Background: The study is based in post-apartheid South Africa and looks at the health and well being of households in the rural northeast. Temporary migration remains important in South Africa because it functions as a mainstay for income and even survival of rural communities. The economic base of rural South Africans is surprisingly low because there is high inequity at a national level, within and between racial groups. There has now been a democratic system in place for 15 years and there is no longer restriction of mobility, but there remain high levels of poverty in rural areas and rising mortality rates. Migration patterns did not change after apartheid in the manner expected. We need to examine consequences of migration and learn how to offset negative impacts with targeted policies. Aims: To determine a relevant typology of migration in a typical rural sending community, namely the Agincourt sub-district of Mpumalanga, South Africa, and relate it to the urban transition at a national level – Paper (I) . To evaluate the dynamics of socio-economic status in this rural community and examine the relationship with migration – Paper (II). To explore, using longitudinal methods, the impact of migration on key dimensions of health, including adult and child mortality, and sexual partnerships, over a period of an emerging HIV/AIDS epidemic – Papers (III), (IV) and (V). Methods: The health and socio-demographic surveillance system (HDSS) is a large open cohort where the migration dynamics are monitored as they unfold. They are recorded as temporary or permanent migration. Settled refugees are captured using nationality on entry into the HDSS. Longitudinal methods, namely a household panel and two discrete time event history analyses, are used to examine consequences of migration. Results: Migration features prominently and different types have different age and sex profiles. Temporary migration impacts the most on socio-economic status (SES) and health, but permanent migration and the settlement of former refugees are also important. Remittances from migrants make a significant difference to SES. For the poorest households the key factors improving SES are government grants and female temporary migration, while for less poor it is male temporary migration and local employment. Migration has been associated with HIV. Migrants that return more frequently may be less exposed to outside partners and therefore less implicated in the HIV epidemic. There are links between migration and mortality including a higher risk of dying for returnee migrants compared to permanent residents. A mother’s migration can impact on child survival after accounting for other factors. There remains a higher mortality risk for children of Mozambican former refugee parents. Interpretation: Migration changes the risks and resources for health with positive and negative implications. Measures such as improved transportation and roads should be seen as a positive, not a negative intervention, even though it will create more migration. Health services need to adapt to a reality of high levels of circular migration ranging from budget allocation to referral systems. Data should be enhanced at a national level by accounting for temporary migration in national censuses and surveys. At individual level we can offset negative consequences by treating migrants as persons striving against adversity, instead of unwelcome visitors in our better-off communities.

