Background: HIV transmission is greatly reduced when antiretroviral treatment (ART) suppresses an infected person’s HIV viral load. It is unclear, however, whether the contextual risk of incident HIV is optimally reduced by widespread individual-level suppression of HIV viral load alone or in combination with other HIV prevention services. HIV service coverage and community norms can influence risk in small area geographies; and contextual factors, like gender inequality and stigma, may foster environments conducive to HIV transmission. Yet, the relationship between places with high HIV levels and the clustering of area risk factors is unknown. The goal of this dissertation is to learn if and how a geographically focused combination implementation strategy could reduce population-level HIV risk. Analyses explored whether small area risk profiles explain area differences in HIV. The guiding hypothesis is that in high HIV prevalence settings, low HIV service uptake in a geographically defined area increases the prevalence of high HIV viremia, leading to greater HIV transmission and incident HIV. Methods: A systematic review was conducted to examine the association between population-level measures of HIV viral load and incident HIV infection in generalized and concentrated epidemics. Publications were English, peer-reviewed articles published from January 1, 1995 through February 15, 2019 that explicitly defined HIV viral load and assessed outcomes of HIV recency, incidence, seroconversion, or new diagnosis. Studies sampled general or key populations through population-based surveillance registries, household-based enumeration, cluster sampling, or respondent driven sampling. Descriptive statistics summarized review findings. The Swaziland HIV Incidence Measurement Survey (SHIMS) data were used for the remaining analyses. Using a two-stage cluster-based design, a nationally representative, household-based sample of adults, ages 18-49 years was enrolled from December 2010 to June 2011 in Eswatini. Consenting adults completed an interview and received home-based rapid HIV testing and counseling. All seropositive samples were tested for HIV viral load using the COBAS AmpliPrep/Taqman HIV-1 Test, v 2.0. Adults testing HIV-seronegative were enrolled in a prospective cohort for the direct observation of HIV seroconversion, completing an interview and home-based rapid HIV testing six months later. Multi-level latent class modeling was performed to identify statistically significant combinations of HIV risk factors and to classify the combinations into small area risk profiles. In the cross-sectional sample, linear regression with robust standard errors assessed the correlation between area profiles and places with high levels of uncontrolled HIV infection, or HIV core areas, measured by the area prevalence of detectable virus (≥20 copies/milliliter) among HIV-positive adults and among all adults, regardless of HIV status. In the prospective cohort, generalized linear regression of longitudinal data assessed the association between area profiles and places prone to new HIV infections (i.e., HIV susceptible areas), measured by area-level HIV seroconversions. Results: The systematic review found an evidence base primarily of lower quality studies and inconsistent HIV viral exposure measurement. Overall findings supported a relationship between increasing levels of suppressed HIV in HIV-infected populations and fewer new infections over time. Better quality studies consistently showed higher population viremia (i.e. HIV viral quantity among all persons, regardless of HIV status) associated with HIV incidence in high prevalence populations; population viral load (i.e., HIV viral quantity among only HIV-positive persons) did not show an association with incident HIV in high prevalence, general populations and was inconsistent in key populations. To determine whether area risk profiles can pinpoint HIV core areas, latent class modeling was used to categorize 18,172 adults into one of six HIV risk types. The risk typology, classified through unique combinations of HIV service uptake and sexual risk behaviors, conveyed an adult’s propensity for HIV transmission and/or acquisition risk. The model next identified the area-level composite prevalences of HIV risk types; estimated the three most frequent, unique composite combinations; and categorized them into area risk profiles characterizing HIV risk: low-moderate acquisition risk, moderate acquisition/transmission risk, and high acquisition/transmission risk. The high acquisition/transmission areas comprised the largest proportions of highest risk transmission and acquisition types. The prevalence of detectable