A research report submitted to the Faculty of Health Sciences (School of Public Health), University of the Witwatersrand, in partial fulfilment of the requirements for the degree of Master in Public Health in the field of Social and Behaviour Change Communication 4 June 2019, Johannesburg / Introduction HIV Testing Services (HTS) represents a critical entry point for reducing HIV risk through personalised counselling and testing (Colpin, 2006, Denison et al., 2008; Fonner, 2014). Despite the significant uptake of HTS since 2010, personal risk perception among South Africans remains low, with individuals continuing to engage in risky sexual behaviour (Statistics South Africa, 2017). This raises concerns about the quality and effectiveness of HTS in reducing HIV risk among HTS clients. In seeking to understand how best to strengthen HTS, lay counsellors who work at the forefront of HTS provision are primary targets for inquiry. This study sought to explore the experiences and perceptions of community-based HTS lay counsellors of providing HTS, the strategies they use to reduce HIV risk among diverse clients, and their perceptions of HTS training and supervision. Methods Qualitative semi-structured interviews were conducted with 12 community-based HTS counsellors at three government-accredited HTS sites in Gauteng and North West provinces. Ethical clearance was obtained in April 2015 and the interviews were conducted from July- October 2015. Interviews were audio-recorded, professionally transcribed, and coded using MaxQDA. Inductive and deductive thematic analysis was used to meet the study objectives. Results The HTS lay counsellors came from diverse personal and educational backgrounds. Their HTS training was not standardised, differing in scope, depth, and duration. Their sector influenced their scope of practice, remuneration and relationship with the Department of Health. HTS Counsellors tended to follow a client-centred approach to HIV counselling; balancing general HIV education with more tailored prevention counselling. Gender norms appeared to influence risk-reduction counselling, in which counsellors advised men to use condoms and women to be faithful to their partners. Counsellors resisted the notion of differential risk among HTS clients, and offered generic, simplified prevention messages tailored to clients‘ age and gender. Counsellors seldom explored known risk factors for HIV infection, such as alcohol and drug abuse, anal sex, and gender-based violence with clients. They prioritised post-test counselling for HIV-positive clients and tended to neglect post-test counselling for HIV-negative clients. . Counsellors recommended regular in-service training, enhanced supervision and debriefing, and formal recognition of the field through establishing standardised guidelines, career paths and a professional body. Discussion This study confirms previous research on the sub-optimal quality of risk-reduction counselling, which varies between sites and counsellors. Although HTS counsellors follow the nationally prescribed, client-centred approach, there is limited evidence that this approach effectively reduces HIV risk (Peltzer et al., 2013). In contrast, theory-based approaches, such as Motivational Behavioural Interviewing, which has effectively reduced unprotected sex, alcohol use before sex, number of sexual partners, and transactional sex among high risk groups globally and in South Africa (Petersen et al., 2014, Simbayi et al., 2004).were largely absent in HTS programmes covered in this study. The HTS lay counsellors in this study are among those who have contributed significantly to the rapid scale up of HTS in South Africa. However, they identified structural challenges detrimental to their work performance and motivation. HTS counsellors are not formally recognised or included within national human resources for health plans, and their job profiles and remuneration are not standardised. The inconsistent management and unfair treatment described by counsellors in this study has been reported across the country (Medecins Sans Frontieres, 2015). Conclusions The major recommendations that emerged from this study include the need for the government to create a supportive legal and policy framework to guide the integration of HTS counsellors into the formal health care system. This could happen by establishing a professional body for HTS counsellors and updating the minimum standards for HTS. Quality could be improved by training counsellors on use of individual and social theories of behaviour change (Petersen et al., 2014) and standardising HTS training curricula at national levels. Strengthening HTS vsupervision to ensure quality HTS counselling and testing nationally is also needed. Overall, this study confirmed that further research is needed to improve the quality of risk reduction interventions in HTS and develop a coherent framework for the integration of lay counsellors into the South African health and social service sectors. / E.K. 2019

