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Background Female Sex Workers (FSW) in Mali are highly vulnerable to HIV. Their prevalence in 2009 was nine times higher (24.2%) than that among pregnant women (2.7%). The aim of this study was to document the effectiveness of HIV prevention programming targeting FSW between 2000 and 2013 funded by the U.S. Government (USG) in Mali. Methods The content, scope and coverage of interventions were assessed through a document review and key informant interviews with FSW peer educators and program managers. Data from the Integrated Sexually Transmitted Infection (STI) Prevalence and Behavior Surveys (ISBS) conducted in 2000, 2003, 2006, and 2009 were analyzed to measure changes in outcomes over time. Multivariate logistic regression was used to control for changes in FSW demographics and to analyze sub-groups. Results From 2000 to 2013 the USG was the key partner to the government of Mali (GOM) for HIV testing, surveillance, STI treatment, and behavior change communication (BCC) targeting FSW. The USG spent over $42 million on HIV programming between 2003 and 2013. Since 2001, programming for FSW covered most urban areas and transport hubs in Mali. USG partners exceeded their goals, making over 1.3 million BCC contacts with FSW and their sexual partners. However, outcomes were negatively impacted by frequent stock-outs of medications to treat STIs between 2006 and 2011. Also, evidence suggests that interventions were of insufficient intensity and coverage. Finally, M&E system was rudimentary and inconsistent, which made it impossible to link outcomes with programming with confidence. Nevertheless, important positive changes in outcomes occurred. Between 2003 and 2009, HIV prevalence dropped from 44.14% to 28.49% (P <0.0001) among Malian FSW, from 21.33% to 12.71% (P =0.0082) among Nigerian FSW, and from 43.42% to 33.67% (P =0.0442) among FSW from other countries. Between 2000 and 2009 HIV testing increased (40% to 76% P <0.0001). Consistent condom use with clients improved for Malian FSW (72.3% to 81.5% P =0.0092). Consistent condom use with boyfriends was low and improved only for Nigerian FSW (9.8% to 28.4% P =0.0003). Factors associated with HIV prevalence in the multivariate model were older age, study year (2003 and 2006), nationality, lack of education, mobility, STI symptoms, gonorrhea prevalence, and younger age at first sex. Conclusions This study documents progress in the fight against HIV among FSW in Mali, but coverage and intensity must be increased and the quality and diversity of interventions must be expanded. The different vulnerabilities to HIV of different nationality FSW should be addressed in future programming and research. Program adoption of and adherence to Mali’s new M&E plan for key populations would do much to facilitate the necessary improvements. / 2017-04-02T00:00:00Z

