This thesis investigates the role of masculinities on men’s sexual and reproductive health in Botswana. Botswana is currently in the throes of a severe heterosexually driven HIV/AIDS epidemic that has eroded some of the developmental gains the country had achieved since independence. A unique feature of Botswana’s HIV epidemic is the rapid and phenomenal increase in infection and prevalence rates in the face of good levels of knowledge of HIV prevention and an early and comprehensive HIV prevention strategy that guaranteed access to free HIV prevention and treatment services, including ARV treatment. The lack of effectiveness of the country’s HIV efforts and subsequent increase in infection rates have been blamed on men’s risky sexual behavior and lack of support of their partners’ decisions to utilize these services. In fact, quantitative studies on men’s sexual behavior and HIV such as the Botswana AIDS Impact Surveys show that men are less likely to use VCT services and more likely to engage in risky sexual behavior that increases risk of HIV infection to themselves and their partners. While studies provide the evidence that implicates men in the rapid growth Botswana’s HIV epidemic, the studies provide little or no explanation of factors that motivate men’s behavior in reproductive health. This lack of insights on factors that motivate men’s behavior leads to stereotypes about male promiscuity and may contribute to the lack of effectiveness of HIV prevention strategies. The current HIV epidemic has thus thrust heterosexual masculinities at the centre of HIV prevention efforts and provides an opportunity for research to interrogate the role of heterosexual masculinities in reproductive health, especially HIV transmission and prevention. The thesis employs qualitative data to provide in-depth appreciation of the prevalent masculine norms and beliefs and to highlight contextual factors and processes that shape and give rise to various masculinities. It further uses quantitative data to provide measures of levels of men’s masculine and gender role beliefs that may influence HIV prevention and transmission and to test the association between masculinities and men’s sexual and reproductive health attitudes and practices. The results show that men’s sense of identity is socially constructed, and revolves around the notion of superiority to women, independence and having and being in control of the family. However, men face many challenges to the realization of this masculine ideal. Men’s perceived difficulty or failure to live up to socially constructed Men, Masculinities and Sexual and Reproductive Health in Botswana vii notions of masculinities affects their experience of sexual and reproductive health programs, especially women’s empowerment and HIV prevention programs. By their nature, these programs tend to challenge men’s dominance of women’s decision on sexuality, and are therefore experienced as a threat to some men’s sense of identity. Quantitative results indicate an association between masculinities and sexual and reproductive health. While men’s sense of masculinities is not the overriding factor determining their sexual and reproductive health attitudes and practices, the results show a strong association traditional masculine beliefs and negative sexual and reproductive health beliefs and practices. However, there is also strong evidence that men and masculinities are responding to contextual factors, such as the HIV epidemic, which has become a specific stress on the local construction of masculinities. In focus group discussions, many men challenged traditional masculine norms, beliefs and practices that increase their vulnerability to HIV infection and those that either encourage or condone violence within intimate relationships. Significantly high proportions of men had positive attitudes towards HIV prevention programs. It is evident that now more than ever (and thanks to the HIV/AIDS epidemic) many men are ready to question the predominant masculine norms, beliefs and practices that increase their vulnerability to infection and disease. These voices of change represent a window of opportunity for research and programs can meaningfully engage with men and masculinities on issues of sexuality, gender roles, sexual and reproductive health and HIV/AIDS prevention and transmission. There is need for future research and interventions to move away from focusing exclusively on individual models of preventive health behaviors to more multilevel, cultural and contextual explanations. Taking account of multilevel, cultural and contextual factors that shape masculinities and men’s sense of identity will ensure increased effectiveness of sexual and reproductive health programs, especially HIV/AIDS prevention programs. On the other hand, failure to account for cultural and contextual factors that shape individuals’ behavior will only ensure that the shortcomings of such intervention program will continue to be blamed on the individual.

A research report submitted to The Faculty of Health Sciences, University of Witwatersrand, in fulfillment of the requirements for the degree Of Masters in Public Health Johannesburg 2005 / ABSTRACT Swaziland is currently faced with a deepening HIV/AIDS epidemic. A systemic review of available information concerning the economic impact of HIV/AIDS on Swaziland was undertaken to collate data and document this impact in order to inform decision makers and planners. The methodology for the systematic review was based on the guidelines described in the Cochrane Reviewers’ handbook. HIV/AIDS has significantly increased the vulnerability of affected Swaziland rural households to environmental shocks. There is an increased burden of orphans due to HIV/AIDS, reduced household labour and income as adults die of AIDS. HIV/AIDS has reduced farm productivity leading to worsening of food insecurity and poverty in affected households. Due to HIV/AIDS, absenteeism in Swaziland organizations has increased by 20- fold. HIV/AIDS is currently the leading cause of death accounting for over 60 percent of all employee deaths. Organisations that have implemented HIV/AIDS workplace responses have been less affected. The micro-sector is the worst affected and it is recommended that policy makers ensure that this sector is protected from the negative impact of HIV/AIDS. The epidemic of negative impacts of HIV/AIDS in Swaziland has not yet reached the peak.