mHealth – Mobile phones in HIV prevention in Uganda by Axel Salomonsson Abstract The use of ”new”  interactive media like the Internet and cell phones in health education is not an entirely new phenomenon and studies shows promising results from such information campaigns in developed countries[1]. In the area of HIV/AIDS prevention, however, no scientific studies have been made on the effects of mobile phone-based information campaigns in developing countries. This study can therefore be seen as a pilot study in this area. As mobile phone ownership has multiplied in Africa over the last decade, it has become one of the most reliable mediums for mass communication about health issues. This is a case study of one HIV/AIDS prevention campaign from 2009, where two NGO’s used a multiple choice SMS quiz to ask questions about HIV/AIDS to ten thousand mobile phone owners in the Arua region in North-Western Uganda. The targeted population could send their answers back and win prizes. They were also encouraged to seek out HIV counseling and testing services at a local clinic. By using a qualitative method consisting of a literature study combined with semi-structured interviews with the people who organized the intervention, as well as with respondents to the SMS quiz , the effectiveness and future potential of using mobile phones in HIV prevention in the East African setting are examined. Additional qualitative interviews with a number of experts from the Ugandan telecom sector, the Ugandan Ministry of Health, and an HIV/AIDS researcher from Makerere University in Kampala was also conducted in order to get a better understanding of the context in which this HIV prevention intervention was implemented. The results show that mobile phones are a feasible medium in HIV prevention, and that it offers an additional channel for information dissemination. By allowing two-way communication, the audience is empowered to participate in the exchange of information, which seems to have a positive effect on attitude and behavior change. Further, by receiving answers via SMS from the targeted population, the mobile can at the same time be used as a monitoring and evaluation tool for measuring knowledge levels on different topics. This information can then help to tailor HIV prevention messages in future campaigns. [1] See Bull, S: Internet and other computer technology-based interventions for STD/HIV prevention, in  Communication Perspectives on HIV/AIDS for the 21st Century. Edgar et al. 2008.

<p>The aim of this study is to investigate the role of female empowerment and NGOs in HIV-prevention. A case study from Babati, northern Tanzania, is presented as part of my investigation and will affiliate theory with reality. Further the study is based on feminist and postcolonial theory as well as gender perspectives on HIV and AIDS.</p><p>A persons gender determines how vulnerable that person is to HIV and related consequences; I will claim that HIV and AIDS threaten women to a greater extent then men and that women’s abilities to empowerment are negatively affected as well. I will also claim that female empowerment is a necessary mean to prevent HIV and that this involves a more profound change than solely equal distribution of resources.</p><p>My study will show how female subordination permeates all societal structures and how this is perceived by NGOs and others in Babati when addressing the HIV- pandemic and its effect on women. I will describe the grass-root actions taken by the NGOs to deal with this and what obstacles they encounter.</p>

A research report submitted in partial fulfilment of the requirements for the degree of Master of Science in Epidemiology in the field of Infectious Diseases School of Public Health, University of the Witwatersrand May 2014 / South Africa continues to grapple with the HIV/AIDS epidemic almost 30 years since the disease was first described. South Africa has 6.4 million people living with HIV thereby contributing 17% to the global burden of HIV/AIDs even though it makes up 0.7% of the world population translating to an HIV prevalence of 10.6% in the general population. . Multiple concurrent sexual partnerships (MCP) and inconsistent condom use are notably the major contributors to the spread or transmission of HIV in South Africa. The South African government has allocated massive financial resources to support HIV/AIDS interventions, however, the epidemic continues to amplify in South Africa and there is a growing need for targeted HIV prevention interventions which will address behaviour change. Objectives The objectives of the study were to determine the differences in sexual risk behaviour between self-identified HIV positive and HIV negative men and identify factors associated with sexual risk behaviour. Methodology This was secondary data analysis of a cross sectional design study called "Risk Perceptions of HIV Positive Men" and it was conducted in clinics from Soweto, Cape Town and the Cape Winelands from October 2010 to July 2011. The sample size was 451 and the study population comprised self-identified HIV positive and negative men between ages 18 - 60 years. Proportion of consistent condom use (CCU) and multiple concurrent partnerships (MCP) were calculated and difference between those self-identified HIV positive and negative were determined using Chi-square tests. Factors associated with MCP and CCU between the two groups was determined using univariable and multivariable logistic regression Results We analysed data for 451 men with a mean age of 39 