Magister Public Health - MPH / Background: STIs are of major public health concern in developing countries, not least because they facilitate transmission of HIV, but also because they are important causes of mortality and morbidity among African populations, resulting in, among other things, adverse birth outcomes, neonatal and infant infections, ectopic pregnancy, anogenital cancer,infertility, pelvic inflammatory disease, and death. Thus, effective treatment needs to be prompt and accurate to control the spread, and morbidity and mortality of STIs. Even though syndromic approach to the management of STIs is effective, most evaluations have focused on syndromic STI management within STI clinics as opposed to research studies. Partner notification is an integral component of the syndromic approach and is aimed at preventing onward transmission of infection as well as re-infection. It includes informing sexual partners of infected people of their exposure, administering presumptive treatment, and providing advice about the prevention of future infection.Methods: This is a cross sectional descriptive study based on a retrospective review of STI data of study participants in KICoS aged 18 to 34 years. A non probability convenience sampling method was used to recruit study participants. A total of 1,277 participants were prescreened into KICoS of whom 847 were enrolled into this study. Data was collected using CAPI and ACASI questionnaires as well as Teleforms which was analysed in SAS for windows 9.1. Results: Syndromic prevalence of STIs was 5.7% while the aetiological prevalence was 32.8%.Risk factors to STI acquisition included, being female, having multiple sexual partners,having lower than tertiary education, using recreational drugs and being HIV. Agreement between the interviewing methods as well between the syndromic and laboratory diagnosis ranged from fair to substantial. This was also true for the agreement between laboratory and CAPI as well as between the laboratory and ACASI. Sensitivity was generally low while specificity was high. Uptake of contact tracing cards was high though with very low uptake of contact treatment with only 2.1% and 0.4% partners of the syndromically and aetiologically diagnosed participants coming for treatment.Conclusions: STI is a problem in this community and thus there should be more emphasis on risk reduction messages in patient education to mitigate the spread of STIs. The performance of syndromic management was very poor against the aetiological diagnosis thus there needs to further review the use of syndromic diagnosis of STIs in research settings. Partner tracing needs to be intensified since there was very poor partner treatment even with high uptake of contact cards.Acknowledgements: This study would have not been what it was without the immense support I received from many individuals all of whom cannot be mentioned here. I would however want to thank the Dr Wairimu Chege (Principal Investigator, KICoS) for her inspiration and encouragement. I would also like to thank my supervisor, Ernie Kunneke for going through this study with me repeated times including on a ride to the airport. On the same note I would also like to thank my lecturers and student administrators at the SOPH. My gratitude also goes to my colleagues Richard Ndivo, Sherri Pals and Eleanor McLellan-Lemal for all the support they accorded me throughout this research.I would also want to give my heartfelt gratitude to my family. My daughter Akinyi who used to type with me at night, her mother Auma for understanding my late nights up and finally to my Parents Mr and Mrs Gideon and Monica Otieno for understanding the importance of education and taking me to school through all the difficulties. Last but not least I would like to express my gratitude to the almighty God for having seen me through this process.

Recent findings by Public Health Ontario (PHO) state that there were approximately 36, 346 confirmed cases of chlamydia in Ontario as of 2011. This represents an incidence rate that increased by 54% since 2006 rising from 177 to 272 per 100,000 in 2011. National rates only increased by 38% (210 to 290 per 100,000), meaning that Brant County rates surpassed both, increasing by over 100% (150 to 395 per 100,000). The main objective of this series of manuscripts is to develop a clear profile of re-infected individuals in comparison to non-repeaters, while considering co-infections wit gonorrhea. The secondary objective was to determine the sexual network as well as spatial distribution patterns of cases in Brant County. The study period is from January 1st, 2006 until December 31st, 2015, Data were extracted from the integrated public health information system (iPHIS). Basic descriptive statistics will be performed followed by a Cox-regression analysis in order to compare individuals who are repeaters with those who are not repeaters. Within the study period, there were 2,829 cases of chlamydia and 328 were reinfections. We identified twelve hotspots with high chlamydia infection rates of which, 58 per cent occurred within the previously identified core group, in the urban core of Brant County.

