Previous research has shown that excessive cardiovascular reactivity may be important in the development of coronary heart disease. The present study examines the role of masculine cognitive appraisal of stress as a mediator of cardiovascular reactivity in men. The reactivity of men who differed on a measure of cognitive appraisal of masculine gender role stress (MGRS) was compared using the cold-pressor test under conditions of high and low masculine performance challenge. Under conditions of minimal challenge, it was predicted that high and low MGRS men would not differ on reactivity. Under high challenge, high MGRS men were expected to show greater reactivity than low MGRS men. Since coping responses are related to appraisal of stressful situations and impact on cardiovascular reactivity, subjects' coping responses were also assessed. Analysis of results for systolic blood pressure confirmed the major predictions. High MGRS men showed greater systolic blood pressure reactivity than low MGRS men under high challenge and equal or less reactivity under low masculine performance challenge. In general, the high and low MGRS groups did not differ in their use of coping strategies as a function of the high and low challenge condition. The implications of MGRS appraisal for men's health are discussed. / Master of Science

Aim 1. Accelerated antiretroviral therapy (ART) initiation, including starting ART on the day of HIV diagnosis, has emerged to be one of the approaches to improve ART uptake by shortening or removing some preparatory steps before ART initiation. By doing so, accelerated ART initiation is thought to remove some structural barriers associated with ART initiation process. However, several concerns still need to be addressed, such as whether the expedited process would lead to adverse treatment outcomes after ART initiation. Searched strategy was developed using both MeSH and free text terms relevant to accelerated ART initiation (same-day, immediate, rapid). Exclusion criteria were studies that did not focus on HIV, did not involve HIV treatment, included individuals with HIV aged lower than 12, and contained non-human subjects. Additionally, we excluded articles that were case-reports, qualitative studies, systematic reviews, commentary, points of view, and conference presentations. Four electronic databases (PubMed, Embase, Web of Science, MEDLINE) were used to identify relevant studies published in English between January 2015 and December 2023. Outcomes were retention, viral suppression, pre-ART screening procedures, preferred baseline antiretroviral regimens, additional baseline medications, and adverse events after ART initiation. Two independent researchers were involved in the study selection process. Of 5,455 studies retrieved, 25 studies were included in the review (Cohen’s kappa: 0.88). Six studies reported findings from randomized controlled trials conducted in Lesotho (n=2), Haiti (n=1), South Africa (n=3), and Kenya (n=1), with one study conducted in both South Africa and Keya; 19 studies were observational cohort study from Ethiopia (n=4), West Africa (n=1), Italy (n=2), the United States (n=3), South Africa (n=3), Kenya (n=1), Rwanda (n=1), Sub-Saharan African region (n=1), the United Kingdom (n=1), Turkey (n=1), and China (n=1). The majority of the studies were conducted in urban areas (n=19). Of the 25 included studies, 19 had same-day ART initiation as the intervention or the exposure (three studies measured the time to ART initiation from the day of care engagement, and 16 studies measured it from the day of HIV diagnosis). There was heterogeneity in the pre-ART screening procedures, from relying on symptomatic screening and history assessment to using non-molecular rapid tests to help identify individuals with increased risk of clinical contraindications. Despite this, individuals with symptoms consistent with WHO stage 4 neurological diseases were not eligible for ART. Efavirenz-based ARV was the most regimen reported. The majority of PWH preferred to start ART within 7 days of HIV diagnosis or care engagement (range: 56.5%-86%). Our review suggested mixed results on retention in care and viral suppression after ART initiation, although many studies indicated potential benefits. Despite this, no study reported an association between clinical adverse events, including deaths, and accelerated ART initiation. Our review suggested that accelerated ART initiation can potentially increase ART uptake while not negatively impacting treatment outcomes in some settings. New tools in HIV treatment, such as safer drug regimens and injectable ART, may help improve PWH’s experience and reduce the burden associated with pill burden and frequent clinic visits. Aim 2. Accelerated antiretroviral therapy (ART) initiation has been proposed to address some structural barriers