years (std. dev. 11.30). Out of the 451 men 311 (69%) identified themselves as HIV positive and there was a statistical significant difference in baseline characteristics between HIV positive and HIV negative men (age, race, relationship status, employment status, education level, religion, area of residence, age at sexual debut, condom use at first sex, sexual orientation and circumcision status). HIV positive men were four times more likely to have used condoms consistently in the last six months compared to HIV negative men (AOR=3.72, CI: 1.95-7.11), however, HIV positive men were also four times more likely to have had Multiple Concurrent Partnerships in the last 12 months compared to HIV negative men (AOR=4.60, CI: 2.09- 10.12) . Other factors associated with sexual risk behaviour were; relationship status, age group, race, age at sexual debut, alcohol frequency, sexual orientation and perceptions about undetectable viral load reducing HIV transmission risk. Conclusion and recommendation There is a difference in sexual risk behaviour between men who identified themselves as HIV positive and those who identified themselves as HIV negative. Men who identified themselves as HIV negative were less likely to have used condoms consistently in the last six months. Though the HIV positive men are using condoms consistently they have multiple concurrent partners. There is need to strengthen post HIV test counselling coupled with targeted messages for both HIV positive and HIV negative men.

A research report submitted to the School of Public Health, University of the Witwatersrand (Johannesburg, South Africa) in partial fulfilment of the requirements for the degree of Master of Public Health for the year 2014 / Introduction: After 12 years of implementing the national Prevention of Mother-to-Child Transmission of HIV (PMTCT) programme in South Africa, interventions to prevent MTCT of HIV are now offered in more than 95% of public antenatal and maternity facilities country-wide free of charge (MRC, 2010), even though HIV/AIDS-related diseases are said to be a major cause of death in young children (UNICEF, 2011). The context within which women make decisions about PMTCT participation depends on, amongst other things, the level of their knowledge about HIV/AIDS (Leonard et al, 2001; Sematimba et al, 2004). The concept of behavior-based programming is central to a behavior change approach to reducing Mother-to-Child Transmission of HIV. This places behaviours at the centre of the program design process (Moore, 2003). Understanding the providers and users of the PMTCT interventions’ knowledge and experience on HIV and PMTCT is therefore important to ensure appropriate interventions to address beliefs, attitudes, myths and misunderstandings. Methodology: Semi-structured interviews were conducted with users of the PMTCT programme, while structured survey questionnaires were collected with the providers of the PMTCT programme in early 2012. Users of the PMTCT programme were asked questions regarding HIV knowledge, experience of HIV testing in pregnancy, PMTCT knowledge and experience of the PMTCT programme. We also asked questions on infant feeding choices and practices. Forty six interviews were carried out with participants at three ANC Clinics with PMTCT services in Soweto - Gauteng. Thirty were users of PMTCT programme and sixteen were providers of PMTCT service. Results: All participants understood that HIV was a virus that affected the immune system. Results show that there is generally a good understanding of HIV and how it is transmitted. In addition there was a good understanding on methods to prevent acquiring HIV. There was a general feeling that a lot of people were afraid of being tested. Interestingly, most participants believed that people who were pregnant or sick had no choice but to get tested. Most of the participants believed that education should be a tool used to motivate more people to get tested for HIV. Most users in this study disclosed their HIV status and PMTCT programme use. Overwhelmingly the decision to participate was based on the desire not to infect their infants. Women had been informed that mixed feeding increased the risk of transmission by breast feeding. There were a few participants who believed that HIV infected women should not breastfed. It was found that almost two-thirds of the women in this study were formula feeding their infants. Reason cited for formula feeding was that they did not want to infect their infants. As far as PMTCT knowledge was concerned, it was found that almost all health care providers knew that the most common route of HIV acquisition was through heterosexual sexual practices. All the HCWs knew that prolonged breastfeeding increased the risk of transmission. Reassuringly all HCWs knew not to use invasive delivery procedures and that risk of transmission was decreased with low maternal viral load. Only 50% of the HCWs indicated that the first choice of WHO- recommended mother-to-child regimen for antiretroviral prophylaxis in PMTCT was Zidovudine (ZDV) and Nevirapine (NVP) (WHO, 2012). The HCWs understood that infant formula did not provide superior nutritional support or antibody protection. They also knew that formula feeding carried increased risk of diahorrea