This thesis is devoted to general practice (GP) networks in Belgium, their development and their activities within the Belgian health system context. These networks are specific research tools for the repeated or continuous collection and analysis of data related to diseases and other health events observed in general practice, including interventions of general practitioners. The thesis focuses on three not-for-profit general practice research networks which are operational today: (1) the national Network of Sentinel General Practices (SGP), coordinated by the Federal research institute Sciensano; (2) the Flemish Intego network, coordinated by the Academic Center for General Practice of Catholic University Leuven; (3) the network of the Fédération des maisons médicales et des collectifs de santé francophones (FMM) with its Monitoring Chart (Tableau de bord), which collects data from Wallonia and the Brussels-Capital Region. The thesis is divided into a general introduction, three main parts and a final discussion with concluding remarks. The general introduction outlines the importance of data from general practice and the contribution of GP networks to research. Furthermore, it points out the importance of general practice for the control of sexually transmitted infections (STIs), a specific field of action. The first main part of the thesis investigates the research question of how the three GP research networks developed within the specific context of the Belgian health system. It is based on the interpretation of written sources such as project reports, annual network reports, research publications, parliamentary documents, relevant websites and the existing research literature. The context analysis included a comparison with the Netherlands since the latter have strong traditions with regard to the position of the general practitioner in the health system (gatekeeper to secondary care, whereas in Belgium the patient generally chooses his/her health provider, and a Global Medical File administered by the general practitioner is not mandatory in Belgium), to general practice research networks and computerisation. It could be shown (1) that Belgium has held a middle position in the European Union regarding GP computerisation; (2) that, contrary to the Netherlands, an operational national GP network based on data from electronic health records (EHRs) could not be established; and (3) that Belgian health system computerisation, which advanced substantially in the last decade, put the issue of health data collection and storage by a new digital service on the agenda. Subsequently, three sub-chapters focus on the development of the three GP networks from their foundation until today. They demonstrate that the SGP and Intego were founded as innovative tools originating from Flemish general practice research, whereas the Monitoring Chart originated from the dynamism of Integrated Primary Health Care Centres (IPHCCs, Maisons médicales) in French-speaking Belgium. Acting as health observatories was both part of the mission of the IPHCCs and the demand of the Regional governments. With time, the research designs of the three GP networks became more sophisticated. Furthermore, European cooperation of the SGP with other GP networks since the late 1980s stands out, since the vision to establish a European sentinel general practice network led to joint influenza surveillance as one of its lasting achievements. In continuation of the developments described above, the second main part of the thesis addresses the missions and the organisation of the three GP networks today as well as their respective strengths and limitations in comparative perspective. It is based on network publications and reports, relevant websites and informal information from the networks themselves. The comparison shows that there is little overlap between the activities of the three GP networks, given the different areas of investigation and the complementarity of supplementary information collected by the SGP versus routine data extraction from EHRs in the other two networks. Furthermore, Intego and the Monitoring Chart essentially cover different parts of the country. The prospective research design of the SGP allows formulating hypotheses and designing research questionnaires with precise definitions of diagnoses before the start of a new research topic in order to minimise inter-observer variability, whereas the diagnosis in the other two networks is the result of the general practitioner's clinical judgement. The Intego network disposes of a substantial number of routine parameters collected over more than two decades by now. With these data, the researchers can design retrospective cohort studies without recording or recall bias by the GP who does not know during his/her daily routine for which research questions his/her data may be used later. The Monitoring Chart stands out by its comparatively strong presence in the Brussels-Capital Region and its data from the less well-to-do part of the population. The third main part of the thesis focuses on STIs which provided a research opportunity, given that Belgian public health efforts to control them have increased