A thesis submitted to the Faculty of Science, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Doctor of Philosophy. 21 October, 2014. / Three decades ago, the discovery of the Human Immunodeficiency Virus (HIV) was announced. The subsequent HIV pandemic has continued to devastate the global community, and many countries have set ambitious HIV reduction targets over the years. Reliable methods for measuring incidence, the rate of new infections, are essential for monitoring the virus, allocating resources, and assessing interventions. The estimation of incidence from single cross-sectional surveys using tests that distinguish between ‘recent’ and ‘non-recent’ infection has therefore attracted much interest. The approach provides a promising alternative to traditional estimation methods which often require more complex survey designs, rely on poorly known inputs, and are prone to bias. More specifically, the prevalence of HIV and ‘recent’ HIV infection, as measured in a survey, are used together with relevant test properties to infer incidence. However, there has been a lack of methodological consensus in the field, caused by limited applicability of proposed estimators, inconsistent test characterisation (or estimation of test properties) and uncertain test performance. This work aims to address these key obstacles. A general theoretical framework for incidence estimation is developed, relaxing unrealistic assumptions used in earlier estimators. Completely general definitions of the required test properties emerge from the analysis. The characterisation of tests is then explored: a new approach, that utilises specimens from subjects observed only once after infection, is demonstrated; and currently-used approaches, that require that subjects are followed-up over time after infection, are systematically benchmarked. The first independent and consistent characterisation of multiple candidate tests is presented, and was performed on behalf of the Consortium for the Evaluation and Performance of HIV Incidence Assays (CEPHIA), which was established to provide guidance and foster consensus in the field. Finally, the precision of the incidence estimator is presented as an appropriate metric for evaluating, optimising and comparing tests, and the framework serves to counter existing misconceptions about test performance. The contributions together provide sound theoretical and methodological foundations for the application, characterisation and optimisation of recent infection tests for HIV incidence surveillance, allowing the focus to now shift towards practical application.