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Thesis (MPhil)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: In efforts to combat the global HIV/AIDS pandemic, the WHO/UNAIDS published the Joint Strategic Action Framework to Accelerate the Scale-up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa which outlines the aim of a VMMC (voluntary medical male circumcision) prevalence of 80% among males 15-49 year old in 14 countries by 2016 (WHO/UNAIDS, 2011). In line with this directive, South Africa has launched a national VMMC campaign. However, a lot of ethical issues remain unaddressed surrounding VMMC. These can be categorised as individual considerations (autonomy and informed consent; non-maleficence and unintentional, unforeseen harm; risk compensation in circumcised men; risk of undermining current HIV prevention strategies; age of circumcision), community considerations (cultural considerations; justice: the gender divide and female subjugation; distributive justice; social stigmatisation as a result of VMMC), national considerations (adverse events and complications on a macro level; cost saving and unforeseen expenditure of VMMC; the implications of international funding for VMMC; the public health ethics of VMMC; risks of “de-medicalisation” of a surgical procedure; the ever present danger of corruption), global considerations (female genital mutilation; non-sexual HIV transmission; a dangerous shift in focus) and other considerations (a statistical perspective on VMMC; circumcision technique; lack of ethical awareness; dealing with medical uncertainty). Finally, I shall consider neonatal circumcision, which is in itself a contentious issue, and has no role to play in VMMC. The unresolved issues raised by these ethical considerations cast doubt on the moral status of VMMC and I conclude that the VMMC campaign as it stands in South Africa currently is morally indefensible. There is, undeniably, a pressing need for HIV/AIDS prevention strategies in South Africa and other developing countries but the role of circumcision has been overemphasised to the detriment of more holistic approaches. While there are no easy answers to any of the ethical dilemmas presented in this thesis, it is imperative to raise ethical awareness surrounding VMMC. / AFRIKAANSE OPSOMMING: In ‘n poging om die globale MIV/VIGS-pandemie te bekamp, het die WHO/UNAIDS in 2007 die Joint Strategic Action Framework to Accelerate the Scale-up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa gepubliseer wat ‘n aksie-plan is wat poog om ‘n voorkoms van VMMC (vrywillige mediese manlike besnyding) van 80% in 14 lande onder 15-49 jaar oue mans in 2016 (WHO/UNAIDS, 2011) te bewekstellig. In ooreenstemming met dié riglyn, het Suid-Afrika 'n nasionale VMMC veldtog geinnisiëer. Maar baie van die etiese kwessies verbonde aan VMMC is nie bevredigend aangespreek nie. Hierdie kwessies kan geklassifiseer word onder individuele oorwegings (outonomie en ingeligte toestemming; nie-kwaadwilligheid en onbedoelde, onvoorsiene skade; risiko vergoeding in mans wat besny is; VMMC ondermyn die huidige MIV-voorkoming strategieë; ouderdom van besnyding), gemeenskap oorwegings (kulturele oorwegings; geregtigheid: die oorweging van die geslag verdeel en vroulike onderdanigheid; distributiewe geregtigheid; sosiale stigmatisering as gevolg van VMMC), nasionale oorwegings (newe-effekte en komplikasies op 'n makro-vlak; kostebesparing en onvoorsiene uitgawes van VMMC; die implikasies van internasionale befondsing vir VMMC; die openbare gesondheid etiek van VMMC; risiko's van "de-medikalisering" van 'n chirurgiese procedure; die alomteenwoordige gevaar van korrupsie), globale oorwegings (vroulike genitale verminking; nie-seksuele oordrag van MIV; 'n gevaarlike verskuiwing in fokus) en ander oorwegings ('n statistiese perspektief op VMMC; besnyding tegniek; die gebrek aan bewustheid van hierdie etiese kwessies; die hantering van mediese onsekerheid) bespreek. Ten slotte, sal ek neonatale besnyding ondersoek, wat op sigself 'n omstrede kwessie is, en geen rol behoort te speel in VMMC nie. Die onopgeloste kwessies wat deur hierdie etiese oorwegings aan die lig gebring word veroorsaak twyfel oor die morele status van VMMC. Ek lei dus af dat die VMMC veldtog soos dit tans bestaan in Suid-Afrika moreel onverdedigbaar is. Daar is ongetwyfeld 'n dringende behoefte vir MIV/VIGS- voorkoming strategieë in Suid-Afrika en ander ontwikkelende lande, maar die rol van besnydenis word oorbeklemtoon ten koste van ‘n meer holistiese benadering. Hoewel daar geen maklike antwoorde op enige van die etiese dilemmas wat in hierdie skripsie verken is nie, is dit noodsaaklik dat etiese bewustheid rondom VMMC verhoog word.

In spite of a decline in HIV incidence rates among African American women, they still bear the most significant disease burden among U.S. women. Findings from numerous studies indicate probable explanations for the disparity, such as the impact of poverty, limited healthcare access, low literacy, and living in areas with high HIV rates. Additionally, many study results provide insight regarding prevention strategies. However, the aim of this study is to explore African American women’s perceptions regarding what HIV prevention communication, if any, occurred with their reproductive health providers (RHPs). In this study, 20 African American women with unknown HIV status participated in face-to-face interviews designed to explore their perceptions about HIV prevention communication with their RHPs. Audio-taped interviews were transcribed verbatim and coded using NVivo10 software. Guided by constructs of the Health Belief Model, inductive and deductive coding yielded four key themes: (1) patients’ lack of expectation to receive information; (2) failure of RHPs to initiate and offer information; (3) patients’ desire to receive information; and (4) patients’ recommendations regarding their preferred methods to receive HIV prevention communication. Results indicated that RHPs missed prime opportunities to initiate and offer HIV prevention information during routine reproductive health visits with women at greatest risk. These findings and recommendations for practice will be useful when designing, implementing and evaluating HIV prevention patient education protocols. The recommendations provide strategies to help RHPs seize every opportunity to address HIV prevention with this highly vulnerable population.