associated with the ART initiation process and improve ART uptake. Despite this, there has yet to be a consensus on how this approach should be implemented, especially concerning the clinical readiness screening procedures. While emerging literature has reported the clinical safety of accelerated ART, limited data are reported from Thailand. Given the heterogeneity of clinical profiles of people with HIV (PWH) in different regions, past studies may not be generalizable to Thailand. Additionally, as different screening procedures affect the time to ART initiation, we need to learn how these procedures impact treatment outcomes. Data were obtained from PWH from 10 ART facilities in six provinces (Chiang Rai, Chiang Mai, Chonburi, Ubon Ratchathani, Songkhla, and Bangkok) in Thailand between July 2017 and July 2019 and followed up until January 2021. All PWH registered in HIV care were included in the analysis, regardless of baseline clinical status. ART facilities were categorized into three models according to the hospital policy on pre-ART laboratory screening procedures: Model A did not consider any lab results at the initiation, Model B considered only CD4 count, and Model C considered other non-CD4 baseline laboratory results. Log-Poisson regression was used to assess the impact of hospital policies on adverse outcomes (deaths, ART discontinuation, loss to follow-up) at months three, six, 12, 18, and 24 after care engagement. Logistic regression was used to examine the impact of hospital policies on viral non-suppression (VNS, HIV-1 RNA>50 copies/mL) at months six, 12, and 18 after ART initiation. Multilevel mixed model was used to account for potential clustering within each hospital policy. Of 10,926 PWH in the dataset, 9,695 (88.7%) were included in this study. Among these, 68% (6,571/9,695), 13% (1,236/9,695), and 19% (1,888/9,695) were in Models A, B, and C, respectively. Both Models A and B had 2 ART facilities each, while Model C had 6 ART facilities. 54.2% (5,257/9,695) self-reported to be men who have sex with men, and the overall baseline median CD4 (IQR) was 168 (129-404) cells/mm3. Compared to Model A, the average risk ratio (95%CI) of adverse events at months three, six, 12, 18, and 24 for Model B was 1.14(1.08-1.20), 1.40(1.31-1.49), 1.19(1.10-1.27), 1.11(1.02-1.21), and 1.32(1.21-1.44), respectively, while it was 1.21(1.16-1.27), 1.76(1.67-1.85), 1.59(1.50-1.67), 1.81(1.71-1.90), and 1.98(1.88-2.10) for Model C, respectively. Of 9,695 PWH, 6,785 (70%) had a confirmed date of ART initiation; 37% (2,513/6,785), 34% (2,332/6,785), and 13% (851/6,785) PWH had information on viral load status at months six, 12, and 24 after ART initiation, respectively. Among these samples, compared to Model A, the average odds ratio (95%CI) of VNS for Model B at months six, 12, and 18 was 0.79(0.59-1.06), 1.06(0.71-1.55), and 1.47(0.49-3.58), respectively, while it was 1.01(0.77-1.32), 0.68(0.40-1.09), and 0.93(0.31-2.22) for Model C, respectively. ART facilities that considered CD4 or any other non-CD4 baseline laboratory results before starting ART had, on average, a higher likelihood of adverse outcomes after the initial care engagement visit and viral non-suppression after ART initiation than ART facilities that did not consider any baseline laboratory result. Aim 3. Clinical screening and psychosocial readiness assessments prior to antiretroviral therapy (ART) initiation are imperative to ensure clinical safety and ART adherence among people with HIV (PWH). However, multiple preparation steps and long wait times associated with ART initiation can contribute to HIV care disengagement and low ART uptake. To address some of the barriers associated with lengthy assessment process, accelerated ART initiation, an approach to start ART on or near the day of HIV diagnosis, has been proposed. Despite this, concerns with the expedited preparation process remain, especially with the PWH’s readiness to have optimal HIV care adherence. This study examined the impact of time to ART initiation on adverse outcomes after care engagement and viral non-suppression (VNS) after ART initiation among PWH in Thailand. Data were obtained from PWH from 10 ART facilities in 6 provinces (Chiang Rai, Chiang Mai, Chonburi, Ubon Ratchathani, Songkhla, and Bangkok) in Thailand between July 2017 and July 2019 and followed up until January 2021. PWH who tested negative for cryptococcal antigen test at baseline and had a confirmed date of ART initiation were included in the analysis and were categorized into three groups based on the time interval between care engagement (defined as the day that PWH first registered at an ART facility) and ART initiation: (1) same day (ART initiation upon the day of care engagement or same day), (2) 1-7 days, and (3) more than 7 days. Log-Poisson regression was used to assess the