receive treatment at district hospitals (supervised by tertiary hospitals), are supported by peer volunteers, and where possible a 'one-stop service' is implemented. It was considered by many respondents as the best way to cover children's diverse care needs across the continuum. Qualitative investigation of patients' and caregivers' experiences showed that many service- users, who are increasingly approaching adolescence, live in extreme poverty with an elevated perception of HIV stigma. To avoid recognition, some travel to distant hospitals for treatment, yet most rural residents are generally very satisfied with the services in their community-focused local district hospital. Most caregivers take treatment adherence and regular clinic attendance very seriously; they value psycho-social support and information they receive from peer-support volunteers highly. The prior caregivers of children living in orphanages suggested that, apart from poverty, the difficulties facing families have changed since ART became widely available. In the pre-ART era stigma and chronic ill health were major reasons for extended families choosing to send children to orphanages. Drug resistance, difficulties with treatment adherence and coping with adolescent behaviour are now more likely to be among the reasons. Quantitative data sources confirmed these findings and found that most children sought treatment late in the course of their HIV disease. This finding is consistent over time despite the introduction of free treatment and of strategies to prevent mother-to-child-transmission (PMTCT) nationwide. Many children at the study sites are orphaned, and live with elderly and poorly educated caregivers with limited treatment literacy and low aspirations. Overall the triangulated findings reveal a high standard of paediatric HIV care is delivered in Thailand through a sophisticated system. Using the concept of a continuum to analyse child HIV services has identified strengths such as strong links between communities and clinics forged by peer supporters. It has also identified some gaps and changes over time. Given the current profile of children entering and already enrolled in the programme now is the time to address missed opportunities for early paediatric treatment, prioritize adolescents' needs and strengthen existing capacity of health-workers and volunteers to identify and respond to children's social, economic and psychological conditions. The national committee that co-ordinates the multi-sectoral HIV policy response could maximize the opportunities presented by the strengths of the current Children's ART Network to better address the entirety and complexity of paediatric needs, rather than paediatrics as an adjunct to adult services.

Surveillance of infections in blood donors and blood recipients can be useful for both transfusion medicine and public health. This thesis describes how an enhanced surveillance system for transfusion-transmissible infections has been established in England and Wales. Data from the surveillance system (1995 to 1999) have been used to monitor test performance and to describe the epidemiology of HBV, HCV and HIV in blood donors. The prevalence and incidence of HBV, HCV and HIV infections in blood donors have been monitored and were generally stable, and low compared to other countries and to other groups in the UK. HCV prevalence decreased throughout the 1990s. The exposure histories reported by infected donors indicate that donor selection largely succeeds in excluding high-risk groups, but also identify some failures in communication of, or compliance with, exclusion criteria. Diagnosed, reported, post-transfusion infections were rare and after investigation only 20% (21) were shown to have been transmitted by transfusion. The majority (52%) of reported transfusion-transmitted infections, and resulting deaths (3 of 4) were due to bacteria. The number of undiagnosed infections is not known but was estimated for HIV, HBV and HCV by calculations of the probability of infectious donations entering the blood supply due to true or false negatively to tests performed on donations prior to release. Various methods and assumptions have been used to investigate the robustness of these estimates and to develop an appropriate method for ongoing use in England and Wales. An enhanced surveillance system for transfusion-transmissible infections, that works in collaboration with national surveillance of infectious diseases and of non-infectious complications of transfusion, has been shown - despite some limitations - to provide data and analyses that have aided transfusion medicine and public health in England and Wales. This surveillance continues to develop and improve and further related work is planned.

Across Thailand there has been a general reduction in the incidence rate of HIV infection in all but one special population group: married women and their offspring whilst the incidence rate is relatively low (1.2%) it has remained steady for a number of years. This participatory approach aims to understand the married women's points of view and to facilitate their self-care to prevent HIV/AIIDS for themselves and their next child. The research utilised a three phase design: exploratory, explanatory and intervention phases. The findings from the first two phases have substantively informed the construction of the intervention phase. The overall findings of the research indicated that women have general knowledge about HIV/AlIDS and carried out general self-care practices. Specific self-care practices however were lacking. Through the participatory intervention phase the research has been able to illuminate a number of important factors pertaining to women's self-care most-noticeably: the importance of support; the strategies women adopt to balance health and social risk; the importance of consciousness raising; and the need for culturally sensitive health care programmes. The research concludes by presenting an analytical model of women's self-care for the prevention of HIV/AIDS and makes a series of recommendations with regard to the development of existing Thai health care services, the enhancement of the current educational curricula, and the incorporation of participatory approaches in health promotion and health care provision for families.

