In 2011 the National Academy of Medicine identified research gaps related to transgender populations and suggested a research agenda that included, among other goals, investigating health outcomes related to transition related care. The overarching goal of this dissertation therefore is to add to the body of knowledge about the state of health of transgender individuals, including utilization of gender-affirming care, preventive care and screening practices for human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). This dissertation includes three manuscripts. The first is a retrospective chart review including 1670 transgender patients, aged 18 and up (mean age 35.57 years), at a community health center to examine utilization of gender-affirming procedures as well as investigate the prevalence of smoking and uptake of colon cancer screening compared to New York City benchmarks using data from the New York City Community Health Survey (NYC CHS). The results revealed transgender individuals had high uptake of gender affirming hormones (81.9%) but fewer had undergone gender-affirming surgeries (31.5%). Transgender individuals had almost double the rate of current cigarette smoking compared to adults aged 18 and up in the New York City Community Health Survey (OR=1.92, 95% CI=1.61, 2.28) and also had suboptimal colon cancer screening rates compared to New Yorkers aged 50 and older (OR=0.16, 95% CI=0.11, 0.23). The second paper is a scoping review of the literature to investigate postoperative outcomes related to vaginoplasty procedures in transgender women. One hundred and three articles met inclusion criteria and provided information on immediate as well as long term health outcomes. The review demonstrated many inconsistencies in the timing of follow-up as well as how outcomes were measured, but provided invaluable information on the many types of postoperative issues that may be seen after vaginoplasty surgery. Lastly, the third paper examined the prevalence of HIV and STI testing behavior and prevalence of HIV infection among transgender people in a community health center setting. This analysis demonstrated that HIV screening rates were lower than expected (55.7%) given the elevated HIV prevalence in the population. In the multivariate analysis the odds of HIV screening among transmasculine individuals was higher in those who had undergone gender affirming surgeries (OR=1.67, 95% CI= 1.08, 2.58), had a substance use history (OR=5.18, 95% CI=1.41, 18.99) and a history of genital warts (OR=4.64, 95%CI=1.24, 17.34). Among transfeminine individuals the odds of HIV screening were higher in those with only cisgender male partners (OR=2.18, 95% CI=1.52, 3.11), gender affirming surgery (OR=2.56, 95% CI=1.53, 4.31), substance use history (OR=2.76, 95% CI=1.23, 5.78) and genital warts (OR=2.69, 95% CI=1.20, 6.02). HIV prevalence was higher among transfeminine compared to transmasculine individuals (28.1% vs. 2.8%, p<.001). In the multivariable analysis having only cisgender male sex partners increased the odds of HIV infection among transmasculine individuals (OR=10.58, 95% CI=1.33, 84.17), while having at least a high school diploma reduced the odds of infection (OR=0.08, 95% CI=0.01, 0.72). Among transfeminine individuals increased odds of HIV-infection were seen in those who were unemployed (OR=1.7, 95% CI=1.1, 2.64) and those who had a history of genital warts (OR=2.54, 95% CI=1.37, 4.70). White individuals had a lower likelihood of HIV infection (OR=0.40, 95%CI=0.21, 0.73). Overall these three studies provide important information about transition-related, primary and preventive healthcare for transgender populations. The findings of elevated cigarette smoking, underutilization of colorectal cancer screening and low HIV and STI screening rates occurred in this study despite the fact that transgender people were engaged in medical care. Clinics and other health settings that provide transgender health services should include robust metrics for monitoring uptake of preventive health care services and work to improve uptake of services when disparities are evident.

