[pt] Esta pesquisa trata das relações entre organizações internacionais e locais na área do combate à AIDS, mais especificamente a relação entre o Programa das Nações Unidas de HIV/AIDS e as ONGs locais que atuam nesse campo, como o Grupo pela Vidda (Brasil) e a Aids United (Estados Unidos), voltados para o esforço do controle epidemiológico do HIV/AIDS. A dissertação apresenta, primeiramente, o contexto histórico da pandemia e do ativismo nesses países. Em segundo plano, são analisadas as atividades do UNAIDS e como se estruturam o Grupo pela Vidda e a AIDS United com o objetivo de compreender a atuação e as formas de colaboração entre essas organizações. A última seção traz considerações finais sobre as relações entre tais grupos a fim de compreender como se dá a participação e colaboração de organizações locais no sistema internacional. / [en] This research deals with the relationship between international and local organizations around combating AIDS, more specifically the relationship between the United Nations HIV/AIDS Program and local NGOs that work in this field, such as Grupo pela Vidda (Brazil) and the Aids United (United States), focused on the epidemiological control of HIV/AIDS. The dissertation first presents the historical context of the pandemic and activism in these countries. In the background, the activities of UNAIDS and how the Grupo pela Vidda and AIDS United are structured are analyzed with the aim of understanding the performance and forms of collaboration between these organizations. The last section brings final considerations on the relationships between such groups to understand how the participation and collaboration of local organizations in the international system takes place.

<p>This thesis is an analysis of how international policies on HIV prevention can be understood through a postcolonial perspective and how these prevention strategies are reflected nationally and locally in Babati, Tanzania. To gain knowledge of these aims I have focused on UNAIDS and the US’ government policies to get an idea of where the international discourse about HIV prevention stands. My empirical data in Babati is collected by semi-structural interviews with people who work with HIV prevention. I have used Chandra Talpade Mohanty’s understanding of Third World women, together with Jenny Kitzinger theory about women in HIV discourses and Karen M Booth’s view of how international policies are trying to empower women to reduce their risk of HIV infection. To assist my analysis I have focused on three notions, which are recurring in the HIV prevention discourse, these are: empowerment of women, condom use and sexual behaviour. These notions help to establish the HIV discourse and later I have compared the results with my theoretical framework and empirical findings. My final conclusion is that international policies on HIV prevention can be seen as imperialistic as they are promoting a certain change in sexual behaviour, such as reduction of partners and abstinence until marriage.</p>

This thesis is an analysis of how international policies on HIV prevention can be understood through a postcolonial perspective and how these prevention strategies are reflected nationally and locally in Babati, Tanzania. To gain knowledge of these aims I have focused on UNAIDS and the US’ government policies to get an idea of where the international discourse about HIV prevention stands. My empirical data in Babati is collected by semi-structural interviews with people who work with HIV prevention. I have used Chandra Talpade Mohanty’s understanding of Third World women, together with Jenny Kitzinger theory about women in HIV discourses and Karen M Booth’s view of how international policies are trying to empower women to reduce their risk of HIV infection. To assist my analysis I have focused on three notions, which are recurring in the HIV prevention discourse, these are: empowerment of women, condom use and sexual behaviour. These notions help to establish the HIV discourse and later I have compared the results with my theoretical framework and empirical findings. My final conclusion is that international policies on HIV prevention can be seen as imperialistic as they are promoting a certain change in sexual behaviour, such as reduction of partners and abstinence until marriage.