in recent years and that the three GP networks engaged in research activities in this regard. The first sub-chapter addresses challenges for the surveillance and monitoring of STIs due to the nature of the pathogens, followed by a sub-chapter about characteristics of STI surveillance and monitoring in Belgium. Afterwards, a sub-chapter describes health policy efforts in order to establish the Belgian HIV Plan 2014-2019. The development of the HIV Plan was analysed by applying the policy streams model of John Kingdon. The analysis was based on published government statements, parliamentary documents, and websites of stakeholders, and showed that the Federal Ministry of Health initiative to achieve the HIV Plan was characterised by a coordinating role with a participatory approach towards the other Belgian governments and stakeholders. The 2013 protocol agreement of the Belgian governments committed them to principles, actions, and cooperation regarding HIV prevention, testing, treatment of persons living with HIV and care for their quality of life, but not to budgets, priorities or target figures. The implementation of the plan, highlighting aspects relating to general practice, is addressed in the subsequent sub-chapter. Two further sub-chapters are based on the analysis of retrospective cohort studies with Intego data from 2009 to 2013, based on EHR routine registration by over 90 general practitioners in Flanders. In the first sub-chapter, the frequencies of gonorrhoea and syphilis diagnoses were investigated. Case definitions were applied. Due to small case numbers obtained, cases were pooled and averaged over the observation period. Frequencies were compared with those calculated from mandatory notification. A total of 91 gonorrhoea and 23 syphilis cases were registered. The average Intego annual frequency of gonorrhoea cases obtained was 11.9 (95% Poisson confidence interval (CI) 9.6; 14.7) per 100,000 population, and for syphilis 3.0 (CI 1.9; 4.5), respectively, while mandatory notification was calculated at 14.0 (CI: 13.6, 14.4) and 7.0 (CI: 6.7, 7.3), respectively. In spite of limitations such as small numbers and different case definitions, the data suggests that the general practitioner was involved in the large majority of gonorrhoea cases, while the majority of new syphilis cases did not come to the knowledge of the general practitioner. The second sub-chapter deals with the prescription of antibiotics to treat gonorrhoea in general practice in Flanders 2009-2013. Belgian guidelines recommended ceftriaxone or alternatively spectinomycin from 2008 onwards and azithromycin combination therapy since 2012. The study investigated to which extent contemporary gonorrhoea treatment guidelines were followed. Ninety-one gonorrhoea cases with ten chlamydia and one genital trichomonas coinfections in 90 patients were registered between 2009 and 2013. The proportion of cases with ceftriaxone and/or spectinomycin prescriptions rose from 13% (two of 15 cases) in 2009 to 56% (nine of 16 cases) in 2013. Combination therapy of ceftriaxone and/or spectinomycin together with azithromycin rose from 0 of 15 cases (0%) in 2009 to 7 of 16 cases (44%) in 2013. Although numbers are small, the results suggest that gonorrhoea therapy guideline adherence improved between 2009 and 2013. Future opportunities, recommended in the final discussion, include (1) extending provider-led STI testing in Belgium, with a prominent role for general practitioners; (2) investigating barriers and facilitators for the achievement of the Global Medical File, notably if sensitive and potentially stigmatising issues such as STIs or mental health are involved; (3) making task delegation by the general practitioner towards other primary health care providers more attractive; (4) facilitating general practitioners' tasks by the introduction of support features into the EHR in order to improve registration and quality of care in general; (5) eliciting Regional government support in order to investigate the diagnostic profiles of the patient population of IPHCCs; and (6) establishing an extended network for the collection and analysis of "production data" (such as the number of contacts, interventions, referrals, prescriptions and diagnostic requests) from general practitioners and other primary health care providers, proceeding from the know-how and the experience of the three investigated GP networks. / Doctorat en Sciences de la santé Publique / info:eu-repo/semantics/nonPublished