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

Background: The burden of Sexually transmitted infections (STIs) is high globally. The World Health Organisation (WHO) recommends syndromic management of these STIs, based on presentation with signs and symptoms, in resource-limited countries. Due to this syndromic approach, there is little current data on STI prevalence, including asymptomatic STIs, in high risk populations. Methods: We reviewed secondary data collected as part of the screening procedures of 6 clinical trials between 2012 and 2017 in Cape Town, South Africa. These trials recruited populations of different sexual orientation and gender, mostly key populations at risk of HIV and STI acquisition. Routine screening for STI symptoms and testing for Chlamydia, Gonorrhoea, Trichomonas, Syphilis and HIV was performed for all of the studies at screening/enrollment. Results: A total of 639 participants were screened; 411 (64.3%) self-identifying as female, 198 (31%) males, 29 (4.5%) transgender women and 01 (0.2%) transvestite. Median age was 20 years (IQR: 18-24), with the 15-24-year age category contributing 77% to the cohort. Laboratory testing diagnosed 239 (37.4%) people with STI infections in this cohort; only 28 (11.7%) people were symptomatic. 119 (88.8%) of Chlamydial, 64 (82.1%) of Gonorrhoeal, 23 (92%) of Trichomonal and 31(79.5%) of Syphilis infections elicited no signs and/or symptoms. Conclusion: A vast majority of STIs in this high-risk population were asymptomatic. Laboratory testing of causal organism was more reliable in diagnosing STIs than the use of signs and/or symptoms as recommended by WHO.

Indiana University-Purdue University Indianapolis (IUPUI) / The emergence and development of electronic health records have contributed to an abundance of patient data that can greatly be used and analyzed to promote health outcomes and even eliminate health disparities. However, challenges exist in the data received with factors such as data inconsistencies, accuracy issues, and unstructured formatting being evident. Furthermore, the current electronic health records and clinical information systems that are present do not contain the social determinants of health that may enhance our understanding of the characteristics and mechanisms of disease risk and transmission as well as health disparities research. Linkage to external population health databases to incorporate these social determinants of health is often necessary. This study provides an opportunity to identify and analyze health disparities using geographical information systems on two important sexually transmitted diseases in chlamydia and gonorrhea using Marion County, Indiana as the geographical location of interest. Population health data from the Social Assets and Vulnerabilities Indicators community information system and electronic health record data from the Indiana Network for Patient Care will be merged to measure the distribution and variability of greatest chlamydia and gonorrhea risk and to determine where the greatest areas of health disparities exist. A series of both statistical and spatial statistical methods such as a longitudinal measurement of health disparity through the Gini index, a hot-spot and cluster analysis, and a geographically weighted regression will be conducted in this study. The outcome and broader impact of this research will contribute to enhanced surveillance and increased effective strategies in identifying the level of health disparities for sexually transmitted diseases in vulnerable localities and high-risk communities. Additionally, the findings from this study will lead to improved standardization and accuracy in data collection to facilitate subsequent studies involving multiple disparate data sources. Finally, this study will likely introduce ideas for potential social determinants of health to be incorporated into electronic health records and clinical information systems.

Chlamydia trachomatis is the most common sexually transmitted bacterial pathogen worldwide. Chlamydia spp. infect epithelial cells of the respiratory, intestinal, and reproductive tracts. Chlamydial infections in women may lead to pelvic inflammatory disease, ectopic pregnancy, chronic pelvic pain, and infertility. In addition to infecting infection the female reproductive tract (FRT), Chlamydia also infects the gastrointestinal tract (GIT) of animals and humans. In mice Chlamydia muridarum disseminates from the FRT to the GIT via internal routes and in a stepwise manner. Initially Chlamydia spreads from the FRT to infect the FRT-draining iliac lymph nodes (ILNs), then the spleen, and then the GIT. The first step of this dissemination (FRT to ILN) is mediated by tissue CD11c+ DCs. Chlamydia transport from ILN to the spleen is dependent on cell transport and is mediated by sphingosine 1-phosphate (S1P) signaling. The third step of Chlamydia transport from the spleen to the GIT is significantly hindered in splenectomized mice. However, which cells mediate this transportation of the second and the third step remain unknown. Using mouse-specific C. muridarum as a model pathogen we show that following depletion of CD8+ T cells or monocytes, Chlamydia dissemination to the spleen and the GIT is significantly hindered. Furthermore, this study reveals that Chlamydia may infect various cell types which then mediate its dissemination internally. It remains to be determined what role systemic dissemination may have in Chlamydia pathogenesis.