Background Globally, external HIV-related stigma is a major threat to all HIV prevention, care and treatment interventions including the recently launched Universal Test and Treat (UTT) strategy in South Africa and the 90-90-90 targets set by UNAIDS for the global response by 2020. The 90-90-90 targets are put in place to track the progression from HIV testing to durable viral load suppression among people living with HIV. The targets guide HIV programmes to achieve 90% known HIV status, to access 90% antiretroviral therapy and to suppress 90% viral loads (UNAIDS, 2017). Achievement of the 90-90-90 targets has since become a part of South Africa's National Strategic Plan for HIV, TB and STIs 2017-2022. External HIV-related stigma in this study was defined as the presence of one or more of the following attitudes and behaviours: rejection, avoidance, intolerance, stereotyping, discrimination, and physical violence towards people living or perceived as having HIV. There have not been many efforts to attenuate HIV-related stigma in South Africa, as it continues to exist. There has been a scale up of other HIV responses, such as HIV Counselling and Testing (HCT) and treatment, with the argument made that in scaling up these biomedical approaches, stigma would disappear. Furthermore, its exact magnitude, trends over the years and correlates have not been explored fully at national level, hence the present study known as Stigma Assessment Study in South Africa (SASSA). SASSA is based on the Institutional Social Construction theory framework. It explores the external HIV-related stigma magnitude and its trends between 2005 and 2012, as well as the associated factors which influence its prevalence in South Africa at a national level. The study further explores the mediating and moderating factors of external HIV-related stigma and tries to explore external HIV-related stigma by viewing individuals with HIV living in families, societies and structures, with the hope of contributing to the development of new systematic HIV-related stigma interventions in South Africa as well as, strengthening existing ones. Methodology The project used secondary data obtained from three South African national population HIV surveys which were conducted in 2005, 2008 and 2012 by a research consortium led by the Human Sciences Research Council. Sub-samples of the original surveys consisting of respondents aged 15 years and older who had responded to the stigma questions in the three surveys were extracted and included in the SASSA analysis. A nationally representative sample of a total of 16 140 individual respondents from the 2005 survey, 13 134 from the 2008 survey and 30 748 from the 2012 survey was used in the study. Two different measures of external HIV stigma are used in this analysis, one is a summary measure from the latest survey data, i.e. 2012, which was used to do a regression analysis. The summary measure was regarded as reliable to use for the regression analysis as it provides crude effect of the exposure factors on external HIV stigma. However, this summary measure was not included in the previous surveys, i.e. 2005 and 2008, and therefore could not be used for trends analysis. We therefore used 4 individual stigma items for the trends analysis as these were included in all 3 surveys. The use of 4 individual stigma items was important because when data from a variety of sources or categories have been joined together, the meaning of the data can be difficult to see. It was therefore considered ideal to assess the performance of the individual constructs on their individual contribution to the impact on HIV external stigma. Furthermore, analysis using individual constructs provided an opportunity to see specific patterns which could have remained obscure in crude analysis. The first measure of external HIV-related stigma used in the regression analysis was measured by five individual items which elicited attitudes towards people living with HIV (PLHIV). The five items were based on a 9-item scale that was originally developed and tested in a South African population, and the 9-item scale was found to be internally consistent (alpha = 0.75) and reliable (r = 0.67). The 5 items were (1) People who have AIDS are dirty; (2) People who have AIDS are cursed; (3) People who have AIDS should be ashamed; (4) People with AIDS must expect some restrictions on their freedom; (5) A person with AIDS must have done something wrong and deserves to be punished. As explained above, the specific external HIV stigma patterns second measure, which was utilized to explore stigma trends over the years 2005, 2008 and 2012, consists of four individual stigma items which elicited attitudes towards PLHIV. The four individual stigma items included: (1) If you knew that a shopkeeper or food seller had HIV, would you buy food from them? (2) Would you be willing to care for a family member with AIDS? (3) Is it a waste of money to train or give a promotion to someone with HIV/AIDS? (4) Would you want to keep the HIV positive status of a family member a secret? Findings Overall, external HIV-related stigma was found to exist among 38.3% of adult South Africans in 2012. Multiple regression analysis showed that predictors of external HIV-related stigma were race, sex, education level, self-perceived risk of HIV infection and HIV knowledge (p< 0.01). Females were less likely to report external HIV-stigma than males (AOR = 0.9, P< 0.001). Those who perceived themselves to be at high risk of HIV infection were less likely to display some stigma than those who believed they were at low risk (AOR = 0.89, p < 0.01). The study did not find any significant associations between HIV testing or awareness of HIV status, with external HIV-related stigma in this study. Looking at the individual external HIV stigma items used to measure trends, the study reveals a slight decrease in the reporting of stigma over the three time periods (2005 vs 2008 vs 2012) on responses for two of the stigma items (Q1: If you knew that a shopkeeper or food seller had HIV, would you buy food from them, and Q2: Would you be willing to care for a family member with AIDS). While an increase was observed in the reporting of stigma over the three years on responses for two of the stigma items (Q3: Is it a waste of money to train or give a promotion to someone with HIV/AIDS, and Q4: Would you want to keep the HIV positive status of a family member a secret). The structural equation modelling (SEM) showed likelihood ratio test results with a p-value greater than 0.05, a root mean square error of approximation (RMSE) of 0.008 and Tucker–Lewis index (TLI) value of 0.985. The model fit assessment results allow us to accept that an hypothesized model of the study is not far from a perfect model. The SEM results also showed a direct effect of sex on HIV knowledge statistically significant at p < 0.001, with race having an effect of 3.3% and education a direct effect of 9.5%, and both of these showed a statistically significant effect (p < 0.001) respectively. HIV knowledge showed to have a statistically significant inverse relationship on external HIV stigma of -10.4% (95% CI: -12.3-0.09) p< 0.001. Awareness of HIV status had the highest positive direct effect on external stigma of 10% (95% CI: 4.41-15.67%) p<0.001. With regard to indirect effects, sex, race, and education had minimal negative indirect effects on external stigma, which was statistically significant for all the three covariates. With the said effects of external HIV-related stigma, it was found that HIV knowledge independently mediates the relationship between Level of Education, Awareness of HIV status, Race, HIV testing history, and Sex, with External HIV-related stigma. Conclusion External HIV-related stigma still exists in South Africa despite previous success in massive ART rollout, HTC campaigns, and most recently test-and-treat programmes, which were arguably thought to have a parallel effect in the decrease of HIV related stigma. The focus on individualistic health structural approaches that do not generally have stigma-reduction as a specific aim, as discussed, is likely to undermine the successes achieved in the fight against HIV thus far. There is a need to develop innovative holistic interventions which are specifically intended for HIV stigma reduction. These should be inclusive of both social institutional elements and health structural elements to address the challenge of external HIV-related stigma.