Thesis (MCurr)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: HIV infection poses a major obstacle in breastfeeding as it represents the most common way by which children acquire HIV. Exclusive breastfeeding has been discovered as the most effective intervention in preventing mother-to-child transmission of HIV, mortality and promotion of HIV free survival. The main objective was to evaluate the evidence on the effectiveness of exclusive breastfeeding versus formula feeding and/ or mixed feeding in the prevention of HIV-1 transmission from mother to child. To identify the studies, an electronic search was conducted using PUBMED/MEDLINE, CINAHL, CENTRAL and EMBASE databases. Electronic journals, which include the Southern African Journal of HIV medicine (SAJHIV), HIV Medicine Journal and American Journal of Public Health, were also accessed. Manual searches were carried out. In addition, relevant experts were contacted in order to locate more data. There were no limitations with regards to date and language. The review considered studies on infants who were vertically HIV-1 exposed (mother HIV positive during pregnancy, birth and breastfeeding). These infants were exclusively breastfed for six months with administration of antiretroviral prophylaxis and were compared to infants exclusively formula fed. The outcomes measured were vertically acquired HIV infection; mortality and HIV free survival up to 24 months of age. Two reviewers independently selected articles which met the inclusion criteria. They independently extracted the data using a data extraction tool. Disagreements were solved by discussion. Data was then meta-analysed using Rev Man 5.1.0. Methodological quality of each trial was assessed by the reviewers using the Cochrane assessment tool for risk of bias. Two randomised clinical trials and one intervention cohort study (n=2112 infants) comparing exclusive breastfeeding with exclusive formula feeding were included. HIV infection was associated with exclusive breastfeeding as compared with exclusive formula feeding (Risk ratio 1.67, 95% CI 1.26 to 2.23, p=0.0005). Exclusive formula feeding was associated with high mortality from infections (Risk ratio of 0.67 95% CI 0.43 to 0.83, p=0.002 Chi²= 1.30, p=0.52, I²=0%). There were no statistically significant differences in HIV free survival between exclusive breastfeeding and exclusive formula feeding as measured by trialists at 9, 18 and 24 months (Risk ratio 1.19, 95% CI, 0.92 to 1.54, p=0.19, Chi²= 3.15, p=0.21, I²=36 % 3 studies, 1012 infants). None of the studies included reported on mixed feeding. Complete avoidance of breastfeeding is effective in preventing mother-to-child transmission of HIV. HIV infection during breastfeeding might be an indicator of mixed feeding and poor adherence. Formula feeding is only applicable in settings where formula milk is accessible, feasible, acceptable, safe and sustainable (AFASS) because formula feeding carries a high risk of mortality from causes other than HIV. If the AFASS criteria cannot be met, mothers should be encouraged to exclusively breastfeed and ensure that their infants completely adhere to the antiretroviral prophylaxis because they decrease the rate of vertical HIV-1 transmission. / AFRIKAANSE OPSOMMING: MIV besmetting veroorsaak ‘n groot struikelblok vir borsvoeding, omdat dit die mees algemene manier is waarop babas met MIV besmet word. Eklusiewe borsvoeding is as die mees effektiewe intervensie ontdek in die voorkoming van moeder na kind oordrag van MIV, morbiditeit en die bevordering van MIV vrye oorlewing. Die hoofdoelwit is om die effektiwiteit van eksklusiewe borsvoeding teenoor formule-voeding en of gemengde voeding in die voorkoming van MIV oordrag van moeder na kind te evalueer. Elektroniese navorsing is gedoen deur gebruik te maak van PUBMED/MEDLINE, CINAHL, CENTRAL en EMBASE databasisse. Elektroniese joernale wat die Southern African Journal of HIV medicine (SAJHIV), HIV Medicine Journal and American Journal of Public Health insluit, is ook gebruik. Handnavorsing is ook gedoen, asook relevante data van kenners op die gebied, is verkry. Geen beperking is geplaas op taal of tyd nie. Studies op babas wat blootgestel is aan die MIV-1 (moeder MIV positief gedurende swangerskap en borsvoeding) is in die oorsig oorweeg. Hierdie babas is eksklusief vir 6 maande gerborsvoed, met of sonder anti-retrovirale behandeling, en is vergelyk met eksklusiewe formule-voeding. Die resultaat was dat almal tot op 24 maande gemeet is aan MIV besmetting, mortaliteit en MIV vrye oorlewing. Twee resensente het onafhanklik artikels geselekteer wat aan die ingeslote kriteria voldoen het. Hulle het onafhanklik data geselekteer deur van ’n selekteringsinstrument gebruik te maak. Misverstande is deur besprekings opgelos. Data was daarna gemeet en gemetaanaliseer deur Rev Man 5.1.0. Die metadologiese kwaliteit van elk proeflopie is geassesseer deur die resensente wat gebruik gemaak het van die Cochrane evalueringsinstrument om die risiko van onewewigtigheid uit te skakel. Twee ewekansige kliniese proewe en een intervensie kohort studie (n = 2112 babas) wat eksklusiewe borsvoeding vergelyk met 'n eksklusiewe formule-voeding is ingesluit. MIVinfeksie wat verband hou met 'n eksklusiewe borsvoeding is vergelyk met eksklusiewe formule-voeding (risiko verhouding van 1.67, 95% CI 1.26 tot 2,23, p=0.0005). Eksklusiewe formule-voeding hou verband met 'n hoë mortaliteit van infeksies met ’n risiko verhouding van 0.67, 95% CI 0.43 tot 0.83, p = 0.52, Chi ² = 1.30, p = 0.52, I ² = 0%. Daar is geen statisties beduidende verskille in MIV-vrye oorlewing tussen eksklusiewe borsvoeding en eksklusiewe formule-voeding nie wat deur die proefnemers gemeet is op 9, 18 en 24 maande (risiko verhouding 1.19, 95% CI, 0.92 tot 1.54, p = 0,19, Chi ² = 3,15, p = 0.21, I ² = 36% 3 studies, 1012 babas). Nie een van die ingeslote studies het verslag gedoen oor gemengde voeding nie. Algehele vermyding van borsvoeding is effektief in die voorkoming van Moeder na Kind oordrag van MIV. MIV-infeksie gedurende borsvoeding mag ’n aanduiding van gemengde voeding en swak nakoming wees. Formule voeding is alleenlik van toepassing in situasies waar formule-melk toeganklik, uitvoerbaar, veilig en volhoubaar is, want formule-voeding dra ’n hoë risiko van mortaliteit weens ander oorsake buiten MIV. Indien daar nie aan hierdie kriteria voldoen kan word nie, behoort moeders aangemoedig te word om eksklusief te borsvoed en seker te maak dat hulle babas die antiretrovirale profilaksie getrou neem, want dit verlaag die koers van vertikale MIV-1 oordrag.