impact of time to ART initiation on adverse outcomes (deaths, ART discontinuation, and loss to follow-up) at months three, six, 12, 18, and 14 after care engagement. Logistic regression was used to examine the impact of time to ART initiation on VNS (HIV-1 RNA>50 copies/mL) after ART initiation at months six, 12, and 18 after ART initiation. Age, population, hospital policy on pre-ART screening procedures, and baseline CD4 were adjusted in the final models. Of 10,926 PWH in the dataset, 5,528 (50.6%) had complete information on the date of care engagement, negative results for the cryptococcal antigen test, and the date of ART initiation. Among these, 44.23% (2,445/5,528), 38.69% (2,139/5,528), and 17.08% (944/5,528) started ART on the day of, 1-7 days from, and more than 7 days from HIV care engagement visit, respectively. The median age (IQR) was 29 (24-36) and 61% (3,387/5,528) identified themselves as men who have sex with men. The baseline median CD4 (IQR) was 283 (162-412) cells/mm3. Compared to PWH who started ART on the day of HIV care engagement visit, the average risk ratio (RR) of adverse outcomes for those who started ART between 1-7 days at months three, six, 12, 18, and 24 was 0.73(0.60-0.89), 0.66(0.55-0.79), 0.74(0.63-0.86), 0.83(0.71-0.98), and 0.84(0.70-1.01), respectively, while it was 2.27(1.91-2.71), 2.16(1.85-2.52), 1.70(1.46-1.98), 1.93(1.65-2.25), and 2.83(2.44-3.30) for those who started ART more than 7 days, respectively. In the adjusted models, the associations from both groups became statistically non-significant, except for the more than 7 days at month 24 (adjusted RR:1.08; 95%CI:1.04-1.12). Of 5,528 PWH, 29% (1,616/55,28), 36% (1,967/5,528), and 14% (795/5,528) had information on viral load status at months six, 12, and 18 after ART initiation, respectively. Among these individuals, time to ART initiation was determined to have no impact on VNS in both crude and adjusted models. Accelerated ART initiation has the potential to improve ART uptake while maintaining optimal adherence to HIV care. However, HIV programs should recognize and respond to the diversity of needs among PWH to minimize adverse outcomes following ART initiation.

Background: The purpose of this research was to examine how the Three Bridges Community Health Centre conceptualizes and addresses the issue of accessibility for gay men. This research explored the intersection and disjuncture of how accessibility for gay men is understood and practiced from multiple perspectives (staff and clients). It revealed perceived and real barriers and opportunities for gay men in accessing health services, and provides insight into the mechanisms Three Bridges Community Health Centre employs to provide comprehensive health care to a local population that is not easily identifiable. Methods: Case study is the central defining methodological feature of this research. This study applies both inductive and deductive approaches. The data are qualitative, derived from 14 semi-structured interviews, document analysis (25 documents with a total of 398 pages) and participant observation (approximately 33 hours). Analysis and interpretation of the data were accomplished through the various procedures and techniques associated with qualitative data analysis, including the use of a qualitative software package - NUD*IST 4.0. Results: The study revealed twelve main factors that facilitate (and obstruct) accessibility for gay men. They were developing a mission of accessibility for vulnerable populations; assessing gay men's health issues, barriers and needs; utilization of the clinic; delivery of appropriate programs and services; available providers with appropriate knowledge, attitudes and behaviour; cultural accessibility (e.g., gay-friendly environment, multiple languages); geographic accessibility (location); physical accessibility (architecture); financial accessibility (affordability); functional accessibility (convenience); awareness (marketing & publicity of services and location); and partners in accessibility (e.g., community, health authorities, government). Each section of this chapter details how Three Bridges addresses each of these elements (the strengths), the challenges (e.g., time, money and personnel) in addressing these issues, as well as suggestions for improving accessibility. These factors would also be relevant for any primary care setting about to embark upon an examination of how (well) it addresses access for gay men, and other vulnerable populations. Conclusions: Partnerships with community-based agencies and recruitment of queer staff are critical in creating cultural accessibility for queer people. Many of the challenges raised by staff need to be addressed at a policy, region-wide level. Cultural accessibility for queer people also needs to be addressed by other healthcare settings.