Homens que fazem sexo com homens (HSH) são uma população desproporcionalmente mais afligidos pela infecção do HIV. A alta prevalência da infecção entre essa população, evidencia a necessidade de acompanhar novos comportamentos, no qual se destaca o uso das redes sociais móveis para agilizar o ato sexual ocasional. Assim, nosso estudo teve como objetivo analisar as vulnerabilidades de homens que fazem sexo com homens, usuários de aplicativos geossociais de encontro, à infecção por HIV. Para isso foram realizadas duas etapas sequenciais: 1ª- Revisão integrativa da literatura e 2ª - Estudo descritivo e exploratório. A pesquisa obedeceu as diretrizes éticas sobre pesquisas com seres humanos, reguladas pela resolução 466/12 e aprovado pelo Comitê de Ética e Pesquisa da Escola de Enfermagem de Ribeirão Preto /USP (1.921.265/2017). A revisão foi guiada pela questão: o uso de aplicativos de geossociais de encontro para encontrar parceiros sexuais aumenta o comportamento de risco para a infecção pelo HIV por HSH? Pesquisamos as bases de dados PubMed, Web of Science, CINAHL e LILACS, considerando estudos primários publicados até dezembro de 2015, sem restrições de tempo. O conhecimento sintetizado guiou a estruturação e interpretação da próxima etapa. O estudo exploratório objetivou avaliar o conhecimento de homens que fazem sexo com homens usuários de aplicativo de encontro baseado em geolocalização, sobre o HIV/aids e implicações no estabelecimento de parcerias. Realizou-se entrevistas com 30 usuários do Hornet® recrutados no aplicativo pela técnica Time-Location Sampling (TLS). Os depoimentos gerados tiveram tratamento estatístico no software IRaMuTeQ, posteriormente analisados pela Classificação Hierárquica Descendente. A coleta de dados foi propiciada pela TLS modificada a realidade virtual. Na coleta de dados utilizouse a técnica Computer-Assisted Interview (CASI). A coleta foi realizada por dois pesquisadores devidamente treinados, que se registraram no aplicativo para ter acesso aos usuários e criaram um perfil público. Foram abordados os primeiros usuários online, que registraram em seu perfil o status sorológico atual para o HIV/aids. Usuários de aplicativos possuem conhecimento insuficiente sobre medidas de prevenção do HIV/aids, principalmente quando se descarta o preservativo masculino. O sexo com os parceiros encontrados por meio de aplicativos foi caracterizado como ocasional, imediato, desprotegido, associado ao uso de drogas e sem informações sobre o status de HIV dos parceiros. As relações estabelecidas pelos aplicativos revelam novos padrões de comportamento e relacionamento, colocando HSH frente a situações com alto risco de infecção pelo HIV e diferentes formas de proteção, que podem ocorrer simultaneamente / Men who have sex with men (MSM) are a population disproportionately more afflicted by HIV infection. The high prevalence of infection among this population evidences the need to follow new behaviors, in which the use of mobile social networks is emphasized to accelerate the occasional sexual act. Thus, our study aimed to analyze the vulnerabilities of men who have sex with men, users of geossocial applications against HIV infection. For this, two sequential steps were performed: 1st - Integrative literature review and 2nd - Descriptive and exploratory study. The research obeyed the ethical guidelines on research with human beings, regulated by resolution 466/12 and approved by the Committee of Ethics and Research of the School of Nursing of Ribeirão Preto/USP (1.921.265/2017). The review was guided by the question: does using geossocial dating applications to find sexual partners increase the risk behavior for HIV infection by MSM? We searched the databases PubMed, Web of Science, CINAHL and LILACS, considering primary studies published until December 2015, without time restrictions. The synthesized knowledge guided the structuring and interpretation of the next step. The exploratory study aimed to evaluate the knowledge of men who have sex with men using geolocation-based dating software, about HIV/aids and implications for establishing partnerships. Interviews were conducted with 30 Hornet® users recruited in the application using the Time-Location Sampling (TLS) technique. The statements generated had statistical treatment in the IRaMuTeQ software, later analyzed by the Descending Hierarchical Classification. The data collection was provided by the modified TLS virtual reality. The Computer-Assisted Interview (CASI) technique was used for data collection. The collection was performed by two properly trained researchers, who registered in the application to have access to the users and created a public profile. The first online users, who recorded the current HIV/aids serological status in their profile, were discussed. Application users have insufficient knowledge about HIV/aids prevention measures, especially when discarding the male condom. Sex with partners found through applications was characterized as casual, immediate, unprotected, associated with drug use, and without information about partners\' HIV status. The relationships established by the applications reveal new patterns of behavior and relationships, placing MSM in situations of high risk of HIV infection and different forms of protection, which may occur simultaneously

Thesis (MTech (Environmental Health and Occupational Studies))--Cape Peninsula University of Technology, 2016 / Currently, the world faces many challenges such as a food shortages, fossil fuel depletion, floods, earthquakes, recession, wars, and climate change. It also faces diseases such as Human Immune Deficiency Virus /Acquired Immune Deficiency Syndrome /Sexually Transmitted Infections and Tuberculosis (HIV/AIDS /STI and TB). This study focused on HIV/AIDS/STI and TB, and the impact of changes in sexual behaviours of student peer educators as a result of peer education programmes offered by the HIV/AIDS Unit at the Cape Peninsula University of Technology (CPUT). Although young people today have a better understanding of risky sexual behaviours, HIV remains a health problem among the youth in South Africa. HIV/AIDS is a disease that affects all sectors of the population- rich and poor, young and adult, educated and uneducated. Tertiary institutions are places where many young female and male students live independently, unsupervised by their parents or guardians, in either private accommodation or student residences. Under these circumstances it may be expected that some students will explore and experience intimacy in their relationships. Hence, universities could play a vital role in shaping students’ attitudes and behaviours towards relationships, safer practices, and respect for others. Given the current absence of a cure or vaccine for HIV/AIDS, peer education should appear as an important tool in HIV prevention strategy. It draws on several well-known behavioural theories and many researchers view peer education as an effective behavioural change strategy. A formal structured Peer Education Programme was initiated and implemented at the HIV/AIDS Unit at Cape Peninsula University of Technology (CPUT) since 2004. This initiative was in line with one of the twelve strategic objectives of the HIV/AIDS Unit at the CPUT. This study therefore, aimed to assess the reflexive effect that the Peer Education Programme had on student peer educators who volunteer their services at the HIV/AIDS Unit at CPUT. It further attempted to assess the effect of the Peer Education Programme on changes in sexual behaviours that could occur amongst student peer educators. The purpose of this programme was to explore peer educators who were based in the HIV/AIDS Unit applying their acquired knowledge and skills; so that they may become role models for their peers by practising what they taught, and not taught what they proposed to practice. The study furthermore, forms on how effective the Peer Education Programme of CPUT’s HIV/AIDS Unit is in changing sexual behaviours of the student peer educators.