Philosophiae Doctor - PhD / Sexually transmitted infections (STIs) are a problem for both developed and developing countries. Sub-Saharan Africa has the highest rates in the 15-49 years old group. The discovery that these infections playa vital role in the transmission of HIV raised their profile and made their control one of the central strategies of stopping the HIV/AIDS epidemic. In response to the challenge of improving the quality of care for people infected with STIs in the public health sector, the South African Ministry of Health adopted the syndromic management approach, recommended by the World Health Organisation as suitable for resource-poor settings, for use in primary health care clinics. In addition to providing guidelines on clinical management of STIs, the syndromic approach requires health providers to counsel and educate patients about STIs, encourage patients to complete treatment even if symptoms abate, promote condom use and the treatment of all sexual partners. While the management guidelines are clear and detailed around the diagnostic and medication issues, the processes of education and counseling are not as clearly outlined. Furthermore, although the syndromic approach is a viable way of providing good quality care to larger sections of the population than could be serviced through dedicated STI clinics, it requires health providers working in primary health care clinics, most of whom are professional nurses, to perform some tasks for which they may not be adequately trained. This study evaluated the quality of care for persons infected with ST!s by examining the extent to which the syndromic approach was being implemented in primary health care clinics. Interviews, using semi-structured interview schedules, were conducted with STI patients and health providers in twenty-four clinics located in four provinces. Indepth qualitative interviews were also conducted with a sub sample of the patients. For further triangulation the methods of participant observation, through the use of simulated patients, and focus group discussions with various community groups were used. The findings of the study indicate that although primary health care clinics in South Africa are well-resourced, the management of patients with STI's is inadequate. Adherence to the various aspects of syndromic management was poor. Similar to other studies in South Africa, the attitudes of health providers towards patients with ST!s were found to be problematic, a finding that has implications for health-seeking behaviours. The thesis argues that a large part of the problem is related to the multiple roles that nurses have to play in primary health care settings, as well as the content and methodology of the training of nurses who manage STI patients. It further argues for the constitution of the basic health team at primary health clinics to be multi-disciplinary, and for a multi-disciplinary input in the training of health providers.

The goal of the study was to evaluate the content, implementation and applicability of the Soul City social intervention programme (SCI programme) about HIV and AIDS targeted at the youth in the Northern Cape from an ecosystems perspective. The goal of this study was achieved through the realisation of the objectives of the study. The objectives of the study were: To describe the phenomenon of HIV and AIDS among the youth in the Northern Cape, South Africa from an ecosystems perspective; to describe the NSP 2012-2016 and the Provincial Strategic Plan (PSP) for HIV and AIDS in South Africa; to describe and critically analyse the SCI programme's focus on the youth from the ecosystems perspective; to evaluate the content of the SCI programme for the youth with regard to HIV and AIDS in the Northern Cape in the context of the NSP 2012-2016 on HIV and AIDS from the field workers' perspective; to evaluate the implementation of the SCI programme for the youth on HIV and AIDS in the Northern Cape in the context of the NSP 2012-2016 on HIV and AIDS from the perspective of the youth as service users, and lastly, to provide guidelines for the content, applicability, implementation, monitoring and evaluation of the SCI programme for the youth with regard to HIV and AIDS in the context of the NSP 2012-2016, in order to enhance efforts to mitigate the impact of HIV and AIDS among the youth in the Northern Cape. Furthermore, a mixed-methods research approach was adopted to achieve the research goal. The quantitative and qualitative findings are described in Chapters 6 and 7 respectively. Triangulation, as mixed-method design, was utilised in this study. This enabled the researcher to produce complete and well-validated conclusions. The method of data collection for the part of the study about the youth was a group-administered questionnaire. For the qualitative part of this study, semi-structured interviews, with an interview schedule, were utilised to collect data related to the contents, applicability, implementation, monitoring and evaluation of the SCI programme from trained field workers working in the youth sector and specialising in HIV and AIDS. The quantitative data was analysed using both descriptive and association statistical analyses. In the present study, the researcher strived to ensure a high degree of face validity by allowing experts in the field, for example, social workers practising in the field of HIV and AIDS, to scrutinise the research instrument as part of the pilot test. The questionnaire was piloted with 20 youths to enhance both face and content validity further. In the current study, an acceptable degree of reliability was prioritised and therefore a Cronbach alpha coefficient of 0.70 for all categories of the questionnaire was sought. The qualitative data of the semi-structured interviews with Soul City programme implementers was analysed using thematic analysis. An independent