or bacterial infections. There was confusion regarding the duration of exclusive breast feeding. Only half of the HCWs stated that post-natal infant-feeding counselling and follow-up are required whenever a mother decides to change her feeding practice. HCW participants felt that most patients fail to adhere to their medication requirements. This was cited to be mainly due to the fact that patients may not have disclosed their HIV status to the household members. Baby feeding choices are cited as the strongest barriers to the success of the PMTCT programmes. Mothers who have not disclosed their HIV status to their household members find it difficult to comply with the chosen feeding choices especially bottle feeding; they therefore opt for exclusive breastfeeding –which family members attempt to interrupt with mixed feeding practices for a number of reasons. Conclusion: Contrary to studies cited in the literature review, health systems failure was not a major problem in Soweto and therefore was not a factor that could impact on either the knowledge or the experience of users and providers. Even though disclosure rates were high amongst the users interviewed in this study, participants believed that the biggest barrier to people participating in the PMTCT programme was because of stigma, ignorance, and fear that they may be recognised while accessing services by people they may know. Although women had been provided with information on exclusively breastfeed, most users of the PMTCT programme interviewed were bottlefeeding – not due to stigma, but due to fear of transmission. In terms of barriers – adherence was noted as a major problem by providers. This linked to issues of feeding practices - if mothers bottle-feed they are stigmatised and opt for exclusive feeding, but are then forced by family to supplement with the bottle for various reasons. Mothers do not reveal their status, which jeopardises their success on the programme

Background: It is widely acknowledged that Uganda was the first country in sub-Saharan Africa to experience a significant decline in HIV seroprevalence in the 1990s. Framed as the initial ‘success story’ in the history of the global HIV/AIDS pandemic, the behavioural mechanisms and policies accounting for the Ugandan HIV decline have been extensively debated over the past 25 years. With reference to broader debates about the role of evidence in policy, this thesis aims to examine contested explanations for the decline in HIV prevalence in Uganda and the role of evidence in the development of global HIV prevention policy in the 1990s. The thesis examines diverse explanations for Uganda’s HIV decline and how these came to be framed in the context of the emergence of Second Generation Surveillance (SGS), a global HIV/AIDS surveillance framework introduced by UNAIDS/WHO in 2000. Official accounts describe SGS as having been developed on the basis of Ugandan behavioural evidence presented during a key meeting of HIV/AIDS policymakers which took place in Nairobi in 1997. This meeting provides a focal point for examining the role of evidence in global HIV prevention policy and the relationship between evidence and policy pertaining to low income countries in the 1990s. Methods: A review of UNAIDS/WHO documents and 29 in-depth interviews with HIV/AIDS experts from Uganda and international organisations were analysed. Results: UNAIDS documents present SGS as a technocratic, problem-solving response to limitations in established HIV surveillance approaches, developed at a UNAIDS-sponsored workshop in Nairobi, Kenya, in 1997. These official accounts present the emergence of SGS as evidence-based and reflecting a clear consensus that developed during the Nairobi workshop. While interview data suggest agreement around the need for improved HIV surveillance systems, they indicate a more complex picture in terms of the extent to which SGS was evidence-based and highlight contested interpretations of this evidence among HIV experts. Findings from interviews suggest that the introduction of SGS by UNAIDS/WHO may be understood as serving both technical and broader strategic purposes. As indicated in UNAIDS/WHO policy documentation, SGS was intended to improve older global HIV surveillance methodologies via the triangulation of multiple data sources. The introduction of SGS also appears to have served two broader purposes, functioning as something akin to a marketing tool to help promote the institutional identity of UNAIDS, while also signalling a shift towards a ‘multisectoral’ approach that aimed to unify epidemiological and social scientific disciplinary approaches. While interviewees’ accounts coincide in describing a decline in HIV prevalence during the 1990s, they present divergent interpretations of this evidence which became significant in the development of SGS. One interpretation focused on a reduction in multiple partnerships within the Ugandan population as the key change driving the decline in HIV prevalence, while a contrasting explanation focused on increased use of condoms as the primary cause of this decline. Interviewees’ accounts suggest a process of competition, whereby different actors sought to secure the primacy of their interpretation in institutional understandings of Uganda’s HIV decline