viremia progressively increased from low-moderate acquisition, moderate acquisition/transmission, and high acquisition/transmission profiles [17.7%, 25.4%, and 35.1%, respectively]. When compared with low-moderate acquisition areas, the prevalence of detectable viremia was 7.4% [p<.001] higher in moderate acquisition/transmission areas and 17.1% [p<.001] higher in high acquisition/transmission areas. The prevalence of detectable viral load significantly decreased from low-moderate acquisition to moderate acquisition/transmission areas [76.6% versus 68.7%, p<.001], and was significantly higher in high acquisition/transmission areas by 7.3% [p<.001], when compared with low-moderate acquisition areas. To determine whether area risk profiles can predict HIV susceptible areas, a total of 18,172 adults were surveyed of which 4396 [24%] had detectable viremia. 11,880 [96%; n=12,357] HIV-seronegative adults enrolled in the prospective cohort and 11,155 [94%] of them completed an endline visit. Four area profiles were identified, defined by unique patterns in prevalence of HIV viremia and of sexual risk behaviors. The proportion of HIV susceptible areas progressively increased from Profiles A, B, C, and D [14.3%, 21.8%, 24.6%, and 30.8%, respectively]. HIV susceptible areas were more than twice as likely to occur in Profile D than Profile A environments [RR 2.13, 95% confidence interval (CI) (1.13, 4.00); p=0.02]. Profile D areas had prevalences of unknown partner HIV status and detectable viremia at 28% and 24%, respectively. In contrast, Profile A areas had prevalences of only 8% with unknown HIV status and 31% with detectable viremia. Conclusion: This dissertation shows that geographic risk profiles can explain differences in population-level HIV outcomes. Risk factors spatially cluster in predictable, meaningful combinations that can inform an area typology of HIV risk. The co-location of adults predisposed to greater HIV risk may heighten levels of uncontrolled HIV infection, thereby creating potential area sources of ongoing transmission; however, the concurrent levels of other risk factors may have more influence in reducing population-level incidence than previously considered. A composite indicator of contextual HIV risk may reveal places core to HIV transmission and susceptible to HIV acquisition. Such area profiles may help identify the combination of locally specific risk factors that readily promulgate HIV and better inform the design of place-based HIV intervention packages to enhance current strategies towards global HIV control.

Background: Despite substantial global progress against the HIV/AIDS epidemic, the Eastern Europe and Central Asian region has experienced a 43% increase in HIV incidence. The HIV epidemic in Kazakhstan has outpaced that of the region, with the incidence of new infections growing by 73% since 2010. Key populations of people who inject drugs (PWID), female sex workers (FSW) and their sexual partners account for the majority of new infections, where drug policies continue to undermine HIV prevention and control efforts. Kazakhstan has made insufficient progress towards 95-95-95 HIV epidemic control targets, with 78% of people living with HIV (PLWH) knowing their HIV status, of which 57% receive ART, and 48% of those receiving ART achieve viral suppression. Laws, policies and their enforcement can shape social and structural determinants of health, and it is fundamental to understand how punitive legal environments shape the HIV epidemic in Kazakhstan. This dissertation seeks to identify patterns of police violence victimization among FSW who use drugs and examine how police violence is associated with the HIV risk environment. Given the insufficient progress towards 95-95-95 HIV epidemic control targets, this dissertation also seeks to identify how patterns of injection and sexual HIV transmission risk behaviors vary among men and women who inject drugs and examine how criminal-legal involvement is associated with patterns of HIV transmission risk behaviors. Methods: Data on police violence victimization among FSW who use drugs were drawn from Project Nova, a cluster-randomized control trial that evaluated the efficacy of a combination HIV risk reduction and microfinance intervention. A community-based sample of 255 FSW who use drugs were recruited and enrolled between February 2015 and May 2017 in Almaty, Kazakhstan. Latent class analysis (LCA) was used to characterize women into distinct subgroups (i.e., classes) of police violence victimization. Next, multinomial logistic regression was used to examine how police violence victimization subgroups are associated with the physical, social, economic and policy HIV risk