reviewer reviewed the theme generation and analysis to ensure consistency or the interrater reliability of the findings. This aided the researcher to identify patterns or themes from direct quotations and to provide rich data representation. Verbatim quotations from the interviews were used to support the themes. To ensure data trustworthiness, a high premium was placed on credibility, transferability, conformability and dependability. Analyses of three different sources of data, namely the literature review, the youth programme attendees/recipients and interviews with Soul City field workers were undertaken to answer the following research question. "To what extent is the content and implementation of the Soul City social intervention programme applicable to the youth in the Northern Cape?" Subsequently, the sub-question of the study was: "Does the Soul City social intervention programme take the different levels of the ecosystems perspective into account regarding programme content and implementation?" Several key findings were made in the quantitative part of the study, with nine sections of the questionnaire which focussed on: the Biographic details of respondents; Objectives of the Soul City programme for the youth in the Northern Cape; Applicability and relevance of the content of the Soul City Programme; Knowledge gained through attending Soul City; Attitudinal change; Programme delivery; Programme content; Programme facilitation methods and general aspects. Key findings were that there was no statistical association found between any of the variables in most sections of the questionnaire except for combinations of five questions in sections D and G. There was a statistical association found with regard to age where the respondents indicated that the SCP contributed to them achieving their personal life goals. Also in Section D there was a statistical association found where the respondents could see the impact of the SCP on their lives. There was a statistical association found between where respondents indicated that the SCP should focus on ways/strategies to fight poverty in their communities and also when they indicated that the SCP should focus on involving important people/stakeholders such as youth leaders. Lastly, there was a statistical association found between where the respondents indicated that the capacity of the youth in the community to fight the further spread of HIV and AIDS could be built by visiting the community. From an ecosystems perspective, the SCP programme appeared to be influenced by or aligned to micro-, meso-, exo- and macrolevel factors with varying degrees of success and focus areas. The programme's exolevel focus appeared to be more prominent and to a lesser degree the macro- and microlevels. The research found that the SCP is relatively effective regarding programme content and facilitation methods albeit to a limited degree. Furthermore, what was repeatedly clear was a need for the SCP's programme continuation and sustainability, because adequate effort had not been made for this despite the programmes' apparent value when it was operational. / Thesis (DPhil)--University of Pretoria, 2017. / Social Work and Criminology / DPhil / Unrestricted

Recent Findings: Recent data support previous work indicating that estrogen enhances chlamydial development via multiple mechanisms. Progesterone negatively impacts Chlamydia infections also through multiple mechanisms, particularly by altering the immune response. Conflicting data exist regarding the effect of synthetic hormones, such as those found in hormonal contraceptives, on chlamydial infections. Summary: Numerous studies over the years have indicated that female sex hormones affect C. trachomatis infection. However, we still do not have a clear understanding of how these hormones alter Chlamydia disease transmission and progression. The studies reviewed here indicate that there are many variables that determine the outcome of Chlamydia/hormone interactions, including (1) the specific hormone, (2) hormone concentration, (3) cell type or area of the genital tract, (4) hormone responsiveness of cell lines, and (5) animal models.

Purpose of Review: Recent technological developments have vastly improved our ability to study the host microbiome and its role in many disease states. Numerous other reviews have contributed to our understanding of single viruses and gut microbiota or immunological outcomes. Here, we report, in aggregate, the newest data on genital microbiota interactions with the three most common viral STIs. Recent Findings: Four themes emerge: (1) the repeatability of specific community state types corresponding with infection risk, (2) a role for the microbiota as both therapeutic target and major player in treatment efficacy, (3) a need for models in which to study the mechanisms at play in microbiota/virus interactions, and (4) the impact of microbiota populating external genitalia on viral transmission. Summary: The studies reviewed herein suggest a convoluted interplay between host microbiota and viral STIs. More mechanistic studies are needed in order to leverage these interactions to improve prevention and treatment strategies.

