There is a dearth of literature to guide the development of community-based HIV and Sexually Transmitted Infection (STI) prevention and sexual health promotion programs within Inuit communities. The aim of this research project was to create a dialogue with Inuit women to inform future development of such programs. This study employed Indigenous methodologies and methods by drawing from Inuit Qaujimajatuqangit and postcolonial research theory in a framework of Two-Eyed Seeing, and utilizing storytelling sessions to gather data. Community-Based Participatory Research Principles informed the design of the study, ensuring participants were involved in all stages of the project. Nine story-sharing sessions took place with 21 Inuit women ages 18-60. Participants identified several key determinants of sexual health and shared ideas for innovative approaches that they believe will work as prevention efforts within their community. These research results build upon the limited knowledge currently available about perceptions of HIV and STI among Inuit women living in the remote north. / Graduate / 0573 / jenny.r.rand@gmail.com

Magister Public Health - MPH / This study assessed the knowledge, attitudes and practices about MC as an HIV prevention intervention among adult males presenting for HIV Voluntary Counselling and Testing (VCT) services at Onandjokwe District Hospital in northern Namibia. A high level of knowledge of MC, particularly its potential to reduce the risk of HIV infection, STIs and enhance penile hygiene exists among VCT attendees in Onandjokwe District Hospital. MC will most likely to be accepted in this study area, especially when it is implemented to reduce the risk of HIV infection. The study recommends a comprehensive education and information program targeting males and their partners and a training for traditional and medical circumcisers to ensure a high quality of MC services. / South Africa

Au cours des études de survie, certains facteurs ayant un rôle pronostique peuvent être inobservés ou indisponibles. Dans le cadre des essais cliniques randomisés où deux groupes de traitement sont comparés par un modèle de Cox, « l’oubli » de tels facteurs dans le modèle entraîne une sous-estimation en valeur absolue de l’effet du traitement. L’objectif de la thèse est de préciser le rôle de différents déterminants de ce biais et de suggérer l’utilisation de méthodes pouvant le réduire, avec un intérêt particulier pour les essais de prévention à l'infection VIH où de tels facteurs peuvent exister. L’effet des principaux facteurs pouvant influencer le biais est précisé dans une première partie de la thèse. Si certains facteurs sont connus de longue date, d’autres, comme la durée de l’essai n’ont, à notre connaissance, pas été étudiés. L’approche utilisée repose sur l’utilisation d’un « vrai » modèle de type à risques proportionnels. Dans ce modèle, l’effet des covariables « oubliées » est résumé par l’introduction dans l’expression du risque instantané d’un terme aléatoire de « fragilité » propre à chaque sujet. Le biais cherché est calculé comme la limite asymptotique, sous le modèle marginal correspondant au « vrai » modèle, du rapport des risques instantanés déduit du modèle de Cox n’incluant pas la fragilité. Les résultats montrent une nette augmentation du biais, en valeur absolue, avec la durée de l’essai. Cette augmentation est particulièrement marquée pour des distributions de fragilité continues comme celles pouvant être rencontrées en pratique, par rapport à des fragilités binaires. Par ailleurs, les résultats antérieurs de la littérature sont confirmés et précisés. Dans un second temps, les conséquences d’une variation de la fragilité au cours du temps sur le biais sont recherchées. Plus précisément, la situation envisagée est celle qui est rencontrée dans les essais de prévention contre le VIH effectués auprès de populations « instables » vis-à-vis du risque, comme les jeunes ou les prostituées en Afrique sub-saharienne. Ces populations montrent une hétérogénéité comportementale liée aux changements de partenaires sexuels dont le statut VIH est par ailleurs inconnu. Il s’agit d’évaluer le biais en présence d’une telle fragilité « intermittente » au moyen de simulations reflétant les situations réelles. Les résultats montrent que le biais dû à l’omission de la fragilité dans l’analyse, bien qu’inférieur au biais obtenu dans le cas d’une fragilité constante au cours du temps, reste significatif et doit être considéré. Les différentes fragilités générées au cours du suivi sont soit indépendantes