environment. Data on injection and sexual HIV transmission risk behaviors were drawn from Bridge, an implementation science study that evaluated the effectiveness of HIV service integration into needle/syringe programs on retention in care and viral suppression for PWID living with HIV in Kazakhstan. A random sample of 450 men and 166 women who inject drugs were recruited and enrolled in Almaty, Shymkent, and Temirtau/ Karaganda between February 2017 and June 2019. Similarly, LCA was used to characterize distinct subgroups of HIV transmission risk behaviors among men and women who inject drugs. Multinomial logistic regression was then used to identify associations between criminal-legal involvement and patterns of HIV transmission risk. Results: Three subgroups of police violence victimization among FSW who use drugs emerged. Just over half were characterized as experiencing low violence victimization (“Low Violence;” 51%); over one-third were characterized as experiencing all forms of police violence victimization (Poly-Victimization; 34%), and 15% were characterized as experiencing primarily discrimination and extortion from the police. Relative to Low Violence, factors associated with Poly-Victimization included being positive for HIV and/or sexually-transmitted infections (STI) (aOR= 1.78 (95% CI: 1.01, 3.14)), prior tuberculosis diagnosis (aOR= 2.73 (1.15, 6.50)), injection drug use (IDU) (aOR= 2.00 (1.12, 3.58)), greater number of unsafe injection behaviors (aOR= 1.21 (1.08, 1.35)), homelessness (aOR= 1.92 (1.06, 3.48)), greater drug use stigma (aOR= 1.22 (1.07, 1.39)) and sex work stigma (aOR= 1.23 (1.06, 1.43)), greater number of sex work clients (aOR= 2.40 (1.33, 4.31)), working for a boss/pimp (aOR= 2.74 (1.16, 6.50)), client violence (aOR= 2.99 (1.65, 5.42)), economic incentives for condomless sex (aOR= 2.77 (1.42, 5.41)), accessing needle/syringe exchange programs (aOR= 3.47 (1.42, 8.50)), recent arrest (aOR= 2.99 (1.36, 6.55)) and detention (aOR= 2.93 (1.62, 5.30)), and negative police perceptions (aOR= 8.28 (4.20, 16.3)). Compared to Low Violence, Discrimination and Extortion was associated with lower odds of experiencing intimate partner violence (aOR= 0.26 (0.12, 0.59)), but no other significant associations with the risk environment upon adjusting for socio-demographic characteristics. Distinct patterns of HIV transmission risk behaviors emerged among men and women, in which men were characterized as having Low Sexual Risk (41.8%), Injection & Sexual Risk (36.4%), and High Injection Risk (21.8%) behaviors. Class membership in the Injection & Sexual Risk and High Injection Risk class was associated with greater criminal-legal involvement, compared to the Low Sexual Risk class. This is demonstrated by higher odds of multiple detentions ((aORInjection & Sexual Risk = 1.28 (1.10, 1.49); aORHigh Injection Risk = 1.25 (1.06, 1.46)) and drug court participation (aORHigh Injection Risk = 5.29 (1.03, 27.20) in the past six months, committing crimes while under the influence of alcohol or drugs (aORInjection & Sexual Risk = 2.79 (1.53, 5.11); aORHigh Injection Risk = 2.76 (1.34, 5.65), and perceived police discrimination (aORHigh Injection Risk = 1.79 (1.01, 3.19). Women who inject drugs were characterized as having Low Injection & Sexual Risk (60.7%), Sex Work Behaviors (8.4%), High Injection Risk (30.7%) behaviors. Class membership in the Sex Work Behaviors and High Injection Risk class was associated with greater odds of being detained (aORSex Work Behaviors= 4.59 (1.27, 16.53) and experiencing verbal police harassment (aORSex Work Behaviors= 3.31 (1.20, 9.15); aORHigh Injection Risk = 2.91 (1.32, 6.40), compared to the Low Injection & Sexual Risk class. Conclusion: Results from this dissertation show that police violence against FSW who use drugs is pervasive in Kazakhstan. Patterns of police violence victimization among FSW who use drugs vary, with multiple forms of police violence victimization being associated with greater HIV susceptibility. This dissertation also demonstrates that men and women who inject drugs and are living with HIV have a high prevalence of injection and sexual HIV transmission risk behaviors, despite low viral suppression, and that patterns of HIV transmission risk behaviors vary by gender. Moreover, criminal-legal involvement is associated with injection and sexual HIV transmission risk, particularly among men who inject drugs. Collectively, these results support drug policy reforms and suggest that decriminalization of drug use and possession may promote enabling environments that support harm reduction, and subsequently reduce HIV transmission through injection and sexual networks of PWID in Kazakhstan.