The intention of this study was to evaluate the effectiveness of the implementation of the HIV and AIDS management at schools in the Tshwane South District. The rationale was based on the gap in research regarding evaluation of the implementation of intervention programmes at schools, especially the management and leadership intervention strategies. The Foundation for Professional Development (FPD), a South African Medical Association self-funding education provider in the health sector, had conducted a training intervention with the members of the School Management Teams (SMT) of the Tshwane South District schools. The application of the skills, knowledge and attitudes gained through this training was the main focus for evaluation. For that reason, the Success Case Method (SCM), an innovative programme evaluation design, was used. The first phase of the SCM involved using a short questionnaire to identify appropriate participants for the second phase, which involved in-depth telephone interviews as directed by the SCM. The second phase also involved probing, understanding and documenting the successes, thus allowing an evaluation of the findings. The findings of the study indicate that some SMTs are actually implementing the skills, knowledge and attitudes gained in the FPD training with success, albeit with differing levels of effectiveness. It was also found that there are unsuccessful SMTs that are not implementing or are unable to implement their learning from the FPD training. There were various reasons for both the successes and non-successes. These included matters pertaining to conflicting directions, policy guidelines, commitment, empathy and attitude of the SMTs in understanding circumstances related to people living with and affected by HIV and AIDS, teamwork, reporting systems, the duration of the training workshop and pace of learning of SMTs members, marketing collaterals, workforce availability and availability or lack of time for implementing the HIV and AIDS programme. The recommendations include the provision of follow-up and material support to schools, including the formation of HIV and AIDS management forums and networks. Recommendations are also made to the FPD for enhancing and sustaining the training and implementation. Further recommendations are proffered to the Department of Education regarding activities for directed and needs-based support for schools. The study contributes to the practice of HIV and AIDS management in that it produced an evaluation report on the implementation of HIV and AIDS management at schools. This should be useful to practitioners at school, community and departmental levels regarding the status of HIV and AIDS management at schools. The study also contributes to the theory of intervention programmes using the Success Case Method in education, which is a novel, user-friendly and easy-to-use method of evaluation. / PhD (Education Management), North-West University, Vaal Triangle Campus, 2013