entre elles, soit corrélées. Enfin, dans le cas d’une fragilité supposée constante au cours du temps, l’intérêt de l’utilisation d’un essai en « cross-over » est recherché. Dans un tel essai, les sujets exempts d’évènement après un temps de suivi donné changent de groupe de traitement. Dans le cadre des essais de prévention VIH, Auvert & al [2011] ont montré en particulier une diminution du biais avec un schéma en cross-over comparativement à un schéma parallèle classique, en utilisant une fragilité catégorielle dans une étude de simulation. Buyze & Goetghebeur [2011] ont également montré les avantages du cross-over, en particulier concernant l’efficacité relative d’un test de comparaison des deux groupes, en utilisant une fragilité de distribution gamma ou log-normale. Ces résultats sont précisés en calculant formellement le biais asymptotique dans l’estimation du risque relatif pour les différentes distributions possibles de la fragilité omise, continue ou catégorielle. Les résultats obtenus sont nettement en faveur du cross-over, avec une diminution du biais entre 60% et 90% et une amélioration de l’efficacité du test. Le temps de changement de groupe optimal est également recherché. Il apparaît que celui-ci dépend essentiellement de la durée le l'essai et de la valeur de l'effet traitement. / In survival analysis, some prognostic factors can be unobserved or unavailable. In randomized clinical trials framework where two treatment groups are compared in the Cox model setting, the omission of such factors in the model leads to an under-estimation in absolute value of the treatment effect. The aim of the project is to better understand the determinants of this bias and to suggest the use of methods that could reduce it, with a particular interest in HIV prevention trials where such factors are likely to exist. In a first step, the role of the main determinants of the bias is highlighted. While some of them have long been identified, others like trial duration have never been considered to our knowledge. The bias was calculated as the asymptotic limit of the maximum likelihood estimator of the treatment effect when the analysis is done following a proportional hazard model which no takes into account the frailty. The results show a clear increase of the bias in absolute value with the trial duration. This increase is especially marked with continuous frailty distributions, such as those which can be encountered in practice, compared to binary frailties. Also, some previous results have been confirmed. In a second step, a frailty depending on time is considered, as it can be encountered in HIV clinical trials including “unstable” population about infection risk, as prostitutes or young people in sub-Saharan Africa. These populations present a behavioral heterogeneity linked to the change of partner whose the HIV status is unknown. The bias is estimated using a transient frailty with a simulation study reflecting real-life situations. The results show that when the frailty is regenerated during the follow-up, the bias caused by its omission, although lower than the bias obtained with a time-independent frailty, stays significant and has to be considered. The different frailties generated during the follow-up are independent or correlated. Finally, with a “stable” population whose the frailty can be supposed constant over time, the interest of the use of the “cross-over” is searched. In such trial, the subjects which have not presented the event after a given time of follow-up, change of treatment group. In HIV prevention trials framework, Auvert & al. (2011) have particularly shown a decrease of the bias with a cross-over design comparatively to a parallel design, using a categorized frailty in a simulation study. Buyze & Goetghebeur (2011) have also shown the advantages of the cross-over, particularly about the relative efficiency of the comparison test of the two treatment groups, using gamma or log-normal frailty distributions. These results are specified calculating explicitly the asymptotic bias of the hazard ratio estimate for different possible distributions of the omitted frailty, continuous or categorized. The obtained results are clearly in favor of the cross-over, with a decrease of the bias between 60% et 90% and a significant improvement of the efficiency of the comparison test. The optimal switch time and its prognostic factors are searched. It appears that it essentially depends on the trial duration and is little affected by the frailty distribution or the value of the treatment effect.