Faculty of Health Sciences School of Public Health 8900179x nmathabathe@eun.org.za / South Africa is ranked as the country with largest number of people living with the Human Immunodeficiency Virus (HIV) in the world. Oral health care workers have a role to play in the national response to the HIV epidemic through the provision of quality oral health services. The aim of this study was to determine the knowledge, attitudes and practices of oral hygienists and dental therapists on HIV/AIDS. A total of 1160 questionnaires were mailed to 831 oral hygienists and 329 dental therapists registered with the Health Professionals Council of South Africa in 2000. The questionnaire covered: demographic factors; general and oral health-specific HIV/AIDS knowledge; attitudes towards HIV/AIDS patients; infection control practices and ethical/legal issues. The response rate was 27.4% (n=318), 255 oral hygienists and 63 dental therapists. Overall, respondents in this study illustrated sound knowledge on oral manifestations of HIV/AIDS and modes of transmission of the virus although 10% reported that the virus could be transmitted through mosquito bites and 25% agreed that HIV could be transmitted via saliva. Respondents reported compliance with basic infection control practices although 35% did not agree that infection control measures that protect against the hepatitis B virus could provide adequate protection against HIV. In addition 73.8% of the respondents reported that additional infection control measures must be taken in the treatment of HIV/AIDS patients in the dental surgery. The results of this study indicate a need for continuous HIV professional education of oral hygienists and dental therapists in order to improve the quality of care provided to HIV infected patients.

HIV/AIDS is prevalent among adolescent youth in South Africa particularly among adolescent girls. Numerous efforts have been made to contain the pandemic through HIV prevention information in schools and through community and mass media campaigns, but all these efforts seem not to have an impact on the sexual behaviour of the youth. Reports from various studies concluded that although these programmes increase adolescents’ knowledge they have a minimal impact on their sexual behaviour. The current study explores perceptions of HIV/AIDS among a group of adolescent girls (between 14 and 19 years old) as well as the impact of these perceptions on their sexual practices and development. The results revealed that perceptions of HIV/AIDS appear to have an impact on adolescent girls’ sexual practices.

Naicker, Nisha. student no: 8900519E. MMed thesis, Public Health Medicine, 2006. / EXECUTIVE SUMMARY Introduction Soul City is a non-governmental organisation that runs a HIV/AIDS Adult Education Training Programme. The training involves fourteen partner organisations. The training programme uses the Soul City HIV/AIDS materials to train master trainers, who then train others (community trainees) to use the materials (A cascade model of training). Objectives of the study The study evaluated whether the training programme has met its objectives, the effectiveness of the training cascade model and the impact of the training. Methodology Study design: The study was divided into 2 sub – studies. The respondents were randomly and proportionately selected per province. Questionnaires were developed and the participants were interviewed telephonically or face to face. Study Period: July- August 2004. Study population: 1. Partner organisations managers and master trainers. Sample size of 30. 2. Community trainees. Sample size of 265. Results Master trainers: Impact of the training on the organisations and individuals was positive, since it strengthened the organisations and improved knowledge and attitudes of participants.A few, mainly administrative problems were experienced by the partner organisations, however these problems were subsequently dealt with. Community Trainees: A large number of community trainees are being trained and they are training others in the community. The majority of the training took place in urban areas. Reaching rural areas was a challenge. 83% of participants had a very good knowledge and understanding of HIV/AIDS related issues. Participants scored highly on assessment of their behaviour as well. The majority of trainees had positive views of the training. Conclusion The study showed that the training programme had met its objectives and the cascade training model used was effective. Thus the training process was effective in training individuals and contributing to positive changes in the partner organisations and on an individual level.