Thesis (MCur)--Stellenbosch University, 2011. / ENGLISH ABSTRACT: The impact of infant feeding practices in the prevention of mother-to-childtransmission of HIV raised concerns in the field of health services. Breast feeding adds an additional 15-30% risk of HIV transmission to the infant; therefore, mothers who are HIV-positive are in need of information regarding safe infant feeding. A descriptive design for this particular study was applied with a primary quantitative approach. A convenient sample of sixty (n=60) participants between the ages of 15 – 37 were taken from subjects that enrolled in the prevention of mother-to-child transmission (PMTCT) programme in Onandjokwe district. The sample formed 85% of the target population (N=71). A structured questionnaire with closed and openended questions was used and completed by the researcher. Ethical approval for the study was obtained from the Ethics Committee at the Faculty of Health Sciences, University of Stellenbosch. Permission to conduct the research was obtained from the Ministry of Health and Social Services, Namibia, and the Onandjokwe district Hospital. A pilot study was conducted that constituted 25% of the sample. Validity and reliability was insured by the pilot study and the consultation of an expert in HIV research and an expert in nursing research. The presentation of results was mostly descriptive in nature by using frequency tables and a pie chart. The results showed that all participants (n=60/100%) were offered HIV counselling and testing during antenatal care. Mothers who were HIV positive knew that there is a possibility that the baby might be infected through breast milk. Furthermore, the study found that 70% (n=42) of participants used breast feeding exclusively, 20% (n=12) used replacement feeding and 10% (n=6) used mixed feeding practices. It was concluded that pregnant women and mothers known to be HIV-infected should be informed of the infant feeding practice recommended by the national or subnational authority to improve HIV-free survival of HIV-exposed infants. This includes information about the risks and benefits of various infant feeding options based on local assessments and guidance in selecting the most suitable option for their own situation. / AFRIKAANSE OPSOMMING: Die invloed van voedingspraktyke vir babas by die voorkoming van moeder-na-kindoordrag van die menslike immuungebrekvirus (MIV) het kommer op die gebied van gesondheidsdienste laat ontstaan. Borsvoeding dra ’n addisionele 15–30% risiko van MIV-oordrag tot die baba by en daarom benodig moeders wat MIV-positief is inligting ten opsigte van veilige voeding van hulle babas. 'n Beskrywende ontwerp vir hierdie besondere studie is gebruik tesame met 'n primêr kwantitatiewe benadering. 'n Gerieflikheidsteekproef van sestig (n=60) deelnemers tussen die ouderdomme 15–37 jaar is gekies uit persone wat ingeskryf het vir die voorkoming van moeder-na-kind-oordrag (VMNKO) program in Onandjokwe-distrik. Die steekproef het 85% van die teikenpopulasie (N=71) uitgemaak. 'n Gestruktureerde vraelys met geslote en oop vrae is gebruik en deur die navorser voltooi. Etiese goedkeuring vir die studie is verkry van die Etiese Kommitee van die Fakulteit Gesondheidswetenskappe, Universiteit Stellenbosch. Toestemming om die navorsing te doen, is verkry van die Ministerie van Gesondheid en Maatskaplike Dienste, Namibië, en die Onandjokwe Distrikshospitaal. 'n Loodsstudie is onderneem wat 25% van die steekproef behels het. Geldigheid en betroubaarheid is verseker deur die loodsstudie en oorlegpleging met 'n kundige op die gebied van MIV-navorsing en 'n kundige in verpleegnavorsing. Die aanbieding van resultate was meestal deskriptief van aard deur van frekwensietabelle en 'n sektordiagram gebruik te maak. Die resultate het getoon dat MIV-berading en -toetsing gedurende voorgeboortesorg aan alle deelnemers (n=60/100%) aangebied is. Moeders wat MIV-positief is, het geweet dat daar 'n moontlikheid bestaan dat die baba moontlik deur moedersmelk geïnfekteer kan word. Verder het die studie bevind dat 70% (n=42) van deelnemers uitsluitlik borsvoeding gebruik, 20% (n=12) gebruik ’n vervanging vir moedersmelk en 10% (n=6) gebruik gemengde voedingspraktyke. Daar is tot die slotsom gekom dat swanger vroue en moeders van wie bekend is dat hulle MIV-geïnfekteer is, ingelig behoort te word oor die babavoedingspraktyk aanbeveel deur die nasionale of subnasionale owerheid vir die verbetering van MIVvrye oorlewing van babas wat aan die MIV blootgestel is. Dit sluit in inligting oor die risiko’s en voordele van verskeie babavoedingsopsies gebaseer op plaaslike assesserings en leiding ten opsigte van die kies van die geskikste opsie vir hulle eie situasie.