This dissertation examines the emergence of queer personhood among black publics and medical cultures in South Africa over the past century. Based on more than two years of fieldwork in South Africa, it contains both a historical and an ethnographic component. The historical research was comprised of archival research and 16 life history interviews exploring how black South Africans reference multiple cultural fields of sexual and gender identities to elaborate composite formations of sexual subjectivity and personhood. In the ethnographic component, I conducted participant-observation and 70 in-depth interviews among various groups, including a number of queer, non-governmental organizations and two global health, HIV-focused clinical sites. In these settings, I examined how social actors, in the context of community settings and global health and community development projects, address sexual and gender nonconformity. Existing scholarship on gender and sexuality in South Africa presumes the existence of only one cultural field of gender and sexual identities in this social field. In contrast, my dissertation argues that multiple cultural fields and sexual ideologies have emerged coevally here. One is a liberal field of sexual subjectivity consisting of globally diffuse concepts of sexual personhood that are historically rooted in a psychiatric style of reasoning, such as homosexual, heterosexual, etc.; the other fields are more localized and are based on ethnic cultural fields of sexual and gender identities. However, they have incorporated aspects of, a globally diffuse psychiatric and anatomical style of reasoning about sexuality. Whereas the `global' liberal sexual ideology dictates a strict alignment of sex and gender, and has done so for some time, the ethnic sexual ideologies I examine, until recently, have not. My work explores the interrelationship of these multiple cultural fields. It follows the enactment of composite sexual subjectivities that are produced when social actors call upon multiple cultural fields of meaning about gender and sexuality. The study demonstrates how race and class mediate the co-emergence of these multiple cultural fields, and how they are entwined with political and economic ideologies and global health knowledge systems. The introductory chapter maps the theoretical and empirical terrain as well as the main questions that are discussed and proposed through the rest of the monograph. The second chapter is a historical analysis of gendered and sexual personhood among black South Africans during the twentieth century. Chapter 3 maps how discourses about cultural authenticity are being used to both contest and constitute LGBTQ sexualities as African. As these cultures and sexual ideologies co-emerge, Chapter 4 examines how they have become entwined with particular political traditions and ideologies during the past century. Chapter 5 explores the ways that biomedicine and public health only reference the a liberal sexual ideology when producing knowledge about black queer bodies and populations in the context of global health HIV interventions. Specifically, I explore the enactment of the MSM and WSW epidemiologic risk categories within HIV science. In Chapter 6, the disjuncture between global health knowledge and everyday experiences of gender and sexuality are highlighted through an ethical case study of the implementation of the HIV intervention known as pre-exposure prophylaxis, or PrEP. The case study concretely demonstrates how the symbolic violence enacted by medical cultures, which only reference the liberal cultural field, conditions structural violence in the form of unjust distribution of health resources among queer groups. The analyses presented in this dissertation suggest new avenues for queer and feminist anthropological inquiry throughout the sub-Saharan African region. In particular, this scholarship contributes to a novel understanding of the political economy of global health and sexuality by exploring how knowledge production and circulation about sexuality within global health contributes to gendered health disparities.

Health information exchange (HIE) has the potential to improve care quality through improved information sharing and coordination of care. In Phase 1, a sociotechnical analysis was conducted at one HIV clinic to explore the interrelated factors that affect the consent of persons living with HIV (PLWH) to electronically share their protected health information (PHI) through a HIE. The findings of the sociotechnical analysis revealed that there is not a single solution that can adequately address the complex, interrelated issues that affect PLWH decision to electronically share PHI. Improvement in the consent process was selected as the target of intervention for Phase 2, which focused on designing and pilot testing a prototype HIE eConsent iPad app at the HIV clinic. A one-group post-test design examined if HIV clinic patients preferred the eConsent or the paper consent. Semi-structured interviews were used to assess overall comprehension of HIE after reading both consents. Over half of the participants favored eConsent as compared to paper consent. The proportion of participants who were able to verbalize essential components of HIE were as follows: more than one component – 35%, one component - 20%, and no component – 45%. While racially and ethnically diverse, the sample was well-educated (50% with a college degree); however, the low comprehension levels suggested that educational attainment was insufficient for HIE comprehension. A hybrid approach that integrates discussion with knowledgeable personnel and multimedia usage may be useful to convey complex information and facilitate HIE comprehension.