Evidence suggests that in the UK people of sub-Saharan African origin are disproportionately affected by HIV and tend to be diagnosed at a more advanced stage of infection compared to other ethnic groups. Late diagnosis is associated with a poorer medical prognosis and may have a detrimental effect on wellbeing. The study aimed to determine whether CD4. cell count at diagnosis (a marker of late diagnosis) and delay before testing following a perception of risk of HIV were related to Theory of Planned Behaviour (TPB) variables (attitude, subjective norm, and perceived behavioural control) in a sample of sub-Saharan African adults with a recent HIV diagnosis. The study had a quantitative, cross-sectional design. Participants completed a structured interview assessing demographic and HIV-testing related variables, including a measure designed specifically for the study to assess TPB variables. CD4 cell count at diagnosis was taken from participants' medical notes. Twenty- five participants took part in the study. The power of the study was therefore too low to adequately test the hypotheses. Exploratory regression analyses were run . It was found that a more negative attitude to testing was significantly associated with a higher CD4 cell count at diagnosis. Those who tested for routine reasons at routine sites had more negative attitudes to testing and a higher CD4 cell count at diagnosis. There was no statistically . significantly association between perceived behavioural control or subjective norm and CD4 cell count or between any of the TPB constructs and delay before testing. A higher perception of risk prior to testing was associated with delayed testing. The limitations and strengths of the study will be outlined, and the clinical, theoretical and research implications of the findings discussed. 3 ,

This dissertation explores the impact of war and internal displacement on HIV / AIDS prevention and treatment interventions in Acoliland, northern Uganda. While the Ugandan government's HIV/AIDS policies have been seen globally as models of success, there were enormous challenges for these policies in Acoliland, which endured over two decades of war and the displacement of nearly 90% of the population. During this period there was infrastructural, economic, social and cultural devastation, with an increase in poverty, sexual violence and gender inequalities. Evidence suggests that HIV / AIDS interventions in Acoliland were far from effective despite seemingly well-funded and supported programmes by the government and international agencies. The study employed qualitative research methods using an exploratory single-case study design, semi-structured interviews and a purposive sampling of 21 participants from various organisations. Findings were thematically analysed within a proposed theoretical framework of Sociocultural Liminality, which draws from the work of Victor Turner (1969), 'The Ritual Process'. In the field of HIV/AIDS and population displacement, Sociocultural Liminality theory makes a unique contribution and adds new ideas to current thinking in policy, research and practice. Findings suggest many problems: social and cultural devastation during war and displacement influences sexual attitudes and behaviours; structural chauvinism affects service delivery; international funding to improve resources appears to have the opposite effect; behavioural theories and conventional HIV / AIDS prevention methods have many limitations; service providers are biased towards secure urban locations; and self-evaluation and reporting of service providers demonstrates a conflict of interests. The study concludes that war and displacement devastate the structure of a society and destroy social and cultural identities, both of which affect HIV / AIDS interventions. Recommendations are made for a deeper understanding of Sociocultural Liminality theory to analyse issues related to social and cultural devastation, power, gender, society, research, policies and humanitarian aid. Suggestions from participants are also discussed. ii

This study aimed to investigate the performance of ELISA based tests for the detection of HIV in an adolescent population (n=7333) in the Mwanza Region of Tanzania. False positive results were observed with all the HIV ELISA tests examined during the study. When tested on serum the Murex Abbott HIV Ag/Ab Combination ELISA, a fourth generation ELISA test, gave HIV false positive results for 8% the population. This test had a positive predicative value of 7.72 in this population which had a HIV prevalence of 0.72%. Positive predictive values of 6 further tests examined ranged from 30.00 - 91.11 %. A critical review of the published literature determined that HIV ELISA specificities were lower in Africa when compared to the developed world. Investigation of treatments that were received by individuals within the study cohort, suggested an association of false positive HIV test results and schistosomiasis infection. Laboratory studies to investigate possible causal factors of false positive ELISA test results determined that false positivity was associated with increasing circulating levels of S. haematobium worm IgG 1 (OR = 53.5, Cl = 10.6-268.9); with increasing S. mansoni egg 19G1 levels (OR = 2.5, Cl = 0.7-8.7); and rheumatoid factor titre (OR = 5.6, Cl = 2.0-15.9). Circulating antibodies to malaria and syphilis were not associated with false positive HIV test results. The poor specificity of the HIV ELISA tests observed in this study suggests they may be unsuitable for testing African adolescent populations, particularly in those regions where schistosomiasis is endemic. We recommend that prior to introducing new HIV tests to sub- Saharan Africa they should be evaluated using local specimens to enable assessment of their specificity.