A research report submitted to the School of Social Science, University of the Witwatersrand in partial fulfilment of the Master of Arts in Demography and Population Studies, November 2017 / Introduction: Across Sub-Saharan Africa, studies have shown transactional sex, characterized by the exchange of money or gifts for sex, to be one of the major contributing factors of HIV/AIDS infection. Risky sexual behaviours such as multiple sexual partners, non-condom use and transactional sex are driving forces behind negative health outcomes of young people. Thus, the aim of the study is to determine the association between socio-economic status and transactional sex among young women in South Africa, primarily to investigate whether transactional sex is a survival strategy or not among young women in South Africa. Methods: Secondary data analysis was done from a cross-sectional study conducted in 2012 by the Third National Communication Survey. This analysis was limited to 4 586 167 (weighted) sexually active females aged 16-24 who reported engaging in transactional sex. STATA version 13 was used to analyse this data. Descriptive statistics was used to analyse data at the univariate level. The Chi-squared test was conducted to test the relationship between the outcome variable and the independent variables. The complementary log-log regression model was used to analyse the data at multivariate level to identify the association between demographic factors (age, race, marital status, type of residence and province), socio-economic characteristics (education status or training status and employment status), beliefs towards behaviour, subjective norms towards behaviour and transactional sex. Results: Transactional sex was higher among women whose age at first sex was 18-19 (6.34%) compared to women of older ages 20+ years (0.4%). African women were likely to engage more in transactional sex (3.46%), compared to women of other races (2.48%). This study has found that a relationship between women who were not in Education, Employment and Training (NEETS) and transactional sex did not exist (AOR 1.10, 95% CI: 0.62-1.96). Single women had higher odds of engaging in transactional sex compared to cohabitating women and married women (AOR 1.04, 95% CI: 0.42-2.54). Conclusion: The findings of this study have shown that although transactional sex is a common behaviour among young women in South Africa, there is no relationship between socio economic status and transactional sex. Being NEETS has no association with young women engaging in transactional sex, which means that young women were more likely to engage in transactional sexual relationships for reasons other than survival; that is reasons for having fashionable clothes, cars, expensive holidays, and airtime. However, factors such as early age at first sexual encounter, race, and beliefs about behaviour and subjective norms were associated with transactional sex. The fact that some young women believed that they would not be infected with HIV suggests that there is a need to have intervention programmes to educate young people about HIV risk factors. This study is relevant in informing health policies, planning and programme designs of sexual and reproductive health services in South Africa. Transactional sex is a sensitive issue; problems of underreporting may be expected. / XL2018

Thesis submitted to: The Department of Psychology School of Human and Community Development , Faculty of Humanities , University of the Witwatersrand In partial fulfilment of the requirements for the degree of Masters in Psychology, Research and Coursework , January 2017 / Background: There is wealth of research that suggests that young heterosexual women are at an increased vulnerability for HIV through engagement in transactional sex. Transactional sex in young women in Sub-Saharan Africa, including South Africa, is rife and financial constraints are a major driver. Quantitative studies conducted in Sub-Saharan Africa suggest that young women that are involved in transactional sex are nearly two or more than three times vulnerable to HIV. The young women are involved in transactional sex with older men in order to access financial needs for survival as well as for purposes of consumerism. Transactional sex is not often understood, and at times it is conflated with sex work. This thesis seeks to add to scientific understanding of transactional sex in the field of health. The goals of this thesis are to explore the participants’ understanding of transactional sex. The thesis also seeks to explore a link between transactional sex and father absence for young women. This thesis fills the gaps identified in the studies of transactional sex. Wherein, there is very little research that has investigated the discourses that shape the practice of transactional sex. The study aim was to deepen scientific understanding of transactional sex in South Africa through examination of the discourses and structural financial constraints that influence transactional sex among young women. The specific objectives of this study were: i. To explore the discourses that shapes the participants’ understanding and their involvement in transactional sex. ii. To analyse the participants’ understanding of transactional sex in KwaZulu-Natal (KZN), Mpumalanga (MP) and the Eastern Cape (EC) provinces. iii. To demonstrate the likely link between transactional sex and income poverty related to father absence. iv. To describe a probable link between transactional sex and vulnerability to HIV infection. Research methods: To meet objective (i) qualitative interview data were collected in three South African provinces which are KwaZulu-Natal, Eastern Cape and Mpumalanga using focus group