Key words: Peripheral neuropathy, HIV/AIDS, Progressive resisted exercise, Performance oriented mobility, Quality of life. Background: Distal symmetrical poly-neuropathy (DSP) has emerged as one of the major neurological complication associated with HIV/AIDS and antiretroviral therapy. People with DSP commonly have problems with pain, mobility, altered gait and balance all which affect their quality of life. While therapeutic strengthening exercise has been reported to attenuate these impairments in other co-morbid conditions like diabetes mellitus and in HIV/AIDS, there is no evidence available on the effects of exercise on DSP in people living with HIV/AIDS (PLWHA).The purpose of this study was to determine the effects of progressive resisted exercises (PRE) on performance oriented mobility and health related quality of life in (PLWHA) related DSP. Objectives of this study were to determine the effects of PRE on gait, balance and pain levels and establish if there is a relationship between performance-oriented mobility and health-related quality of life in PLWHA related DSP. Methods: In order to fulfil the objectives, an assessor-blinded randomized controlled trial was conducted over two studies, with a combined sample of 160 participants sourced from two family care clinics at two central hospitals and ten anti-retroviral therapy dispensing municipal clinics in Harare, Zimbabwe. While the experimental group with 80 participants had an intervention program of PRE sessions of one hour for the lower limbs, done twice per week over 12 weeks, the control group of 80 participants was given advice to walk unsupervised at home. Loss to follow up in this study was at 60% (n=97) and the data was analysed using an intention to treat analysis approach. Results: Participants of an average age of 42.2 years (SD=8.5) constituted of 70.6% (n=113) female participants. Combination antiretroviral therapy containing stavudine, was used by 59% (n=94) of the participants and 59% (n=94) of the participants had moderate to severe neuropathy. Proximal muscles exhibited weakness (hamstring muscles strength = 3.43 kg force (SD=1.5)) when compared to leg muscles (gastrocnemius muscles strength = 12.8 kg force (SD=2.0)). Gait and balance scores did not show differences in effect between the intervention and the control group (95%CI 0.00-0.02, p = 0.8). Similarly there were no differences of effect for muscle strength (95%CI 0.00-0.08, p=0.13-0.8) and pain (95%CI 0.0-0.06, p>0.13). However the effect on quality of life changes were significantly different between the two groups (95%CI 0.00-0.12 p= 0.04). Quality of life was positively associated with gait, odds ratio 1.01 (95%CI 1.00 – 1.04), moderately associated with balance odds ratio 0.68, (95%CI 0.52 – 0.93) negatively associated with pain odds ratio 0.98 (95%CI 0.97 – 0.99). Conclusion: This research study established that progressive resisted exercises have positive effects on the health related quality of life in PLWHA related DSP. However this study did not show a difference of the effects of progressive resisted exercises on performance oriented mobility in PLWHA related DSP when compared to advice to exercise at home. The study findings may not be generalized to all individuals living with HIV/AIDS who have DSP as the participants were from a particular demographic setting. This project may be continued at the participating family care clinics as a roll on of the perceived benefits of exercise for people with HIV related DSP.

Student Number : 9410914W - MA research report - School of Social Work - Faculty of Humanities / The study aimed at exploring the perceptions of occupational social workers on how their service provision has been affected by the HIV/AIDS pandemic. The focus was on whether they thought that the increasing prevalence of HIV/AIDS in the workplace had led to a shift in their service provision. That was done through: - An investigation of ways in which social worker’s service provision has had to be adjusted in the context of HIV/AIDS in the workplace. - An assessment of the extent to which occupational social workers perceive their HIV/AIDS services at macro level to be acknowledged as valuable by management and the workforce. - An exploration of perceptions of occupational social workers on how HIV/AIDS has affected their relationship with management The research was quantitative and qualitative in approach and the design used was descriptive. Various sectors like manufacturing, government departments, para-statal, military and finance that employ social workers were identified. A list of occupational social workers was obtained from the School of Social Work, University of the Witwatersrand and from the Gauteng EAP Association. A non-probability sample of twenty seven social workers participated in the study. Semi structured interviews lasting for approximately forty five minutes were used as a form of data collection. Data collected was analysed through simple descriptive statistics and development of core themes and common concerns. The findings indicated that most occupational social workers perceived their services not to have been affected by HIV/AIDS, management and employees to have regarded their HIV/AIDS macro practice as valuable and their relationship with management have not been affected negatively by HIV/AIDS.