Research has identified the important role that effective parent-adolescent communication about sex and relationships signifies in reducing the chances of adolescents engaging in risky sexual behaviour. However, many parents find it difficult to discuss issues related to HIV prevention at family level because HIV prevention is inherently linked to sex, which is still regarded as a taboo in some countries, including the country of the study, Swaziland. In addition to cultural barriers related to effective parent-adolescent communication, parents seem to lack the knowledge, approach as well as the confidence regarding communication about sex and relationships. The purpose of the study was to use appreciative inquiry (AI) to engage parents of adolescents in the design of interventions to prevent HIV among adolescents in Swaziland. Non-probability, purposive sampling was used to select parents of adolescent children (10-19 years) attending school at the two purposively selected high schools in Manzini. Twenty-four (24), 23 female and 1 male parents took part in AI. Participatory action research was conducted to involve participants actively in the process of initiating interventions for preventing HIV among adolescents. The process was guided by appreciative inquiry. Data was collected by means of appreciative interviews, comprising paired and focus group interviews according to different phases of the 4-D cycle of AI. Thematic analysis of data was done throughout the 4-D cycle of AI. The themes that emerged from appreciative stories of exceptional experiences shared during the discovery phase were perceived gains and open communication. The findings of the dream phase included expressed wishes for open parent-adolescent sexual health communication, support for parents and a community of HIV free adolescents. In the design phase, parents constructed and initiated interventions for effective parent-adolescent sexual health communication and parental comfort with communication about sex. In the destiny phase, parents made statements, which were based on what they committed to do to prevent HIV among adolescents. / Lucwaningo lukhombisa bumcoka bekukhumisana kahle kwemtali nemtfwana loyinsha ngetindzaba tebundlelwane bebantfu labatsandzanako netekulalana kuze kutsi kunciphe kutsi intsha ingabi sengotini yekutfola ligciwane HIV. Kodvwa kubatali labanyenti kulukhuni kukhulumisana nentsha ngetindzaba tekutivikela kuHIV emakhaya ngoba kukhuluma ngalendzaba kufaka ekhatsi tekulalana lokuselichilo kukhuluma ngako emaveni lamanyeti lokufaka ekhatsi leSwatini lapho kwetiwa khona lolucwaningo. Lokunye lokuvimbela kutsi batali bangakhulumi ngalendzaba ngaphandle kwekutsi kulichilo, kutsi batali baswele lwati nekutsi abati kutsi bangayingena njani intsha, kanye nekutsi abatetsembi kutsi bangakhona kukhuluma ngebudlelwane bebantfu labatsandanako kanye nekulalana. Injongo yalolucwaningo bekukusebentisa indlela yekubuketa lokuhle kubatali labakwentako mayelana nekukhulumisana nentsha kuze kutsi bakhe tindlela letingito tokutivikela intsha kuHIV Eswatini. Indlela labakhetfwe ngayo batali labangene lolucwaningo bakhetfwe ngokutsi banebantfwana bentsha labaneminyaka lelishumi kuya kulabo labanelishumi nemfica labafundza etikolweni letimbili letiphakeme letikhetsiwe kaManzini. Babangemashumi lamabili nesine batali labatfolakala kungenela lolucwaningo. Batali babamdzibi munye nebacwaningi kuloluhlelo lokuhlela tindlela tekuvikela iHIV kubantfwana labayintsha. Kwakusetjentiswa tindlela letibuka lokuhle lokwetiwe batali. Imibuto beyihlose kubuta ngalokuhle kodvwa. Imivo yebatali yatfolakala nekutsi bacale babutana bodvwana besebakhulunyiswa baticagogwana ngekwehlukana kwaletigaba letine talolucwaningo. Kuhlanganisa kwemivo kwentiwa ngekutsi kubuketwe tingcikitsi kutotonkhe tigaba talolucwaningo. Tingcikitsi letaphuma kuletingcoco esigabeni sekucala lapho bebakhuluma ngetikhatsi letinhle letabayimphumelelo lapho bebakhumisana nentsha ngekulalana nangeHIV, batsi bevakunemphumelelo nekubhobokelana ekhatsi kwebatali nebantfwana. Ngalesikhatsi sesigaba sekubeka emaphupho abo basho batsi bafisa kube nekubhobokelana phakatsi kwebatali nentsha mayelana nekulhulumisana ngekulalana. Lokunye labakufisile kutsi basekelwe basitwe ngekutsi intsha ikhulunyiswa njani. Ngesikhatsi sesigaba sesitsatfu sekubuketwa kutsi kungentiwani kutsi batali nebantfwana bakhulumisana ngetindzaba tekutsandzana kanye nekulalana batali babhala imivo labo. Ngemuva kwaloko benta tivumelwano tekutsi batakwentanjani uma sebabuyela emakhaya kuze bakhone kuvikela bantfwana bentsha kuHIV. / Health Studies / D. Litt. et Phil. (Health Studies)