discussions (FGDs) and key informant interviews (KIIs). Invitation for participation by key informants (KIs) was sent to older men and women who are stakeholders of the communities studied. The KIs were invited from the social services sector such as the Police, Social Development, Health, Justice and Community-based leaders of faith, healers and youth leaders. For FGDs, participants were invited through meetings that are conducted in the communities and also through the distribution of fliers using facilitators in the communities that were selected as study sites. All participants for this study comprised both females and males above the age of 18 years. Trained field officers conducted FGDs which were gender-matched as well as KIIs. The FGDs varied in length with an average of above one hour each. KIIs were an average of 45 minutes long each. For all the interviews, isiZulu, siSwati and Xhosa were used, accordingly, to suit the participants’ local languages. All interviews were recorded using a digital recorder. After the interviews, the audio records were transcribed and saved in Microsoft word documents which were kept in password protected folders. I later read and coded the data then analysed it using thematic analysis for organising the codes in respective themes. I then used critical discourse analysis for an in-depth analysis of the themes. To meet objective number (ii) and (iii), in addition to text data, I conducted a comprehensive literature review. I present the literature review in Chapter 2 of this thesis. I also used the literature review to interpret the findings of the empirical study in Chapter 4. Findings and discussion: Heteronormative perceptions, Christian religion and African traditional culture as well as safe sex public health interventions are major discourses that appeared to influence the way in which transactional sex was perceived. The gender discourse owed to the consensual perception that transactional sex only happened between young women and older men. This was clear in the research findings. The main findings were; (i) participants’ understanding of transactional sex, (ii) the link between transactional sex and vulnerability to HIV, and (iii) probable relationship between transactional sex and father absence. The participants understood transactional sex as a source of income driven especially by perceived high rates of unemployment and poverty in the study sites. Young women were viewed as receivers of financial and material benefits yet givers of sex to men. The flip side of the same coin was that, men were viewed as the givers of material and financial benefits, and receivers of sex. The discourses found also demonstrated that transactional sex was fuelled by young women and their families’ financial needs. The financial constraints that young women and their families face could be influenced by the absence of the father who is supposedly a provider. Consumerist society that promotes extensive consumption of goods and services also appeared to be influential in the practice of transactional sex particularly for the young women. Conclusion: Transactional sex is not a new phenomenon in the study sites. It has been practiced in a several ways, were the community elders were in control of the transactions that were involved in different sexual intercourses that happened historically. The community elders facilitated financial transactions for sex in the forms of punishment when a man had sex with a young woman outside marriage. This punishment was identified as a payment for damage that the man would have caused. The man could also pay lobola as a form of compensation for the woman that he would have married. Overtime, the practice of these transactions has changed. The young women now consciously get involved in transactional sex so that they can directly receive money and gifts from the men that they give sex to. The change in the practice of transactions and sex reflects the change in the socio-economic conditions where there is a high need for consumerism which is constructed within the context of modernity. Consumerism emerges together with capitalism, which is a relatively new economic model in South Africa. Capitalism requires one to be employed so that they can have access to economic benefits. However, the rate of unemployment challenges the young women and deprives them of accessing the modern materials for consumerism. This influences the young women to consciously adopt the practice of transactional sex. It is this move by young women to decide adopting transactional sex that raises various panics among the elders of the community and the perpetuation of the discourses that transactional sex is an immoral and unacceptable practice. The panic has also become evident in the safe sex public health interventions where transactional sex is perceived as a dangerous practice among young women ad it should not be accepted. The interjection of the discourses of morality in transactional sex obstructs studies to clearly understand the discourses that influence its practice. These obstructions also limit knowledge that could be discovered by research and hence reduces the possibilities for interventions. Recommendations: Based on the findings from this study, it is recommended that research should increase focus on the effects of father absence to the practice of transactional sex. The studies in transactional sex also need to include samples of the at risk groups such as the LGBTI community. Transactional sex needs to be studied among young men as receivers of the financial and material benefits, as suggested in this study. Transactional sex is happening in the communities studied. It is therefore, recommended that public health interventions