and in the development of SGS. Claims of disciplinary bias and institutional marginalisation appear to have contributed to the subordination of explanations focused on a decline in multiple sexual partners, while the policy entrepreneurship of one key actor appears influential in explaining the ascendency of explanations focused on increased condom use. Despite these contestations around the evidence used to inform the development of SGS, UNAIDS documents and peer-reviewed publications from this period emphasise one interpretation (that of increased condom uptake) which thus appears as the official explanation for the success of HIV control in Uganda. The transition from the WHO’s Global Programme on AIDS (GPA) to UNAIDS, and the initiation of a multisectoral HIV prevention approach, appear as important contextual and institutional influences in the interpretation of evidence for Uganda’s HIV decline. The failure of the partnership reduction explanation to align with the evolving institutional and political orthodoxy, and the potential for this explanation to challenge UNAIDS’ new focus on multisectoral HIV prevention, may help to explain why it did not inform subsequent HIV/AIDS policy and does not appear in official accounts of SGS’s development. In contrast, explanations focused on increased condom use were consistent with UNAIDS’ HIV prevention policy agenda (including its emphasis on multisectoral approaches) and appeared to reinforce the organisation’s need for increased financial resources to mitigate HIV/AIDS via the distribution and promotion of condoms. Discussion: This study demonstrates that the development of SGS, and the politics of evidence supporting its introduction, are more complex than existing UNAIDS/WHO accounts describe. Official explanations of the development of SGS provide a simplistic account of how evidence informed policy in a linear and rational way. In contrast, findings from this thesis suggest that SGS served multiple policy functions (i.e. marketing, promotion of institutional credibility, and a demonstration of disciplinary integration) in the context of the recently-formed UNAIDS, and that the role and interpretation of evidence in this context were highly contested. Consistent with the work of Kingdon (1995) and more recently Stevens (2007), this study suggests that personal, political and institutional factors play important roles in shaping how evidence is presented and linked with policy. These findings suggest that more nuanced understandings of the relationship between evidence and policy are needed to explain HIV/AIDS policy development within both sub-Saharan African and at a global level.

Hispanics now constitute the largest ethnic minority group in the U.S. As the country’s fastest growing demographic, social welfare and public health professionals should focus on ameliorating health issues affecting this population. However, Hispanics continue to experience health disparities including high rates of HIV infection. Moreover, South Florida, is home to two counties with the highest per capita incidence of HIV in the U.S. Risks for HIV are heightened in college settings where individuals may have multiple partners and inconsistent condom use. As such, Hispanic college students in a minority serving institution in Miami, FL comprise an ideal group for the implementation of targeted prevention efforts to decrease health disparities related to HIV. This dissertation evaluated the implementation of an HIV prevention effort that utilized social media based technologies to engage Hispanic college students in HIV prevention conversations and services. This dissertation (1) evaluated the effectiveness of exposure to a social media based campaign using an experimental design and (2) provided a systematic review of the campaign’s content and user interactivity. Participants were recruited from students electing to receive free HIV testing on-campus as part of a SAMHSA-funded project. Hispanic young adults (ages 18-24 years) completed baseline and follow-up assessments—reporting demographic and background characteristics as well as perceptions and incorporation of HIV preventive behaviors. Participants were randomized to social media exposure (n=30) or control (n=30) conditions. The exposure condition received three updates per week in the form of social media post updates. Follow-up assessments occurred 4 weeks after HIV testing. Mixed ANOVA and logistic regression analysis were used to examine the impact of exposure over time by comparing mean scores of baseline and follow-up responses between conditions. This dissertation examined the following outcomes: awareness of HIV testing and prevention services, confidence of using condoms, perceived benefits of using condoms, and frequency of reported protected sex acts. While analyses revealed no statistically significant differences between groups, McNemar’s test results indicated a statistically significant increase in awareness of HIV prevention services on the university campus for participants in both study conditions (p< .001). These exploratory results indicate further research is needed to determine the effectiveness of social media based strategies and how such technologies should be harnessed to achieve HIV prevention goals.