Thesis (MPH.) -- University of Limpopo, 2020 / Background of the study: Cervical cancer is a disease that is described as the state of overgrowth of tissue resulting from the disorganisation of cell division that is preceded by several earlier cervical changes, especially at the squamocolumnar junction of the cervix. Factors such as HPV, which is a sexually transmitted infection (STI), low socioeconomic status (SES), intercourse at a very early age, numerous childbirths, poverty and limited access to health care, are some of the contributing risk factors for cervical cancer. Most women in developing countries only seek professional help once the malignancy is already at an advanced stage. Purpose of the study: The aim of the study was to investigate the determinants of cervical cancer in patients seen in the gynaecology clinic at Mankweng hospital. And the objectives were: to profile the sociodemographic characteristics; to profile the contributory risk factors; and, to determine the association of risk factors for cervical cancer with the socio-demographic characteristics of the patients seen in the gynaecology clinic at Mankweng hospital. Research methodology: A quantitative, cross-section descriptive study, which has been validated and used in several studies globally, was conducted at Mankweng hospital, which is a tertiary referral academic hospital in the Limpopo Province, following all cervical cancer patients consulting at gynaecology outpatient clinic during the study period. Data were collected using a structured questionnaire and entered into computer software and analysed. Research findings: Thirty-seven percent of the women who participated in this study were single, 27% were married, 27% widowed and only 9% were divorced. Nearly half (46%) of the participants had secondary education and only 8% had tertiary education. The majority (91%) of the women were unemployed and only 9% were employed. The majority (40%) of the women were at stage II cervical cancer. Nearly two-thirds (62%) had had multiple partners. At the time of the study, 94% of the participants did not have multiple partners. Nearly two-thirds (64%) of the participants had heard about Pap smears before their current diagnosis and 62% of the participants had had a Pap smear before the current results. Few participants smoked cigarette (2%) or used contraceptive (3%). The young age group, single, divorced, with secondary and v tertiary education were more likely to be HIV positive. And the elderly, divorced, widowed and less educated were more likely to have high parity. Recommendations and conclusions: Information about the risk factors for developing cervical cancer, specifically the transmission of HPV, needs to be disseminated to young people. Rather than initiating cervical screening by age group, which may result in young women being refused screening irrespective of their risk, cervical screening guidelines should stipulate the initiation of cervical screening and HPV vaccine from the age of 15 onwards. Present study suggests that young women may be more prone to HPV and HIV due to the fact that young women who are single or divorced, with tertiary education were more likely to have multiple partners, which places them in a risk-based cervical screening target group. A final recommendation and conclusion is that a long-term, in-depth study on cervical cancer in young women in relation to the presence of the risk-factors should be carried out. Attempts should be made to reach women who rarely visit health care services.

Under stress, chlamydiae can enter a non-infectious but viable state termed persistence. In the absence of a tractable genetic system, persistence induction provides an important experimental tool with which to study these fascinating organisms. This review will discuss examples of: i) persistence studies that have illuminated critical chlamydiae/host interactions; and ii) novel persistence models that will do so in the future.

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.

Master of Public Health - MPH / In the Maseru district, the high prevalence of unintended pregnancies among adolescents aged between 15 to 19 years may be due to non-use of modern contraceptive methods. It is therefore important to investigate possible barriers adolescents in Maseru in Lesotho face in accessing contraceptive methods and services. This research has therefore focused on the factors that affect the accessibility and usage of contraceptive services among in-school adolescent girls in Maseru City, Lesotho.The study was an observational, analytical, cross-sectional study. A sample of 10 high schools in Maseru city was selected as study sites, using computer-generated random numbers. A stratified random sampling method was used to enrol a total of 368 sexually active respondents, aged 15-19 years into the study. Data was collected using a structured one-on-one interviewer administered questionnaire and analysis was conducted using the STATA 14 statistical software programme. Ethical approval was obtained from the Biomedical Research and Ethics Committee (University of the Western Cape) and the Lesotho Ministry of Health and Social Welfare. Written parental/caregiver informed consent and written participant consent and assent, as per the Lesotho law were obtained.