should encourage the practice of safe sex to prevent the spread of HIV. The long term interventions should address the structural factors which are; assisting young women to attain education which will make them employable so that they will be able to get sustainable incomes. The practice of transactional sex in KZN, MP and EC are tangled and shaped by the communities’ overarching discourses concerning sex and transactions. The overarching discourses make the practice of transactional sex to happen in a secretive manner particularly among young women. It is recommended that more studies need to be done among the overarching discourses of sex and transactions in these communities. It is important to extensively understand the overarching discourses and their effects through research because this will further unearth the hidden risks that come with the secretive practices of transactional sex. / MT2018

In the context of decreasing mortality and increasing prevalence, prevention of HIV-transmission represents a public health priority. In the United States, the majority of infections are sexually-acquired, with men who have sex with men and minorities disproportionately affected. Although a number of promising biomedical prevention approaches have emerged over the past decade, a further 20 years could be needed before a suitable product becomes widely available. Evidence from vaccine and microbicide trials has shown that success in one population may not be replicated in another. To understand surprising or unexpected results, investigators need chronologically concordant evidence of both study product adherence and viral exposure. Since exposure to HIV cannot yet be independently verified, in seeking to measure this variable, investigators target the sexual behaviors through which it takes place deriving data for these surrogate measures from study participants' voluntary self-reports. Likely sources of reporting bias and efforts to minimize this phenomenon in the context of HIV-prevention research are critically reviewed in Chapter 1. Research describing the role of cognitive and affective functioning in the preparation of responses to potentially threatening questions is examined. Studies investigating techniques such as the use of colloquial language to facilitate comprehension, or variation in the length of the reference period to enhance recall are explored. Research comparing the effect of mode of administration on the amount of proscribed behavior reported - widely believed to correlate with validity - is reviewed. Contextual factors facilitating versus inhibiting disclosure of sensitive information are examined. Finally, risk-behavior measurement approaches used in selected HIV-prevention trials are inspected. Thereafter, the dissertation focuses on the properties of risk-assessment items, formulated specifically to elicit Global recall over six months, or Event-Specific (episodic) memory for selected recent episodes of limited duration, to capture sexual behaviors or temporally related activities. The capacity of the different questionnaire item formats to elicit responses with sufficient construct validity to serve as proxies for HIV-exposure is examined. Data for these studies are drawn from a large randomized controlled trial of a behavioral intervention to prevent HIV-transmission among men who have sex with men. Using a subset of 1295 cases and controls, models with good discriminant validity for HIV are derived separately for the Global and Event-Specific items. Thereafter, selected items from the two formats are combined to produce a single model with excellent discriminant validity, suggesting that these items can adequately represent true HIV-exposure. Next, a preliminary investigation of the contribution of psychosocial items to the predictive model based on exposure measures is undertaken. Specifically, interaction with exposure measures and the increase in discriminant validity obtained using data derived from constructs of partner type/relationship status, substance use, depressive symptoms and perceived self-efficacy is examined first in stratified analysis and then in logistic regression analysis using the case-control data. Effect-modification is observed for perceived relationship status and non-injection drug use. Evaluation of psychosocial items continues in a cohort study with prospective analysis of follow-up data from all trial participants who returned for at least one follow-up visit. Informed by the case-control study, a series of items representing psychosocial constructs known for their association with HIV-infection are tested for main effects and effect-modification. Evidence of the interaction observed in stratified analyses and confirmed in ordinary logistic regression persists in separate, topic-specific GEE analyses with assorted exposure measures, but abates in repeated measures analyses drawing on all available psychosocial items. Lastly, a single lagged variable indicating primary relationship status of the most recent partner (with respect to the preceding study visit) provides a significant addition to the model. Significant main effects for all except depressive symptoms and perceived self-efficacy and the increase in discriminant validity obtained for the multivariable model versus the `exposure-only' model are sufficient to warrant continued use of these risk-assessment items. Despite good predictive validity demonstrated for the sexual risk-behavior and psychosocial items, some inconsistent reporting between the Global and Event-specific formats is evident. Likely sources of this reporting bias are considered in light of the literature, and strengths and limitations of the overall study are discussed in the closing chapter.