BACKGROUND The coverage of HIV/AIDS behavioral surveillance among MSM in China falls far short of what is necessary as the current approach is expensive and time consuming. In addition MSM are difficult to reach in China. Internet-based behavioral surveys have demonstrated a number of advantages compared with the traditional paper-pen method. Chinese MSM are avid users of the Internet. Use of the internet provides an opportunity to access this hard-to-reach population and explore their use of the Internet for sexual purposes as well as to assess risk behaviors among MSM internet users. This thesis aimed to explore the trends in risk behaviors and HIV prevalence among MSM using traditional community-based surveys and Internet surveys, and to analyze the potential of web-based behavioral surveillance among MSM by comparing the differences between Internet and community-based MSM samples, and then to provide insights for the future HIV/AIDS behavioral surveillance, epidemic estimation and prediction as well as health intervention among the Chinese MSM population. METHODS This study has three components. The first focuses on trends in HIV risk behaviors and prevalence among MSM in Harbin in northeast China, based on community-based surveys. Eligible participants were approached by peer recruiters in traditional gay venues and then interviewed by health professionals with a standard questionnaire. Urine samples were collected to screen their HIV status. The second part presents two cross-sectional, Internet-based surveys among MSM in China in 2006 and 2007. The study website was advertised on three selected gay websites using a series of banners, pop-ups and text notifications. After providing consent to the survey, eligible participants were invited to complete an online questionnaire. The third component compares the demographic characteristics and risk behaviors of two samples of Chinese MSM. Participants living in Heilongjiang Province were extracted from the 2006 online survey dataset to compare with the community sample of MSM recruited in Harbin, the capital city of Heilongjiang Province in the same year. KEY FINDINGS Community-based behavioral surveillance Among MSM in Harbin, a trend was observed towards more self-identifying as homosexual (from 58% to 80%) and more living with a male partner (from 12% to 41%) over the study period 2002-06. Although there was a trend towards a reduction in the rate of never using a condom and an increase in the rate of always using condoms during anal sex in the past six months, the prevalence of unprotected anal intercourse (UAI) still remained at high level (from 90% in 2002 to 72% in 2006). Most respondents reported having multiple male sexual partners (≥ 2) in the past six months: 86.5% in 2002, 76.0% in 2004 and 91.6% in 2006. The HIV prevalence (2.2%, 15/674) among MSM in Harbin in 2006 was higher than that in previous survey years (1.3% in 2002 and 0.94% in 2004), but no statistically significant change was detected. Internet-based behavioral surveys Gay website users in China are young and well educated. The majority (85%) have used the Internet to seek sex and meeting sexual partners online, which is one of the most common reasons for visiting gay websites. Traditional gay venues still play an important role in the sex seeking process, especially for MSM who are older and less educated. Gay website users are vulnerable to HIV/AIDS given their high prevalence of UAI (56.6%) and multiple male sexual partners (66.5%). The type of partners plays an important role in determining consistent condom use. An increase in condom use was observed among MSM having sex between commercial partners relative to those having sex with non-regular partners and regular partners. Among the Internet sample, participants who have regular partners are less likely to have sex with females, less likely to have multiple partners and less likely to engage in commercial sex behaviors than those who do not. Comparisons between Internet and community samples There are significant differences in terms of demographic characteristics and risk behaviors between the Internet and community samples of MSM. The Internet sample was significantly younger, more educated and more likely to be students and self identify as homosexual. Among those who had anal sex in the past six months, the Internet sample tended to use condoms less consistently than the community sample. However, using the total sample size as the denominator to calculate the prevalence of UAI, no significant difference between the two samples was observed (AOR 1.02, CI 0.73-1.43, p = 0.905). After adjusting for differences in demographic characteristics, the community sample was more likely to have had sex with females (AOR 2.01, CI 1.22-3.30, p = 0.006) and have had ≥ 6 male partners in the previous six months than the Internet sample (46.1% vs. 20.2%; AOR 4.88, CI 3.51-6.80, p < 0.001). The mean number of male partners for the community sample was 13.5 ± 16.8, whereas it was 6.0 ± 12.2 for the Internet sample. CONCLUSIONS Although there is a trend towards an increase in condom use among MSM in China, they