M.Med.(Internal Medicine), Faculty of Health Sciences, University of the Witwatersrand, 2009. / In Africa, infective endocarditis (IE) is still a disease of young adults with underlying rheumatic heart disease (RHD). As of 2006, almost two-thirds of all persons infected with human immunodeficiency virus (HIV) are living in sub-Saharan Africa. Southern Africa thus remains the epicentre of the global HIV epidemic. The HIV sero-prevalence data reported in Southern Africa are as high as 20% - 30% of the adult population aged between 15 and 49 years. In South Africa, the prevalence of HIV among adults aged 15 - 49 is 18.8%. Based on a simple extrapolation, there is a higher possibility of encountering a significant number of patients infected with HIV and underlying RHD with IE in Southern Africa than in any other part of the world. In Africa because both HIV and valvular heart disease are relatively common, the co-existence of the two conditions in individual patients is not rare. Despite the major advances in diagnosis and management of this classical disease, the overall mortality rates for both native-valve and prosthetic-valve endocarditis remain as high as 20 to 25 percent after 1 year and at 50% after 10 years. However, the mortality rate varies, depending on a number of factors, such as: • the causative microorganism • the presence of complications • the development of perivalvular extension or a myocardial abscess • neurological events • the existence of conditions such as congestive heart failure • renal failure • severe immunosuppression due to HIV infection in intravenous drug abusers • the use of combined medical therapy and surgical therapy in appropriate patients. vi The clinical outcome of infective endocarditis in HIV patients is poor, severe immunodeficiency in IVDAs with IE has been reported to be associated with poor outcome. However, such an association has never been documented in non-IVDAs, particularly in Africa, where the expected majority patients with HIV and IE are non- IVDAs. The clinical profile including bacteriology of infective endocarditis in HIV patients is different from HIV uninfected patients. The clinical impact of the HIV epidemic on infective endocarditis in Africa has not been elucidated in the world literature and there is, moreover, a paucity of literature describing this clinical entity of HIV and IE in Africa. Objective The objective of this study was to highlight the co-existence of infective endocarditis in HIV positive, non-intravenous drug abuse in South Africa and Africa by: reporting three cases admitted at the researcher’s institution within a period of two months; and undertaking a literature review. Methods This was a retrospective case report and literature review study of IE in HIV infected patients. Three HIV positive patients with IE and with or without underlying chronic rheumatic heart disease were reported. The patients were admitted at the researcher’s institution within a period of two months. All three patients did not report intravenous drug abuse. However, all patients died within a short period of admission to the hospital. The systematic review of cases published in the literature was delivered from MEDLINE SEARCH from January 1985 to December 2006. The following key words were used: Human Immunodeficiency Virus, Acquired Immunodeficiency Syndrome, Rheumatic Heart Disease, Infective Endocarditis, and Intravenous Drug Abusers and Non-Intravenous Drug Abusers. Most of the articles were identified in English; where articles were identified in Spanish and French, only abstracts were used. vii Literature emanating from Africa was emphasized. In addition, the references quoted in this study were reviewed for relevance on the topic. Results Three patients with definitive IE and infected with HIV were reported: one patient was without underlying chronic rheumatic valvular heart disease and two showed underlying chronic rheumatic valvular heart disease. There are few reported studies of IE not related to intravenous drug abuse in HIV infected patients in the literature, which is probably attributable to the reported low prevalence of IE in this sub-group of patients. Most of these published studies are limited to a series of case reports and very little data or reports originate from Africa. Conclusion The clinical pattern of IE in HIV positive patients who are not IVDAs is not well described in literature. However, in this anecdotal case report, the three patients studied retrospectively had a poor outcome. Based on this anecdotal report of three cases described, if an extrapolation was done from these numbers and a prospective analysis performed, we would observed a substantial number of non-IVDU cases with infective endocarditis and HIV/AIDS in Africa. The literature review in its current form may shed some light on HIV and IE in non-IVDU patients, but doesn’t specifically address the issue of the potential co-existence of HIV and IE in Africa. Given the high prevalence both HIV/AIDS and rheumatic valvular heart disease in Africa, in future, we are more likely to see a significant proportion of patients with IE and underlying rheumatic valvular heart disease who are coincidentally HIV infected. There is a useful need for prospective studies describing the prevalence and outcome and for subsequently defining the management of this condition in Africa.

Perception of risk was used as an independent variable and behaviour as the dependent variable in the research with the assumption that level of precaution used during sexual practices to safeguard against HIV infection will be positively related to the perception of risk to HIV. The conclusiveness of this approach was dependent on evidence that participants know what risky behaviour can contribute to contracting HIV/AIDS and on their willingness to report their risk perception honestly. A snowball sample consisting of 15 Zimbabwean women living in and around Johannesburg was employed. Research objectives were addressed through semistructured interviews. For all participants, perception of risk was qualified by a number of factors. Common precautionary strategies identified by women were to remain faithful to one partner and being more contemplative when choosing bed partners and using condoms. High risk perception was marked by having had various sexual partners, inconsistently using condoms, fear of sexual violence, mistrust of partners, feeling of fear of vulnerability to HIV whenever they had sex and survival concerns. Migrant women’s adoption of safe sex was limited by their circumstances and strategies of risk management and in particular their biases in assumptions about their partners’ sexual histories. This exposes them to the vulnerabilities of HIV/AIDS. Thematic analysis was used to interpret the data.

MPH, Faculty of Health Sciences, University of the Witwatersrand, 2007