<p>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.</p>

<p>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.</p>

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

Philosophiae Doctor - PhD / The HIV/AIDS epidemic remains an unbeaten challenge that affects all parts of the global population. Since the identification of the epidemic in the early 1980s, nearly 58 million people have become infected with the virus and 25 million people have died of HIV-related complications. This study aimed to elucidate individual and community level factors associated with the uptake of antenatal care (ANC), health facility delivery, HIV Counselling and Testing (HCT), and Prevention of Mother-to-Child Transmission of HIV (PMTCT) services by implementing a hierarchical (multilevel) methodological approach. This study used a cross-sectional, multistage sampling design in which health facilities were first selected (stage 1), followed by recruitment of post-partum women who came for child immunization from each health facility (stage 2), in Tigray region. Structured interview guides were developed for interviews. Four-fifths (80.0%) of mothers used antenatal services at least once during their most recent pregnancy and of these 74.6% of women accessed HCT. Sixty nine percent of women had delivered at a health facility, 79% of mothers and 55.7% of their children had received PMTCT services. Place of residence was significantly associated with ANC attendance and place of delivery, with women living in urban areas almost 2 times (OR=1.75, 95% CI 1.06, 2.92) more likely to deliver at a health facility. With the addition of one health facility per 25000 people, the likelihood of delivering at a health facility increased by 2.45 fold (OR=2.45, 95% CI 1.04, 5.78). Attending ANC (OR=4.54; 95%CI 2.82,7.33) and getting support from husband (OR=1.97; 95%CI 1.25,3.10) were significantly associated with HCT, at the individual level. At the community-level, for the addition iii of one health facility and HCT site for every 25000 people increase the likelihood of HCT utilization by 2.1 and 2.4 fold respectively. Mothers who delivered at a health facility were 18 times (OR=18.21; 95%CI 4.37,75.91) and children born at a health facility were 5 times (OR=4.77; 95%CI 1.21,18.83) more likely to receive PMTCT services, compared to mothers delivering at home. With the addition of one nurse per 1500 people, the likelihood of getting PMTCT services for a mother increases by 7.22 fold (OR=7.22; 95% CI 1.02,51.26). Community-level random-effects were also significant and there was confirmation of nesting at the community-level even after controlling for individual and communitylevel variables. Findings also showed that HCT utilization was nested according to district of residence, contributing 11.3% of the variance. In addition, the variation of mothers getting PMTCT services between districts was only 0.6%, but was 27.2% for children. Conclusion: Factors influencing utilization of maternal health services work at different levels, individual and community. Hierarchical models reveal these differences in ways that single-level (individual or community) models do not. Interventions are needed to increase spouse involvement in ANC utilization, and explore effective ways of increasing health facility delivery among poor women with little formal education in rural areas and increasing the number of health facility per people are important. The government should focus on increasing ANC access, educating couples on the importance of health services utilization, increasing the number of health facilities and HCT sites per population to improve HCT utilization. In addition to these, programmes should focus on increasing health facility delivery, training traditional birth attendants to understand the need for PMTCT and increasing iv HCT coverage to advance getting PMTCT services for mothers at the individual level and for children at both individual and community level. Permission to conduct the study was granted from the Ethics Committee of the University of the Western Cape and from Tigray Region Health Bureau. Verbal informed consent was obtained from each participant in the health facility based interview.

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)

The demand for circumcision in Swaziland has dramatically increased since it was reported that circumcision ensures 60% protection against HIV infection. The aim of this study was to explore the reasons for, and the motives behind, this increasing interest in undergoing circumcision. A generic qualitative research design was used, in which 17 circumcised men selected by convenience sampling at FLAS Clinic, Mbabane, participated. In-depth unstructured face-to-face interviews were used to collect data. The results showed that the main reasons for circumcision are perceived health, hygiene and sexual benefits, community influences, as well as medical reasons. It was concluded that the major motives underlying circumcision are personal and partner safety and satisfaction during sex. These motives were found to be both promotive and threatening to the interests of public health. After evaluating the risks and benefits, it was recommended that mass circumcision be promoted alongside reinforced and accurate health education on circumcision / Health Studies

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)

