Submitted in fulfillment of the requirements for the degree of Doctor of Philosophy (PhD) Health Science, Durban University of Technology, Durban, South Africa, 2017. / Background: The HIV pandemic has attracted unprecedented scale-up in resources to curb its escalation and manage those afflicted. Although evidence from developing countries suggests that public health systems have been strengthened as a result of scale-up, only anecdotes exist in other countries. Despite scale-up, the prevalence of HIV/AIDS is still high and the resultant mortality and morbidity demands a refocus. Furthermore, the HIV/AIDS epidemic has severely strained vulnerable health systems in developing countries leading to concerns among policy makers about non-HIV priority services. Although anecdotally, it is clear that HIV scale-up has had profound effects on health systems, available evidence does not allow for an assessment of the impact of such effects on health care access, service delivery or medical outcomes for non- HIV conditions. The aim of this study was to determine the impact of HIV/AIDS scale-up on non-HIV priority services in the former Nyanza Province, Kenya. Additionally we determined the benefits and detriments of HIV programmes, and identified the elements of successful HIV programs and their effect on scale-up and last but not least determined the perceptions, attitudes and experiences of health care staff towards scale-up and integration of health care services. The first part of the main sequential study reviewed practices during scale-up by looking at public health facilities within the Province at Nyanza in Kenya. This looked at health management information systems (HMIS) and routine health facility client records for five years, 2009-2013 with a comparison of trends in 2009 to that in 2013. This data was reviewed in order to show trends in delivery of HIV priority and non-HIV services. The second part of the study utilized a prospective cross sectional survey to determine perceptions, attitudes and experiences xi of facility personnel towards HIV/AIDS scale up. Randomly sampled facilities involved in the delivery of any aspects of HIV diagnosis care and treatment were investigated. Self-administered questionnaires and in-depth interviews were used to obtain information on impact of HIV services on non-HIV priority services on health managerial staff in the facilities and key informants who have shaped scale up. We created a qualitative codebook based on three major themes identified from the data: (1) Meaning and importance of HIV scale-up (2) Perspectives of scale-up on service delivery on non-HIV services and (Ministry of State for Planning) Health facility staff awareness. The findings indicate that the interventions that were utilized in the scale-up of HIV in 2009 resulted in significant increases in uptake of the service in 2013 (p<0.01) and total integration of HIV and non-HIV services at all the health facilities thereby contributing to improved health outcomes beyond those specifically addressed by HIV programs. This study has also shown that utilization of both HIV and non-HIV services increased significantly for both years after integrated HIV care was introduced in the health facilities (p<0.01). Notable increases were found for ANC utilization (p=0.09), family planning (p=0.09), screening for tuberculosis and malaria (p<0.01) and provision of support services (p<0.01) to HIV infected people. The scale up of HIV in the region had several human resource policy implications resulting from staff turnover and workload. Stakeholder engagement and sustainability are critical in the sustenance of these initiatives. Strategic alliances between donors, NGOs and the government underpinned the scale-up process. Policies around scale-up and health service delivery were vital in ensuring sustainability of scale- up and service integration. This study has attempted to provide evidence on the impact of HIV scale-up on non-HIV service delivery in three different settings, in two different time periods and it therefore concludes that the evidence is mixed with most of the impact being positive with some aspects that still needs development. It is critical to pursue the integration of HIV and non- HIV services in a strategic and systematic manner so as to maximize the public health impact of these efforts. The proposed model, best practices and practices requiring improvement will be communicated to the relevant ministries to ensure its integration into policy. / D

This dissertation brings into perspective the plight of AIDS widows in Kisumu. Often widowhood in general focuses on the older women, while AIDS has created a generation of young widows. A high percentage of these widows are immediately pushed into poverty by the death of husbands. AIDS widows' poverty and vulnerability to external shocks and stresses increases dramatically, while the delicate process of juggling competing needs and pressures becomes a far greater challenge. The range of forces against which widows in Kisumu must struggle is formidable: low self-esteem, complex family relationships, hostile or indifferent communities, systemic gender discrimination and harassment, property loss, unemployment or underemployment, lack of education and a daily grind that leaves widows with scant energy to contemplate the possibility of transforming and regaining their dignity/condition. For these reasons this dissertation contends that the church has an obligation to strategise a holistic intervention to care for these widows who are part of the church and society. This dissertation manifests an on going struggle and quest for adequate instruments to understand AIDS widows in the light of God's promise of the fullness of life to all. AIDS leads to severe social, psychological and financial consequences for the affected families, hence the challenging question how the widows can move from deprivation to begin self-reliant sustainable livelihood is addressed. Since widows' lives are complex and constantly changing, their livelihoods wholly depend on their identifying and building their own various strengths, assets and capabilities. In this way the dissertation suggests that the following areas should be secured overtime. Supportive relationships, networks and environments, that is relatives, the church and church organization, government and other agencies should pool and pull together with the widows. Long-term earning power and financial security is badly needed. That means that their property should be secured and their land be on their hands for continuous utilization, contrast to the current state where they are ejected and driven away of their homes. Up-to-date skills, knowledge, self-esteem, motivation, self-confidence and spiritual well being. In this area it is suggested that capacity building would play a major role in moulding their current and future life. Finally the church is challenged to cultivate an alternative theology to address the ever-growing problem of marginalization and violence against widows. That is to say all forms of prejudice, for example stereotyping, isolation and condemnation must be strongly rejected and urgent need for justice, reason and deep faith be employed. As a result the widows would be integrated and feel valued in the society and the church. / Thesis (M.Th.)-University of KwaZulu-Natal, Pietermaritzburg, 2004.