The intention of this study was to evaluate the effectiveness of the implementation of the HIV and AIDS management at schools in the Tshwane South District. The rationale was based on the gap in research regarding evaluation of the implementation of intervention programmes at schools, especially the management and leadership intervention strategies. The Foundation for Professional Development (FPD), a South African Medical Association self-funding education provider in the health sector, had conducted a training intervention with the members of the School Management Teams (SMT) of the Tshwane South District schools. The application of the skills, knowledge and attitudes gained through this training was the main focus for evaluation. For that reason, the Success Case Method (SCM), an innovative programme evaluation design, was used. The first phase of the SCM involved using a short questionnaire to identify appropriate participants for the second phase, which involved in-depth telephone interviews as directed by the SCM. The second phase also involved probing, understanding and documenting the successes, thus allowing an evaluation of the findings. The findings of the study indicate that some SMTs are actually implementing the skills, knowledge and attitudes gained in the FPD training with success, albeit with differing levels of effectiveness. It was also found that there are unsuccessful SMTs that are not implementing or are unable to implement their learning from the FPD training. There were various reasons for both the successes and non-successes. These included matters pertaining to conflicting directions, policy guidelines, commitment, empathy and attitude of the SMTs in understanding circumstances related to people living with and affected by HIV and AIDS, teamwork, reporting systems, the duration of the training workshop and pace of learning of SMTs members, marketing collaterals, workforce availability and availability or lack of time for implementing the HIV and AIDS programme. The recommendations include the provision of follow-up and material support to schools, including the formation of HIV and AIDS management forums and networks. Recommendations are also made to the FPD for enhancing and sustaining the training and implementation. Further recommendations are proffered to the Department of Education regarding activities for directed and needs-based support for schools. The study contributes to the practice of HIV and AIDS management in that it produced an evaluation report on the implementation of HIV and AIDS management at schools. This should be useful to practitioners at school, community and departmental levels regarding the status of HIV and AIDS management at schools. The study also contributes to the theory of intervention programmes using the Success Case Method in education, which is a novel, user-friendly and easy-to-use method of evaluation. / PhD (Education Management), North-West University, Vaal Triangle Campus, 2013

Récemment, le Chili a vu la victoire des politiques publiques de prévention et de soins de l'infection à VIH promues par la vérité technique de l'OMS et de l'ONUSIDA (notre acception de la vérité technique a été définie dans les derniers travaux de Michel Foucault). Pourtant, l'histoire récente des politiques de santé du Chili dans notre domaine de recherche nous incite à la prudence. Des questions telles que la responsabilité sociale des dépenses de santé ont connu des va et vient répétés dus aux bouleversements politiques de ces dernières décennies. Certains sujets cruciaux pour la prévention de la transmission verticale du VIH / SIDA, liés à la morale privée et à son influence sur les politiques publiques, comme dans le cas de l'avortement thérapeutique, ont longtemps été influencés par la dose laïcité permise par l'église catholique aux partis politiques chiliens les plus conservateurs. La promotion du préservatif comme seul moyen de prévenir la transmission sexuelle du VIH, simple vérité technique «connue» par les politiques publiques du Nord depuis les années 80, a partagé les campagnes de prévention officielles chiliennes avec abstinence et fidélité jusqu'en 2015. Cependant, si une vérité mérite notre sympathie, elle mérite en même temps l'aversion des secteurs de la population tout aussi respectables que nous. Si nous considérons avec bienveillance une vérité technique qui émerge du débat pour s'imposer comme «la vérité», ignorant que ce qui a vraiment été imposé est le prestige de la technicité, nous ignorons probablement le sens du combat politique comme objet scientifique. / Recently, Chile lived the victory of public policies of prevention and care of the HIV infection as promoted by the WHO’s and UNAIDS technical truth (our meaning of the technical truth has been defined in the latest works by Michel Foucault). Yet the recent history of Chile's health policies in our research matters urges us to be cautious. Issues such as social responsibility of health spending have come and gone according to the political upheavals of the recent decades. Some crucial topics for the prevention of vertical transmission of HIV/AIDS, linked to private values and its influence on public policies, as in the case of therapeutic abortion, has long been under the influence of the dosage of secularity allowed by the catholic church to the most conservative political parties. The promotion of the condom as the only way to prevent the sexual transmission of the HIV, a simple technical truth “known” by the northern public policies since the 80’s, shared the official prevention campaigns with abstinence and fidelity till 2015. However, if a truth deserves our sympathy, it deserves at the same time the aversion of sectors of the population just as respectable as we are. If we consider with kindness a technical truth that emerges from the debate to impose itself as "the truth", ignoring that what has really been imposed is the prestige of technicality, we probably ignore the sense of political struggle as a scientific object.

