<b>Introduction</b> Men who have sex with men have been largely unrecognised within African HIV epidemics until recently. This thesis reports on three projects in Mombasa, Kenya and in Oxford that aimed to describe the burden and risk factors for HIV among MSM across sub-Saharan Africa and in Kenya specifically, and to describe patterns of sexual behaviour and partnerships relevant to individual and population HIV risk. <b>Methods</b> <b>1.</b> cross-sectional study of HIV prevalence and risk factors among 285 MSM at enrolment to a vaccine feasibility cohort in Mtwapa, Kenya; <b>2.</b> review and meta-analysis of behavioural and HIV studies in sub-Saharan African MSM until 2010 <b>3.</b> prospective, self-administered daily diary study of sexual behaviour among a sample of 83 IAVI vaccine feasibility cohort participants <b>Main results</b> HIV prevalence was 24.6% among MSM, who frequently reported transactional sex. Receptive anal sex practice, injecting drug use, concomitant STIs, homosexual exclusivity and age were independent risk factors for HIV prevalence. Prevalence studies identified high HIV burden among MSM across Africa, not associated with prevalence amongst the general adult population despite commonplace heterosexual behaviours. HIV prevalence associations with homosexual exclusivity, unprotected anal sex and transactional sex were largely consistent across different contexts. In Mombasa, prospective behaviour studies described a transactional sexual network serving both male and female clients, transaction dictating both relationship patterns and age differences between partners and condom use. Young age, homosexual exclusivity, alcohol use, religious affiliation and low earnings were associated with high risk homosexual behaviours. Heterosexual sex was commonplace, yet heterosexually active MSM had a significantly lower profile of homosexual behavioural HIV risk. <b>Conclusions:</b> There is an urgent need for African countries to identify MSM populations and deliver appropriate and relevant HIV prevention, treatment and care. Effective and accessible responses will benefit African MSM, and likely also enhance wider HIV control efforts.

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In men, the concentration of HIV-1 RNA in semen is an important determinant of HIV-1 infectivity. In sub-Saharan Africa, urethritis has been associated with increases in seminal plasma HIV-1 RNA load in those not receiving antiretroviral therapy. Less is known of the impact of urethritis both within the developed world and in those receiving antiretroviral therapy. In-vitro evidence also suggests that syphilis may stimulate HIV-1 replication, potentially impacting on HIV-1 disease progression as well as its transmission. In this thesis I present a series of studies that examine the effects of urethritis (due to gonorrhoea, chlamydia or NSU), early syphilis and their treatments on HIV-1 RNA loads in blood and semen in homosexual men in the UK. The impact of urethritis on the presence of drug-resistant HIV-1 mutants found in semen among those receiving antiretroviral therapy was also analysed. In addition, effects on CD4 counts were examined in those with early syphilis. Finally a study on the feasibility of research involving semen donation is presented. The research demonstrates that gonococcal and chlamydial urethritis, but not NSU, increase HFV-l RNA load in semen. In comparison with the increases previously demonstrated in Africa, the relative effects were similar but the absolute increases were smaller. Minimal effect was seen in those on suppressive antiretroviral therapy but among those on poorly suppressive antiretroviral regimes and those with gonococcal infection HIV-1 RNA loads in semen were high. In these patients multi-drug resistant HIV-1 was found in both genital and systemic compartments. The studies also demonstrate very little effect of early syphilis on either blood or semen plasma viral loads. However, early syphilis, particularly early latent syphilis, was associated with a reduction in CD4 count that was reversible on syphilis treatment. Studies involving semen donation in symptomatic homosexual men were shown to be feasible.

Since the early 1980s in sub-Saharan Africa (SSA), substantial human and financial resources have been dedicated to monitoring the HIV/AIDS epidemic. Throughout, surveillance data collected at antenatal care (ANC) clinics have been a key data source. ANC surveillance data are well-known to be biased when quantifying population HIV prevalence levels in SSA. Nonetheless, a routinely-accepted, although rarely-tested assumption has been that the data are representative of population-level HIV prevalence trends. More recently, HIV testing data from prevention of mother-to-child transmission (PMTCT) programmes have been proposed as a substitute for ANC surveillance, although these data can be subject to temporal biases too. The primary objective of this thesis is to add to the limited evidence regarding the representativeness of HIV testing data from pregnant women to monitor population-level HIV prevalence trends. Empirical analyses from repeated household-based population surveys and ANC surveillance were done for seven countries in SSA from 2000 to 2010 and among youth aged 15 to 24 years in Manicaland, Zimbabwe from 1985 to 2003. Also, a mathematical model was used to explore temporal bias in ANC surveillance trends in epidemics similar to those in Botswana, Côte d’Ivoire and rural Zimbabwe from 1985 to 2030. Finally, PMTCT programme data were assessed for their representativeness as compared to ANC surveillance data in Manicaland, Zimbabwe from 2006 to 2008. Results showed the representativeness of ANC surveillance data to vary by time period and setting, although trends among youth were more robust than those among adults aged 15 to 49 years across settings, and particularly so among men. Representativeness in the ART-era depends on coverage and scale-up, the setting, and the potential for changing fertility patterns among ART users. PMTCT data for surveillance purposes was of limited use in Manicaland, Zimbabwe from 2006 to 2008. In summary, caution is needed when using HIV testing data from pregnant women to monitor population HIV prevalence trends in SSA.

Thesis (MPH.) --University of Limpopo, 2013 / Setting: The study was undertaken in St Rita’s Hospital, a district hospital for healthin Makhuduthamaga Municipality, Sekhukhune District, Limpopo Province. The purpose of the study was to describe client experiences of HIV-positive post-disclosure tosexual partners at St Rita’s Hospital, Limpopo Province. Research design and methodology: A qualitative, descriptive and phenomenological design was used. Purposive sampling was used to select 15 HIV-positive clients to participate in the study. Semi-structured interviews were conducted for data collection until saturation was reached. Data analysis was done using Techs open-coding method. Research findings: The study found that most of the clients were shocked and worried after testing HIV-positive. Participants whose sexual partners were aware that they were sick, indicated their wish to test and to immediately disclose their HIV-positive status. The study identified that some women found it difficult to disclose their HIV-positive status to sexual partners and continued to have unprotected sex in spite of ongoing counselling and support provided at the clinic. Some women participants who disclosed to sexual partners were accepted and some were rejected by sexual partners. Some women who disclosed their HIV-positive status to sexual partners were unable to motivate sexual partners to be counselled together and have mutual disclosure. These participants therefore continued to have unprotected sex with sexual partners and some became pregnant as sexual partners indicated that they tested HIV-negative elsewhere and were not keen to use condoms. Female participants did not indicate the use of female condoms as part of their responsibility to prevent transmission of HIV. Implications, recommendations and conclusions: The barriers which female participants face to disclose their HIV-positive status to sexual partners and not being able to insist on the use condoms may contribute to a high rate of HIV transmission and disease incidence. There should be establishment of consortiums at community level to provide quality support and follow up to vii clients who face challenges or fear to disclose their HIV-positive status to sexual partners. KEYWORDS • Clients’ experiences • Disclosure • Experiences, • Sexual partner • HIV-positive