Thesis (M. Cur.) --University of Limpopo, 2011. / HIV/AIDS is one of the major challenges facing South Africa today. Over 5.5 million people are infected with HIV and the majority of these infections are in the reproductive age group. Since the start of the epidemic, over 12.2 million women worldwide have been infected with HIV (WHO, 2000:10). The risk of women contracting HIV is rising globally. HIV seems to be a major cause of infant mortality. It is estimated that approximately 55% of women in South Africa are HIV-positive (National Department of Health, 2007:7). It is, therefore, important that knowledge and attitudes of women regarding mother-to-child transmission (MTCT) of HIV infection are explored to reduce the high infant mortality rate and the incidence of MTCT of HIV infections, and to develop preventive programmes on HIV and AIDS. In view of these considerations, the objectives of this study were to explore and describe the knowledge and attitudes of women with regard to MTCT of HIV infection and to provide guidelines for the prevention of MTCT of HIV infection. The study was conducted in the rural area of the Ehlanzeni District in the Mpumalanga Province, South Africa at Bourke’s Luck and Elandsfontein clinics. An explorative, descriptive, qualitative research design that is contextual in nature was used. The population consisted of all pregnant women and those in pueperium between 25-40 years of age. Non-probability purposive sampling was used. Participants were selected according to inclusion criteria. Data were collected using semi-structured interviews. The research findings revealed that some participants had knowledge and understanding regarding MTCT of HIV infection while others lacked knowledge and understanding which could impact on MTCT of HIV infection.

No abstract available. / Thesis (M.A.)-University of Natal, Durban, 2003.

Thesis (Ph. D.)--University of Hawaii at Manoa, 2004. / Includes bibliographical references (leaves 174-184). / Also available by subscription via World Wide Web / xv,184 leaves, bound ill. 29 cm

Despite good intentions and commitment from health providers, it is difficult for HIV positive pregnant women to access Prevention of Mother to Child Transmission of HIV (PMTCT) services (Skinner et al 2005:115). The aim of this research was to find out the extent to which socio-economic and cultural factors influence access to and utilization of PMTCT services. It appeared that despite having a legal plan and framework to ensure that PMTCT services are available and free, the realities confronting HIV positive women in South Africa as suggested by the literature contradicted this objective. Inevitably, these contradictions were identified as some of the main factors contributing to lack of access and inadequate utilization of PMTCT services. These factors were identified through a review of fifteen studies selected based on their relevance to the research aim. The findings were presented according to the following themes: Functioning of clinics, adherence to ART, uptake of VCT and infant feeding practices. According to research evidence, the major socio-cultural factors influencing access and utilization of PMTCT services include fear of stigma and discrimination which are related to cultural norms and practices. The socio-economic factors include transport costs, lack of food, medicines and formula milk which are all related to poverty and unemployment. The research also found that health system constraints such as long waiting times in clinics, stock-outs of formula milk, medicines and test kits influenced the utilization of PMTCT services by HIV positive women.