African Americans living in the Southeastern region of the United States disproportionately contract sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). Facebook and other social media sites are becoming a way to deliver health-related messaging to targeted populations. The purpose of this quantitative, cross-sectional study was to examine the association between selected demographic factors and impact of social media on intent to change sexual behaviors among 112 African Americans between the ages of 18 and 49 in the Southeastern United States who viewed STI/HIV prevention materials on Facebook within 1 year prior to the study. The theory of planned behavior was used to help understand and interpret the findings. Participants completed an online self-report survey containing questions about their exposure to sexual health messages on Facebook and their intent to change behavior. Results of the multiple logistic regression analyses indicated that gender (p =.462), age (p =.122), education (p =.593), and income (p =.200) were not statistically associated with the dependent variable, intent to change risky sexual behaviors. A majority of respondents indicated the intention to change their sexual behaviors as a result of viewing HIV prevention messages on Facebook, and that the messages were the most important factor in their decision to change behavior. Facebook messaging may be an effective platform for reaching African Americans and influencing behavior; however more research is needed to fully understand the use of social media for STI prevention. The social change implication of this research is the potential to decrease HIV/STI associated morbidity and mortality among this population.

This research analyzed themes relating to the concepts of risk, risk taking, and pleasure by completing a secondary analysis of participant transcripts collected from the PrEP-RN study conducted by Dr. O'Byrne at the University of Ottawa in collaboration with Ottawa Public Health. Analysis was completed to relate risk, risk taking and pleasure in the context of PrEP-RN, but also identify areas for educational improvement in relation to the selected concepts. The research question sought explanation on the relationship that risk has with risk reduction and risk taking, including analysis of condom usage, risk conversation with partners and general sexual health practices while on PrEP. Additionally, the research sought to answer if PrEP-RN participation had any impact on sexual pleasure, analyzing subthemes of stereotyping, security and desire relating to pleasure. Transcript analysis identified that a reduction in condom usage, improved frequency of sexually transmitted infection testing, promotion of conversations with partners surrounding PrEP and sexual health, and a reduction in sexual fear and anxiety with partners were major themes stemming from PrEP-RN participation. A need to increase education surrounding continued condom usage while on PrEP and identify ways to reduce stigmatization of PrEP were identified as ways to improve the PrEP-RN program.

The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic has surpassed forty years with many medical advancements in prevention and treatment. Often believed to be at negligible or low risk by society at large, sexual minority women have remained understudied regarding their risk of HIV and other sexually transmitted infections (STIs), leaving their sexual health inadequately understood and supported in healthcare and social services. The sexual health of young South Asian sexual minority women, who are multiply minoritized due to their intersecting identities, has been entirely overlooked. This qualitative study aimed to understand the knowledge, attitudes, and practices of young South Asian sexual minority women as it pertains to their HIV/STI risk. Barriers and facilitators to accessing community-based sexual health supports and services were also investigated. A community-engaged approach was taken to develop this study in partnership with the Alliance for South Asian AIDS Prevention to investigate the HIV/STI risk context and sexual health needs of this group residing in the Greater Toronto Area. A maximum variation sampling strategy was used to recruit six young South Asian sexual minority women and semi-structured in-depth interviews were conducted to collect narrative data. Narrative analysis of the data found socio-cultural and structural influences which guide the HIV/STI risk context for this group. The participants illuminated an inadequate understanding of sexual health when engaging in sex with women, an overall low HIV/STI risk perception, barriers to adequate sexual healthcare and health promotion resources, and multiple minority stressors which impacted their access to safe sex. These findings have major implications for school-based sexual health education, medical training for healthcare practitioners, and sexual health support and services provided by community-based sexual health organizations in the Greater Toronto Area. / Thesis / Master of Public Health (MPH)