are vulnerable to HIV/AIDS infection given their high prevalence of UAI and multiple sexual partners. Public sector officials at all levels need to recognize this risk for HIV transmission. Health promotion and behavioral interventions should be enforced and scaled up to meet the need for controlling HIV transmission among MSM in China. Since the Internet has become a risk environment for MSM and the online MSM population is significantly different from the traditional community MSM group, online MSM should be included as a risk group in national HIV sentinel and behavioral surveillance and the coverage of surveillance for this specific group should be expanded to better understand the health promotion needs of this community as part of an HIV/AIDS strategy in China. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1339648 / Thesis (Ph.D.) - University of Adelaide, School of Population Health and Clinical Practice, 2008

Background: The purpose of this research was to examine how the Three Bridges Community Health Centre conceptualizes and addresses the issue of accessibility for gay men. This research explored the intersection and disjuncture of how accessibility for gay men is understood and practiced from multiple perspectives (staff and clients). It revealed perceived and real barriers and opportunities for gay men in accessing health services, and provides insight into the mechanisms Three Bridges Community Health Centre employs to provide comprehensive health care to a local population that is not easily identifiable. Methods: Case study is the central defining methodological feature of this research. This study applies both inductive and deductive approaches. The data are qualitative, derived from 14 semi-structured interviews, document analysis (25 documents with a total of 398 pages) and participant observation (approximately 33 hours). Analysis and interpretation of the data were accomplished through the various procedures and techniques associated with qualitative data analysis, including the use of a qualitative software package - NUD*IST 4.0. Results: The study revealed twelve main factors that facilitate (and obstruct) accessibility for gay men. They were developing a mission of accessibility for vulnerable populations; assessing gay men's health issues, barriers and needs; utilization of the clinic; delivery of appropriate programs and services; available providers with appropriate knowledge, attitudes and behaviour; cultural accessibility (e.g., gay-friendly environment, multiple languages); geographic accessibility (location); physical accessibility (architecture); financial accessibility (affordability); functional accessibility (convenience); awareness (marketing & publicity of services and location); and partners in accessibility (e.g., community, health authorities, government). Each section of this chapter details how Three Bridges addresses each of these elements (the strengths), the challenges (e.g., time, money and personnel) in addressing these issues, as well as suggestions for improving accessibility. These factors would also be relevant for any primary care setting about to embark upon an examination of how (well) it addresses access for gay men, and other vulnerable populations. Conclusions: Partnerships with community-based agencies and recruitment of queer staff are critical in creating cultural accessibility for queer people. Many of the challenges raised by staff need to be addressed at a policy, region-wide level. Cultural accessibility for queer people also needs to be addressed by other healthcare settings. / Education, Faculty of / Educational Studies (EDST), Department of / Graduate

Submitted by Biblioteca Central (biblioteca@unicap.br) on 2018-10-04T18:42:45Z No. of bitstreams: 2 fernanda_azevedo_lima.pdf: 2240991 bytes, checksum: bd47c577028df724ffa125f0575a331e (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2018-10-04T18:42:45Z (GMT). No. of bitstreams: 2 fernanda_azevedo_lima.pdf: 2240991 bytes, checksum: bd47c577028df724ffa125f0575a331e (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2018-06-18 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / The purpose of this thesis was to problematize how men build subjectively with prostate cancer being crossed by different real discourses about masculinity. There for, a qualitative empirical research was carried out, with eleven subjects diagnosed with this type of cancer and using the urology services of two hospitals: a private one and a public one settled down in the city of Recife. Some ethnographic resources were used, from the following instruments: the Narrative Interview and the Field Diary. The results were analyzed through Foucault's Enunciative or his Discursive Analysis, which aims to understand a set of conditions of existence that make possible the construction of a datum phenomenon. This author problematized his objects of study, starting from the historical conditions in which they emerged and understood the subject as an inhabitant crossed by the relations of knowledge, power and the ethics of a historical moment. In this thesis, the concept of hegemonic