<p><font size="4" face="TrebuchetMS,BoldItalic"><font size="4" face="TrebuchetMS,BoldItalic"> <p>The study used a qualitative approach. Fourteen (14) in-depth interviews were conducted with English and Luganda speaking adult male and female clients on antiretroviral treatment (ART), in TASO Mulago. A focus group discussion (FGD) was conducted with 8 purposively selected ART clients who were considered to be &lsquo / expert&rsquo / clients in TASO Mulago. These participants were expert clients/ peer educators, who were open about their HIV status and have been involved in HIV/AIDS education and advocacy. The individual interviews and the focus group discussion were transcribed verbatim, and subjected to thematic and content analysis. Male and female participants who were married (primary relationship) disclosed their sero-status to their sexual partners, while few of those cohabiting or in steady relationship (only one) disclosed to their partners. Enabling factors to disclose to current sexual partners included: desire for partner to get treatment, need for the partner&rsquo / s support, having prior knowledge of partner&rsquo / s HIV status, out of anger, and having anxiety about the future. Some of the barriers to disclosure included: fear of blame and disappointing the partner, fear of abandonment, fear of stigma and discrimination. Participants suggested that couple counselling and testing, economic independence, peer support and involvement of the TASO staff in disclosure should be considered to facilitate or promote disclosure to sexual partners.</p> </font></font></p>

The aim of this study is to investigate the role of female empowerment and NGOs in HIV-prevention. A case study from Babati, northern Tanzania, is presented as part of my investigation and will affiliate theory with reality. Further the study is based on feminist and postcolonial theory as well as gender perspectives on HIV and AIDS. A persons gender determines how vulnerable that person is to HIV and related consequences; I will claim that HIV and AIDS threaten women to a greater extent then men and that women’s abilities to empowerment are negatively affected as well. I will also claim that female empowerment is a necessary mean to prevent HIV and that this involves a more profound change than solely equal distribution of resources. My study will show how female subordination permeates all societal structures and how this is perceived by NGOs and others in Babati when addressing the HIV- pandemic and its effect on women. I will describe the grass-root actions taken by the NGOs to deal with this and what obstacles they encounter.

The Men, Internet, and Sex with Men Study was a qualitative inquiry into how men who have sex with men (MSM) use the Internet in their sexual lives. The study responds to calls for HIV prevention to become more resonant with men’s online experiences. Men’s use of the Internet in their sexual lives was explored through structural interactionist and social risk theories. The study was a focused ethnography, drawing on semi-structured interviews with 23 MSM from the Greater Toronto Area. The sample included men aged 20 to 61, from a variety of sexual orientations (gay, bisexual, and heterosexual) and HIV statuses. Data analysis focused on the contextual aspects of men’s use of the Internet for sexual purposes and their sexual risk behaviour. This study focused on how men’s use of the Internet for sexual purposes was situated within and influenced by the contexts of their use. The participants’ online experiences were socially-situated from the outset: men saw the Internet as a “solution” to challenges in their sexual lives; their online interactions were structured by online rules of engagement and discourse from the offline gay community; and their sexual risk behaviour was mediated by social context and sexual interactions. The participants’ stories revealed the existence of an online subculture for sex seeking. Men also talked about the links between their online and offline experiences, where the Internet played a role in developing their sexuality but could also foster isolation and addiction. The men emphasized the importance of online HIV prevention and offered suggestions on how prevention more generally might be improved. The Internet holds both promise and pitfalls for HIV prevention. The findings from this study underline the need for prevention efforts that focus on individual- and structural-level prevention which can respond to men’s experiences both online and offline.