<p>Problem: Gay, bisexual, and queer (GBQ) adolescent males are disproportionately affected by negative sexual health outcomes compared to their heterosexual counterparts. Their sex education needs are not sufficiently addressed in the home and the larger ecological systems. The omission of their sex education needs at a time when they are forming a sexual identity during adolescence compels GBQ males to seek information in unsupervised settings. Evidence-based interventions aimed at ensuring positive sexual health outcomes through sex communication cannot be carried out with these youth as research on how parents and GBQ males discuss sex in the home has been largely uninvestigated. </p><p>Methods: This naturalistic qualitative study focused on the interpretive reports of 15- to 20-year-old GBQ males’ discussions about sex-related topics with their parents. From a purposive sample of 30 male adolescents who self-identified as GBQ, participants who could recall at least one conversation about sex with their parents were recruited for one-time interviews and card sorts. This strategy revealed, using Bronfenbrenners’ Bioecological Theory, their perceptions about sex communication in the context of their reciprocal relationship and the ecological systems that GBQ males and their parents navigate.</p><p>Results: Parents received poor ratings as sex educators, were generally viewed as not confident in their communication approach, and lacked knowledge about issues pertinent to GBQ sons. Nevertheless, participants viewed parents as their preferred source of sex information and recognized multiple functions of sex communication. The value placed by GBQ youth on sex communication underscores their desire to ensure an uninterrupted parent-child relationship in spite of their GBQ sexual orientation. For GBQ children, inclusive sex communication is a proxy for parental acceptance. </p><p>Results show that the timing, prompts, teaching aids, and setting of sex communication for this population are similar to what has been reported with heterosexual samples. However, most GBQ sons rarely had inclusive guidance about sex and sexuality that matched their attraction, behavior, and identities. Furthermore, the assumption of heterosexuality resulted in the early awareness of being different from their peers which led them to covertly search for sex information. The combination of assumed heterosexuality and their early reliance on themselves for applicable information is a missed parental opportunity to positively impact the health of GBQ sons. More importantly, due to the powerful reach of new media, there is a critical period of maximum receptiveness that has been identified which makes inclusive sex communication paramount in the pre-sexual stage for this population. Our findings also indicate that there are plenty of opportunities for systemic improvements to meet this population’s sexual education needs.</p> / Dissertation

Research report submitted in partial fulfilment for MSc (Med) in Epidemiology and Biostatistics in the School of Public Health, 2013 / Concurrent sexual partnerships are a sexual network pattern that speeds the spread of HIV/AIDS and Sexual Transmitted Infections(1). Multiple and concurrent Sexual Partnerships (MCP) are part of behavioural drivers and are playing main role in the increase of HIV incidence(2). The main aim of the study is to identify the possible socio-demographic and behavioural factors that are associated with concurrent sexual partnership in 4 communities of South Africa(SA), so as to inform HIV prevention programmes in designing targeted interventions for addressing this problem in specific communities. The ultimate goal is to reduce the incidence of new HIV infections

A dissertation submitted to the Faculty of Health Sciences, University of Witwatersrand, Johannesburg in fulfillment of the requirements for the degree of Master of Science in Medicine, Johannesburg , 2013 / South Africa’s Prevention of Mother-to-Child Transmission (PMTCT) programme is critical for eliminating vertical HIV transmission and reducing infant mortality. Early treatment of HIV-infection to curb infant deaths requires earlier diagnostic testing than the currently recommended six-week test. This study describes the continuum of PMTCT care at a Johannesburg hospital to identify interventions for improvement and investigates birth HIV testing for infants. Data from a cohort study at the hospital evaluating diagnostic assays in HIV-exposed infants were collated with routine clinical data, validated and analysed. Among 838 mother-infant pairs, 38% of mothers attended antenatal clinics early enough to receive optimal antenatal prophylaxis. Only 72% of infants accessed six-week testing at the hospital; a further 10% underwent testing elsewhere. Of 38 HIV-infected infants, 29 were infected in-utero and could have been identified at birth (sensitivity of 76.3% for birth testing), compared to only 26 (68%) diagnosed by six-week testing at the hospital. Majority (88%) of these 26 infants accessed antiretroviral therapy, but treatment was only initiated at a median age of 16.0 weeks and 43% of HIV-infected infants who initiated treatment had defaulted or died before the end of the study. Mathematical modelling demonstrated that birth testing would be superior to a six-week test to maximise infants diagnosed and life years saved, with the ideal algorithm being a birth and ten-week test. The PMTCT programme can be enhanced by earlier antenatal care for women and earlier infant diagnosis. Birth testing would diagnose HIV-infection before infants die or default from the PMTCT programme, thereby enabling effective monitoring of MTCT, and would allow earlier treatment initiation to reduce early infant mortality.