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

Mild Traumatic Brain Injury (mTBI), often called concussion, has become a growing public health concern, prevalent in both athletic and military settings. In response, many researchers have explored cognitive outcomes post-mTBI, with a plethora of meta-analyses summarizing these findings; however, these meta-analyses examine solely mean performances on cognitive tasks, ignoring intra-individual variability (IIV) in cognitive performance that may elucidate neuropsychological impairment following mTBI. The current thesis involved two studies, responding to both the growing meta-analytic research and limited IIV findings. Study 1: Many meta-analyses have amalgamated individual study results on post-mTBI neuropsychological outcomes. With the abundance of meta-analyses, a systematic review of meta-analyses stands as the next logical step. Method: A systematic literature search yielded 11 meta-analyses meeting inclusion criteria (i.e., English-language systematic reviews/meta-analyses covering post-mTBI observational cognitive research on late adolescents/adults), with their findings qualitatively synthesized based on moderator variables (i.e., cognitive domain, time since injury, past head injury, participant characteristics, comparison group, assessment technique, and persistent symptoms). Results: The overall effect sizes ranged for both general (range: .07-.61) and sports-related mTBI (range: .40-.81) and differed both between and within cognitive domains, with executive functions appearing most sensitive to multiple mTBI. Cognitive domains varied in recovery rates, but overall recovery occurred by 90 days post-injury for most individuals and by seven days post-injury for athletes. Greater age/education and male gender produced smaller effects sizes, while high school athletes suffered the largest deficits post-mTBI. Control-group comparisons yielded larger effects than within-person designs, while assessment techniques had limited moderating effects. Conclusions: Overall, meta-analytic review quality remained low with few studies assessing publication or study quality bias. Meta-analyses consistently identified adverse acute mTBI-related effects and fairly rapid symptom resolution. Study 2: The long-term outcomes of executive functions and IIV following mTBI are unclear due to inconsistent and limited research, respectively. Further, the relationship between physical activity (PA) and cognitive performance at young adulthood remains almost fully unexplored. In turn, the current study aimed to (a) assess the diagnostic utility of both executive functions and IIV at predicting mTBI history and (b) evaluate the interaction between PA levels and mTBI on both of these cognitive metrics. Method: Altogether 138 self-identified athletes (Mage = 19.9 ± 1.91 years, 60.8% female, 19.6% 1 mTBI, 18.1% 2+ mTBIs) completed three executive-related cognitive tasks (i.e., N-Back, Go/No-go, Local-Global). Ordinal logistic regression analyses examined the joint effect of person-mean and IIV as predictors of mTBI status. Multi-level models examined mTBI and PA levels as predictors of trial-to-trial changes in performance. Results: Only mean response time (RT) for the Local-Global task predicted mTBI status, while no IIV variables reached unique significance. PA levels predicted subtle within-task decreases in RT across Local-Global trials. Conclusions: IIV research on mTBI remains limited; however, the preliminary results do not indicate any additional predictive value of IIV indices above mean performances. For executive functions, shifting appeared most affected, with past researchers identifying post-mTBI impairment in attentional processing. Higher PA levels minutely benefited within-task shifting and mean inhibitory performance, although these finding require cautious interpretation. / Graduate / 0622 / jkarr@uvic.ca

The innate immune system is a critical first line of defense against invading pathogens. Innate immunity directly detects pathogens, sets up an appropriate adaptive response, and can directly kill pathogens. Drosophila may lack an adaptive immune response, but have a robust innate immune system with a variety of defense effector mechanisms. While the responses to bacteria, fungi, and RNA viruses have been well characterized, not much is known about the response to DNA viruses. My studies have set out to characterize the Drosophila immune response to a DNA virus, utilizing the large dsDNA virus, Invertebrate Iridescent Virus 6 (IIV-6). IIV-6 infection causes shortened lifespan, and in later stages of infection, flies present with abdominal swelling and iridescent blue color. Our objectives were to identify pathways flies use to protect themselves from IIV-6 infection, determine how this protection is mediated, and to identify any immune inhibitors that IIV-6 uses to suppress innate immune signaling. I have found that IIV-6 strongly up-regulates a class of stress proteins with unknown function, termed Turandots, after infection in vivo or in vitro. This induction is dependent upon viral replication, requires JAK-STAT activation, and activation of p38b MAPK. In addition, the unpaireds, which function as JAK-STAT ligands, are upregulated after IIV-6 infection in a p38b-dependent manner. Together, this data suggests that p38b activation leads to production of unpaired cytokines and activation of JAK-STAT signaling to induce Turandots. I have also found that IIV-6 infected cells secrete protective factors. This response is induced within 12 hours of IIV-6 infection, exosome-mediated, and provides robust protection to naive cells challenged with an mCherry-expressing strain of IIV-6. Additionally, IIV-6 inhibits two major immune responses in Drosophila, the IMD and Toll pathways. Stimulation of IIV-6 infected Drosophila S2* cells with either IMD or Toll stimulators results in very poor antimicrobial peptide responses. Yet, IMD and Relish are still cleaved upon stimulation in IIV-6 infected cells, indicating that the block is downstream. In support of this finding, IIV-6 infected flies respond very poorly to infection with the enterobacteria Erwinia carotovora carotovora compared to mock-injected flies.