masculinity was considered, holding it as a discourse, according to Foucault, who reckons it a set of knowledges that function as truths. The results of this study point to a thin line between subjection and resistance to the discourses that circulate in our society, in the way these men are constituted and in the positions of subject that they assume. When it comes to health care, our interviewees assume positions of subject dependent on their own women, crossed by speeches that it is from the "nature" of the woman to take care of husbands and children. On the other hand, the strong man's discourse is used to ground the position of male domination about the female. Speeches about what they are allowed to do to be considered "males" lead these men not wanting to perform the rectal examination. They narrate the fear that, in making such an examination, they become "familiarized", which is associated with homosexuality. However, the discourses that circulate in a certain society, and ours is no exception, are multiple and almost always contradictory. The presence of programs that encourage human health care, PNAISH and the Campaign Blue November Campaign, call men to self-monitoring, and configure control and power over their lives (biopower and biopolitics). These discourses emerge as imperatives in building a culture of health care and, thus, other seemingly contradictory subject positions are assumed, it is 'obligatory' to take care of health and to be healthy. In addition, when medical guidance is not engaging in sex, it leads them to a reductionist understanding of human sexuality; sex is understood only as intercourse. It indicates a vigilant, normalized and controlled sexuality, with "truths" imposed by diverse knowledge, without problematizing these discourses. Finally, it was found that, despite cancer, being culturally a stigmatized disease associated with death, it was possible for some of these men to resist, not only believing in the possibility of cure, but constructing other ways of existing, an aesthetics of existence. / O objetivo desta tese foi problematizar como os homens se subjetivam tendo câncer de próstata sendo atravessados por diferentes discursos de verdade sobre a masculinidade. Para isso, realizou-se uma pesquisa empírica qualitativa, com onze sujeitos diagnosticados com esse tipo de câncer e que estavam utilizando os serviços de urologia de dois hospitais: um particular e um da rede pública da cidade do Recife. Utilizaram-se alguns recursos etnográficos, a partir dos seguintes instrumentos: a Entrevista Narrativa e o Diário de Campo. Os resultados foram analisados por meio da Análise Enunciativa ou Discursiva de Foucault, a qual visa compreender um conjunto de condições de existência que possibilitam a construção de um dado fenômeno. Este autor problematizava seus objetos de estudo, a partir das condições históricas em que eles emergiam e compreendia o sujeito como habitante atravessado pelas relações de saber, poder e da ética de um momento histórico. Trabalhou-se, nesta tese, com o conceito de masculinidade hegemônica, considerando-a um discurso, de acordo com Foucault, que o considera um conjunto de saberes que funcionam como verdades. Os resultados deste estudo apontam para uma tênue linha entre sujeição e resistência aos discursos que circulam em nossa sociedade, no modo como estes homens se constituem e nas posições de sujeito que assumem. Quando se trata dos cuidados com a saúde, nossos entrevistados assumem posições de sujeito dependentes de suas mulheres, atravessados pelos discursos de que é da “natureza” da mulher cuidar de maridos e filhos. Por outro lado, o discurso do homem forte é usado para embasar a posição de dominação masculina sobre o feminino. Discursos sobre o que lhes é permitido fazer para serem considerados “machos”, levam estes homens a não querer realizar o exame de toque retal. Narram o receio de, ao fazer tal exame, ficarem “acostumados”, o que é associado à homossexualidade. Porém, os discursos que circulam em uma sociedade, e a nossa não é exceção, são múltiplos e quase sempre, contraditórios. A presença de programas que incentivam os cuidados com a saúde do homem, PNAISH e a Campanha Novembro Azul, convocam os homens à autovigilância, e configuram controle e poder sobre suas vidas (biopoder e biopolíticas). Estes discursos emergem como imperativos na construção de uma cultura de cuidados com a saúde e, desta forma, outras posições de sujeito, aparentemente contraditórias, são assumidas, é “obrigatório” cuidar da saúde e ser saudável. Além disso, quando a orientação médica é a de não praticar sexo, leva-os a um entendimento reducionista da sexualidade humana, sexo é entendido apenas como o coito. Isso aponta para uma sexualidade vigiada, normatizada e controlada, “verdades” impostas por saberes diversos, sem problematização desses discursos. Por fim, percebeu-se que, apesar do câncer ser, culturalmente, uma doença estigmatizada associada à morte, foi possível, para alguns desses homens, resistir, não somente acreditando na possibilidade de cura, mas construindo outros modos de existir, uma estética da existência mais própria.