Employee involvement and participation in HIV-prevention interventions at the workplace remains a barrier to effective programme implementation, which contributes significantly to programme failure and the consequent continued spread of HIV among employees at the workplace. This study explores employee involvement and participation in HIV-prevention interventions at a Bulawayo tyre manufacturing firm. It assesses factors affecting employee involvement and participation in these interventions, and examines the implications of these findings for programme implementation. I used a semi-standardised interview schedule to conduct in-depth, face-to-face qualitative interviews and a self-administered questionnaire to collect quantitative data. The responses showed the nature of employee involvement in HIV-prevention at the firm was at a co-option level, and the type of participation was mere token participation. I recommended that the firm should develop a clear understanding of the importance of stakeholder involvement in HIV-prevention programmes. / Sociology / M.A. (Social Behaviour Studies in HIV/AIDS)

This study was an attempt to investigate the influence of socio-cultural factors on HIV prevention strategies among HIV discordant couples in Harare, Zimbabwe. HIV sero-discordance is a scenario whereby one partner is HIV-positive and the other is HIV-negative. HIV sero-discordant couples are a unique and vulnerable population that encounters many peculiar challenges. When dealing with this population, researchers have to deal with contradictory ideas and perceptions presented by each partner making up the couples and also understand the relationship in the context of cultural values, norms and the dynamic of power and oppression. In addition to this, the concept of HIV sero-discordance and the frequency of its occurrence are poorly understood in most African communities. Despite the growing evidence of HIV discordance, HIV prevention strategies have largely focused on clinical aspects at the expense of socio-cultural issues that impact on HIV prevention strategies targeted at HIV sero- discordant couples. The study seeks to contribute to the conceptualization and design of intervention programs dealing with sero-discordance. The study is underpinned by the symbolic interactionism theory and was qualitative in design involving 13 HIV discordant couples in heterosexual relationships enrolled in the HIV Preventions Trials Network 052 Study (HPTN 052 Study) being undertaken by the University of Zimbabwe’s department of medicine. The study utilized 2 Focus Group Discussions (FGD) and 10 in-depth interviews (IDI) to collect data. The study’s findings indicate that discordant couples are in fact critical stakeholders in the uptake of all the available HIV prevention strategies. Failure to acknowledge this tenet is self-defeating as evidenced by the perception of viewing condom use within a marriage as humiliating for a woman. The study further noted that practitioners in the HIV prevention domain must guard against over-relying on the scientifically demonstrated efficacy of the strategies. The study recommends that HIV prevention strategies must be socially and culturally acceptable and embedded for them to be more efficacious. / Sociology / M.A. (Social Behaviour Studies in HIV and AIDS)

The study reports on the perceptions of the midwives and pregnant women of the PMTCT of HIV programme at the antenatal care and maternity ward at the Johan Heyns Community Health Centre. A qualitative approach was adopted to conduct the study. Purposive sampling was used to select participants and was informed by social behavioural theories. Data was collected using interviews and analysed using thematic categorisation. The findings show that at the first PMTCT encounter participants had little to no knowledge of the PMTCT programme, generally displayed a lack of interest, experienced emotional distress, and fear at the thought of having to disclosing their HIV-positive status to their partners/family and had certain trepidations about participating in the PMTCT programme. The participants’ perception on their roles was that their roles were interlinked, midwife needs the recipients (pregnant woman) and pregnant woman needs the provider (midwife) therefore one cannot do PMTCT without the other. The study recommends that the capacity building of pregnant women be optimised, that PMTCT awareness campaigns for women of childbearing age should be a priority and PMTCT skills to be prerequisite for midwives deployed to ANC clinics and maternity ward units. / Health Studies / M. A. (Social Behaviour Studies in HIV/AIDS)

A quantitative and descriptive type of study design was followed using structured self-administered questionnaires distributed among 84 conveniently selected male adolescent learners from Nanogang Community Junior Secondary School (NCJSS) in Gaborone. The purpose of this study was to describe factors that influence the uptake of safe male circumcision (SMC) as a human immune-deficiency virus (HIV) prevention strategy among male adolescent learners. The study findings show that protection from HIV and other sexually transmitted infections (STIs) was found to be the main reason for adolescent learners undergoing male circumcision (MC) (p<.01). Reasons such as maintenance of genital hygiene, culture, religion, and the enhancement of sexual pleasure were not found to be significant factors. Misconceptions such as the belief that girls do not like circumcised partners were found to be the main reason for adolescent learners not undergoing MC (p<.05). A number of factors which were claimed in previous studies to be obstacles for the uptake of MC, such as surgical complications, peer pressure, stigma, and discrimination, were not found to be major obstacles / Health Studies / M.A. (Public Health)

The study investigated the role of churches in HIV prevention among young adults in the Polokwane Municipality of the Limpopo Province. Qualitative research method was followed. Data was obtained and tape-recorded during the in-depth face-to-face interviews. Fourteen churches are affiliated with the Limpopo South African Council of Churches, seven of which run HIV/AIDS programmes and services. They were the target of this study, which investigated how churches could give more support to people infected with HIV. Results show that churches are determined to assist in the prevention of HIV. They have already contributed to supporting those with HIV and those affected by HIV and AIDS. The findings / Sociology / M.A. (Social Behaviour Studies in HIV/AIDS)

The study reports on the perceptions of the midwives and pregnant women of the PMTCT of HIV programme at the antenatal care and maternity ward at the Johan Heyns Community Health Centre. A qualitative approach was adopted to conduct the study. Purposive sampling was used to select participants and was informed by social behavioural theories. Data was collected using interviews and analysed using thematic categorisation. The findings show that at the first PMTCT encounter participants had little to no knowledge of the PMTCT programme, generally displayed a lack of interest, experienced emotional distress, and fear at the thought of having to disclosing their HIV-positive status to their partners/family and had certain trepidations about participating in the PMTCT programme. The participants’ perception on their roles was that their roles were interlinked, midwife needs the recipients (pregnant woman) and pregnant woman needs the provider (midwife) therefore one cannot do PMTCT without the other. The study recommends that the capacity building of pregnant women be optimised, that PMTCT awareness campaigns for women of childbearing age should be a priority and PMTCT skills to be prerequisite for midwives deployed to ANC clinics and maternity ward units. / Health Studies / M.A. (Social Behaviour Studies in HIV/AIDS)