INTRODUCTION: Human Immunodeficiency Virus (HIV) infection remains prevalent among the minority and drug using population in the United States. Testing for HIV is an important and cost effective way to reduce HIV prevalence. OBJECTIVE: To assess the HIV testing behavior of people who use non-injected drugs (PWND) and compare it to that of people who use injected drugs (PWID), in order to determine which factors, in terms of social context as well as individual risks, predict HIV testing among the PWND. METHOD: A cross-sectional study of HIV testing behavior of PWND compared to PWID was conducted and the data was analyzed by applying negative binomial regression models. Then, a negative binomial regression using generalized estimating equation (GEE) was employed in order to identify the predictive factors for HIV testing among PWND over a 2-year period. RESULTS: Individuals who reported using injected drugs tended to undergo HIV tests more often compared to those who used non-injected drugs, PR (95% CI) = 1.24 (1.02, 1.51), p = 0.03. The interaction term between injection status and emotional support in relation to HIV testing was significant, 0.75 (0.59, 0.97), p = 0.03. PWID that had access to greater emotional support on average tended to test for HIV less frequently than did PWID with less emotional support. In stratified analyses, emotional support was negatively associated with testing among PWID and positively associated among PWND, though both relationships were borderline significant. HIV testing among users of illicit drugs was dependent on emotional support. According to the GEE models examining the factors predicting HIV testing among PWND, sexually transmitted infections, non-injected heroin use, being in drug treatment, engagement in sexual transactions, and instability in drug networks were the main factors contributing to being HIV tested, as well as frequency of testing. The positive influence of emotional support on these variables was borderline significant. CONCLUSION: People who use non-injected drugs are less likely to test for HIV compared to those who use injected drugs, though they may share similar risk factors for HIV transmission and acquisition. To exert a greater impact on the HIV epidemic, interventions and policies encouraging HIV testing in this subpopulation, which remains under-recognized by both researchers and health practitioners in terms of the potential risks for contracting the HIV, are warranted.

This dissertation uses three types of routinely collected data from HIV care and treatment facilities in sub-Saharan Africa to investigate the association between the availability of adherence support and active outreach services on patient non-retention, loss to follow-up, and measured death after ART initiation. Following a literature review summarizing the state of knowledge concerning the influence of programmatic services on patient retention in care and survival, these relationships are first examined in an aggregate analysis of over 232,000 patients at 349 HIV care and treatment facilities initiating ART between January 2004 and December 2008. Key findings are that several adherence support and outreach services are associated with reduced rates of non-retention, loss to follow-up, and death. Specifically, facilities offering three or more adherence support services, written educational materials promoting ART adherence, one-on-one or group adherence counseling sessions, reminder tools, and food rations to promote ART adherence were associated with reduced non-retention and loss to follow-up, while facilities offering on-site support groups for HIV+ patients, peer educators, provision of reminder tools, and food rations to promote ART adherence were associated with reduced death rates. In sub-analyses investigating six- and 12-month retention after ART initiation, facilities offering three or more separate adherence support services, routine review of medication pickup and/or dedicated ART pharmacists, and active patient outreach to trace patients missing visits had lower non-retention. Taken together, this analysis provides evidence that program-level services found efficacious in experimental settings are also effective in operational settings. Next, a sub-analysis is conducted among facilities also providing electronic patient-level data to investigate similarities and differences in the association between adherence support and outreach services and patient non-retention, loss to follow-up, and measured death using aggregate vs. patient-level estimates of these outcomes, and to assess whether adjustment for patient-level differences between facilities change these measures of association. In multivariate analyses, clinics offering active patient outreach had lower rates of non-retention in both the ART cohort analysis and the patient-level analysis, and clinics offering food rations to promote ART adherence were associated with a lower risk of ascertained death in both the facility-level and patient-level analyses, but this association was diminished after adjustment for patient-level covariates. In contrast, various adherence counseling or support services were associated with lower non-retention in the ART cohort analyses but not in the patient-level data analyses. When compared with the results in the first paper, fewer associations were observed, suggesting either that the countries with patient-level databases are not representative of the entire range of HIV care and treatment facilities assessed in the first paper, and/or the specific facilities with electronic databases are more similar to each other than they are to facilities without electronic databases. Finally, the dissertation concludes with an investigation into the relationship between loss to follow-up and measured death. For this analysis, estimates of the death probability among patients lost to follow-up are created under varying assumptions (either assuming that the death probability among those lost to follow-up is equivalent to the death probability within various strata of covariates, or assuming that the probability of death is greater among patients lost to follow-up). Key findings from this analysis are that ratio comparisons of death rates between facilities offering different services are robust to changes in the death probability if patients lost to follow-up are assumed to have a similar probability of death, conditioned on covariates, as those not lost to follow-up, but that associations between facility services and death rates are masked under the scenario where the facility service is associated with loss to follow-up and the death probability is assumed to be higher, conditioned on covariates, then the death probability among patients not lost to follow-up.