A dissertation submitted to the Faculty of Humanities, in fulfilment of the requirements for the degree of Masters of Arts in Journalism and Media Studies at the University of the Witwatersrand in 2016 / The research set out to investigate how the Voluntary Medical Male Circumcision (VMMC) programme in South Africa facilitated stakeholder participation in its communication processes to improve the uptake of services in the context of national targets. Studies reviewed have highlighted challenges in the implementation of the participatory model to achieve communication goals. This qualitative study used document analysis, in-depth interviews and Focus Group Discussions (FGDs) for data collection. The research has revealed other limiting factors including unequal opportunities to influence decisions as a result of varying levels of authority and access to mediated public spheres. While those with power end up being further empowered through participatory approaches in terms of voice and visibility, the representation of the inputs of the lower level stakeholder group is limited to head count. A five-day visit to a VMMC clinic in Alexandra Township attributes marginalisation by exclusion from decision-making processes as one of the reasons for people’s inability to translate knowledge into the positive public response. The study was inconclusive about the influence of the model on the actual service uptake because the purpose was to provide a textual description of the participants’ experiences and not the impact. / XL2018

Renewed efforts are needed to address rapidly rising HIV incidence among sexual and gender diverse (SGD) individuals—particularly cisgender gay, bisexual, and other men (MSM) and transgender and nonbinary individuals (TSM) who have sex with men—in Kazakhstan. Intervention research is uniquely positioned to advance HIV prevention through surveying factors shaping the HIV epidemic among MSM and TSM in Kazakhstan, developing and testing the effects of an HIV prevention intervention, and assessing overall social impacts of conducting research. This research proceeded to describe strategies and lessons learned during implementation of a stepped wedge clinical trial of an intervention designed to increase the number of MSM and TSM in the HIV care continuum in Kazakhstan cities of Almaty, Shymkent, and Nur-Sultan. Thus, this three-paper dissertation aimed to: (1) identify psychosocial factors associated with lifetime, past-12-month, and past-6-month HIV testing among a sample of MSM and TSM enrolled in the clinical trial; (2) describe the process of implementing remote training of facilitators for remotely delivering the HIV preventive intervention; and (3) assess social impacts of participating in the clinical trial. MSM and TSM from the study cities were recruited into the clinical trial and administered a structured behavioral survey at their primary visit and at follow-up visits every six months thereafter. After a period of no intervention implementation (‘pre-implementation period’), the intervention was implemented sequentially every six months in the study cities. Among 304 MSM and TSM enrolled in the clinical trial during the pre-implementation period, lifetime and past-12-month HIV testing were positively associated with polydrug use and negatively with sexual transmission HIV risk, and past-6-month HIV testing was negatively associated with sexual risk. The process of developing and implementing remote training of facilitators was guided by a protocol outlining phases involving formative assessment and planning, fundamentals training, and feedback loop and technical assistance. Out of 627 MSM and TSM who completed their primary assessment during the clinical trial, 579 (92%) returned for at least one follow-up visit; of these individuals, 88% reported at least one positive social impact, while 2% reported at least one negative social impact. Findings underscore the value of expanding access to substance use treatment for HIV prevention among MSM and TSM in Kazakhstan, the viability of remote training of facilitators for remote intervention delivery, and the feasibility of conducting HIV prevention research involving MSM and TSM with many benefits and few risks.

In this dissertation I examine the influence and impact of consumer politics in the first five years of the AIDS epidemic. Using historical methodologies and leveraging a range of archival materials alongside scholarly and journalistic accounts of the era, I argue that gay men and People with AIDS deployed critical medical consumerism in their earliest responses to the disease. The politics of People with AIDS challenged the normative understanding of the sick by the medical and public health professions that claimed authority to shape the response to the AIDS epidemic. In the context of AIDS, this authority was shared with the gay and lesbian organizations that responded to the epidemic on behalf of the gay and lesbian community. People with AIDS wanted more power in each of these encounters. Living with AIDS involved numerous complex networks of medical, clinical, and care service relationships. In the context of America’s for-profit healthcare and service system and given the social service orientation of community-based responses, they positioned themselves as consumers. I examine the influence and impact of critical medical consumerism in the founding of the earliest AIDS service organizations, the earliest writing by people with AIDS in New York City, the emergence of political organizing among People with AIDS and their allies and its impact on the closure of the New York City bathhouses, the creation of community-based clinical research organizations and the founding of the well-known direct-action group, ACT UP. Critical medical consumerism appeared both as a way of generating and sharing information among People with AIDS, and a language of critique by People AIDS of the community and government responses to the epidemic. Through the lens of consumer politics, I also reexamine well historicized moments in this history, providing a more complex history to a founding document in the politics of AIDS, The Denver Principles. In this dissertation, I conclude that consumer politics is an essential political, social, and cultural lens through which People with AIDS understood the epidemic, though it is not without its limits. In the final chapter, I examine possibilities of future research in this field and the limitations of consumer politics for both the historical actor who deployed it, and for historians who examine this period of history.

Thesis (D. Tech.) -- Central University of Technology, Free State, 2009