Introdução: O cenário da epidemia da AIDS vem se modificando no Brasil e no mundo e o perfil epidemiológico das pessoas vivendo com HIV/AIDS vem sofrendo sucessivas alterações desde a década de 80. Embora os homens representem em números absolutos, o maior número de notificações do total de casos de AIDS, a velocidade de crescimento da epidemia é maior entre as mulheres. O Brasil tem uma resposta à epidemia de DST/AIDS reconhecida internacionalmente, baseada nos princípios do SUS à universalidade, à equidade e à integralidade na assistência. Um dos capítulos desta resposta é a prevenção da transmissão vertical do HIV. O tema que vem ganhando importância na medida em que a AIDS recebe status de doença crônica e as mulheres soropositivas podem fazer as suas escolhas reprodutivas. A prevenção da transmissão vertical do HIV contempla testagem para diagnóstico precoce, terapia antirretroviral durante a gravidez e o parto, terapia antirretroviral para o recém-nascido e a não amamentação. Objetivo- Conhecer como as ações de prevenção e controle da transmissão vertical do Vírus da Imunodeficiência Humana são percebidas pelas gestantes e puérperas atendidas pelo Programa Estadual de DST/AIDS, e sua satisfação, ou insatisfação, em relação à assistência recebida. Método- Nossa amostra foi composta por 14 mulheres, sendo 13 soropositivas para o HIV que engravidaram e tiveram pelo menos um filho no contexto da soropositividade e uma, soronegativa para o HIV e mãe adotiva de uma criança soropositiva. Para a coleta de dados foi utilizada a metodologia qualitativa, com base em entrevistas individuais, semiestruturadas, realizadas em 2010. Resultados - Não houve aconselhamento para a testagem de nenhuma mulher da amostra. As mulheres apresentaram, no geral, uma falta de identificação com o perfil de pessoas que podem se infectar com o HIV, sendo surpreendidas com o diagnóstico. Oito pais apresentaram status sorológico desconhecido, sendo que três negaram-se à testagem. Há dificuldades por parte das mulheres, para promoverem relações sexuais protegidas com o uso do preservativo masculino. Os efeitos adversos dos antirretrovirais são descritos como obstáculo importante à adesão ao tratamento. O alojamento conjunto foi o cenário das piores vivências dentre toda a assistência recebida, destaque dado ao tema aleitamento materno. Há uma lacuna entre as demandas das mulheres em produzir e relatar as suas narrativas e a inexistência de espaços de escuta, seja individualmente na relação com o profissional médico, seja em grupos. Conclusões - A ausência do aconselhamento como espaço de abordagem e esclarecimentos, informações e escolhas, dificulta uma ação mais oportuna para a redução da transmissão vertical do HIV. As mulheres comuns não são atingidas pelas informações sobre HIV/AIDS oferecidas pelas campanhas para prevenção da infecção. O uso do preservativo para evitar a infecção ainda é uma decisão masculina. As mulheres raramente encontram interlocução entre os profissionais, para tirarem suas dúvidas e planejarem sua vida reprodutiva de forma mais segura. Apesar da falta de discussão sobre o planejamento terapêutico, a via de parto e os cuidados com o bebê, as mulheres seguem a prescrição e seguem com seus medos e suas dúvidas / Introduction: The scenario of the AIDS epidemic has been changing in Brazil and worldwide, and epidemiological profile of people living with HIV / AIDS has undergone successive changes since the 80\'s. Although men represent in absolute numbers, the highest number of notifications of all cases of AIDS, the epidemic growth rate is higher among women. Brazil has a response to the epidemic of STD / AIDS internationally recognized principles of the SUS: universality, equity and integrity in service. One of the elements of this response is the prevention of vertical transmission of HIV. The theme that is gaining importance, as AIDS gets the status of chronic disease and HIV positive women can make their own reproductive choices. The prevention of vertical transmission of HIV includes testing for early diagnosis, antiretroviral therapy during pregnancy and delivery, antiretroviral therapy for the newborn and not breastfeeding. Objective -To study how the prevention and control of vertical transmission of human immunodeficiency virus are perceived by pregnant women and new mothers assisted by the State Program of STD / AIDS, and their satisfaction or dissatisfaction in relation to care received. Methods -Our sample consisted of 14 women, 13 HIV-positive pregnant and who had at least one child in the context of being HIV positive and one was seronegative for HIV and an adoptive mother of an HIV positive child. To collect data we used the qualitative methodology, based on individual interviews, semi-structured, conducted in 2010. Results - There was no counseling for the testing of any women in the sample. Women had, overall, a lack of identification with the profile of people who can become infected with HIV, being surprised by the diagnosis. Eight male partners had unknown HIV status, and three refused to be tested. There are difficulties, for women, to promote safe sex with condom use. Adverse effects of antiretroviral drugs are described as barrier to treatment adherence. Rooming-in was the scene of the worst experiences among all the care received, highlighting the theme of breastfeeding. There is a gap between women\'s demands to produce and report their stories and the lack of opportunities to listen, either individually in relation to the medical professional, either in groups. Conclusions - The lack of counseling as a space for dialogue and explanations, information and choices, hampers a more timely action to reduce vertical transmission of HIV. The \"ordinary\" women are not affected by information about HIV / AIDS provided by the campaigns to prevent infection. The use of condoms to prevent infection is still a male decision. Women are rarely have the opportunity to with professionals, to expose their questions and plan their reproductive lives more safely. In this setting of lack ofparticipation on treatment planning, delivery or baby care, women follow the \"prescription\" and move on with their fears and doubts