“Strange Bedfellows” examines how the political economy of Medicaid and hospital provision shaped the social, political, and thus material response to the HIV/AIDS epidemic in the United States. By doing so, this study explores the consequences of a decade-plus shift that began in the late 1960s, wherein federal, state, and local policymakers deemphasized epidemic preparedness and acute care in favor of downsized hospitals, increased outpatient services, and more “personal responsibility.” Over the course of seven chapters, the study links the transformation of Medicaid into a welfare medicine program; federal health planning’s shift from the pursuit of equality to cost-cutting; the role that anti-inflation policy played in curtailing subsidies for hospitals and clinics, which reduced access to acute care; the diminution of civil rights protections for quality healthcare; and the effects these developments had on the response to HIV/AIDS. Challenging the notion that the HIV/AIDS epidemic was unforeseen and, thus, impossible to plan for, the study demonstrates how a series of purposeful decisions by presidential administrations, Congress, state legislatures, and city officials led to chronic underinvestment in public and voluntary hospitals that served poor people and people of color. A story of the neoliberal transformation of the Medicaid program and public and voluntary safety net hospitals, this dissertation illustrates how healthcare and welfare politics intertwined from the mid-1960s to the new millennium in ways that confounded the United States’ epidemic preparedness. A healthcare system focused on chronic disease by the 1960s and cost cutting in the 1970s could not cope with an emergent infectious disease like HIV/AIDS.

Despite increased involvement in the criminal justice system among populations of migrants, people who inject drugs, and drug-involved men in community corrections, few studies investigate associations between involvement in the criminal justice system and sexual and injection drug risks among these key-affected populations and their intimate partners. To address these gaps the following dissertation study investigated the association between exposures to the criminal justice system and sexual and injection drug risks among three key affected populations: 1) male labor migrants in Almaty, Kazakhstan, 2) people who inject drugs and their intimate partners in Almaty, Kazakhstan, and 3) drug-involved men in community corrections in New York City, NY in the United States. Using the three-paper model, the following dissertation sheds new insights into how exposures to the risk environment shape sexual and injection HIV risks to inform HIV prevention research and practice with populations disproportionately involved in criminal justice systems.

The thesis portrays various spaces in Mumbai where certain non-normative sexualities interact in relation to the consumption of cultural or material resources with which they build their gender, identity and sexuality. In relation to it, this piece of work interrogates the hijra or the popular transvestite population in Mumbai, and the ways in which they represent their bodies. It explores linkages between these processes, and the modern consumption of beauty practices, feminization of their bodies like the consumption of female hormone tablets, and surgical measures like silicone breast implants. Through these mechanisms, the hijras embody beauty and other facets of bodily modifications in constructing their identity. These embodied practices of beauty by the hijras further charts the new meaning of the hijra body in respect to the local identification of their identity in relation to the global transgender identities. Furthermore, with regards to the body modifications and construction of identities, the research also draws attention to the transsexual identified individuals in Mumbai and the clinical discourses that are related to transsexual experience in this context. Thus, the thesis as a whole negotiates the various strands of transgender identities in Mumbai and (dis) similarities in which hijras represent their identities to the society, and claim their gender.