This thesis contributes to debates on the role of civil society organizations (CSOs) in global governance by asking if their participation in the global response to HIV/AIDS has been transformative – with transformation conceptualized as change towards a more equitable order. Adopting a critical International Relations approach, and applying qualitative methods, it analyzes how CSOs used the initial failure of biomedical responses to the epidemic to advance a human rights frame, which justified their participation in global governance. This frame complemented conceptions of AIDS exceptionalism, and has recently shifted in response to an increased focus on key populations. CSOs continue to advance the rights frame in global institutions – the focus here being on how they have done so within UNAIDS and the Global Fund to Fight AIDS, Malaria and Tuberculosis. However, rigid bureaucracies and dominant power relationships limit CSOs’ ability to transform these institutions to be more responsive to and representative of those affected by the epidemic. CSOs have further struggled to influence the largest global donors of the HIV/AIDS response – the Global Fund and PEPFAR – to direct greater resources to rights-based initiatives, despite CSO participation in resource mobilization. Though CSO participation has been restricted by donor state power, bureaucratic structures, and changes in the political economy of global health, CSOs have continued to promote potentially transformative alternatives, and so have continued to represent the interests of those most affected by the epidemic. This allows potential for further transformative alternatives.

In their first meeting of the new millennium the UN Security Council put HIV/AIDS on the agenda as a security issue. This was the first time a non-traditional security issue was discussed in such a forum. Based upon the normative discussions raging within the field of securitization theory, this study seeks to analyse the empirical outcomes that the securitization effort, of putting HIV/AIDS on the Security Council agenda, might have had. While many studies argue the normative points of securitization when it comes to non-traditional security issues, this study turns to an empirical case. Based upon the resolution 1308, following the Security Council’s meeting, UNAIDS was chosen in order to uncover the possible outcomes of the securitization efforts. By using bureaucratic theory to develop a framework for the textual analysis of UNAIDS meeting documents from 1998-2005, this study uncovers undeniable changes to the nature and structure of the organization. The positive results yielded in the analysis of UNAIDS highlight that the use of securitization as a practical policy tool in to advance an issue at hand could well be a way forward with similar areas lacking sufficient attention and/or funding.

Philosophiae Doctor - PhD / The continued success of antiretroviral programmes in the treatment of HIV is dependent on access to a cost-effective HIV drug resistance test (HIV-DRT). HIVDRT involves sequencing a fragment of the HIV genome and characterising the presence/absence of mutations that confer resistance to one or more drugs. HIV-DRT using conventional DNA sequencing is prohibitively expensive (~US$150 per patient) for routine use in resource-limited settings such as many African countries. While the advent of ultra deep pyrosequencing (UDPS) approaches have considerably reduced (3-5 fold reduction) the cost of generating the sequence data, there has been an even more significant increase in the volume of data generated and the complexity involved in its analysis. In order to address this issue we have developed Seq2Res, a computational pipeline for HIV drug resistance test from UDPS genotypic data. We have developed QTrim, software that undertakes high throughput quality trimming of UDPS sequencing data to ensure that subsequently analyzed data is of high quality. The comparison of QTrim to other widely used tools showed that it is equivalent to the next best method at trimming good quality data but outperforms all methods at trimming poor quality data. Further, we have developed, and evaluated, a computational approach for the analysis of UDPS sequence data generated using the novel Primer ID that enables the generation of a consensus sequence from all sequence reads originating from the same viral template, thus reducing the presence of PCR and sequencing induced errors in the dataset as well as reducing. We see that while the Primer ID approach does undoubtedly reduce the prevalence of PCR and sequencing induced errors, it artificially reduces the diversity of the subsequently analysed data due to the large volume of data that is discarded as a result of there being an insufficient number of sequences for consensus sequence generation. We validated the sensitivity of the Seq2Res pipeline using two real biological datasets from the Stanford HIV Database and five simulated datasets The Seq2Res results correlated fully with that of the Stanford database as well as identifying a drug resistance mutations (DRM) that had been incorrectly interpreted by the Stanford approach. Further, the analysis of the simulated datasets showed that Seq2Res is capable of accurately identifying DRMs at all prevalence levels down to at least 1% of the sequence data generated from a viral population. Finally, we applied Seq2Res to UDPS resistance data generated from as many as 641 individuals as part of the CIPRA-SA study to evaluate the effectiveness of UDPS HIV drug resistance genotyping in resource limited settings with a high burden of HIV infections. We find that, despite the FLX coverage being almost three times as much as that of the Junior platform, resistance genotyping results are directly comparable between both of the approaches at a range of prevalence levels to as low as 1%. Further, we find no significant difference between UDPS sequencing and the "gold standard" Sanger based approach, thus indicating that pooling as many as 48 patient's data and sequencing using the Roche/454 Junior platform is a viable approach for HIV drug resistance genotyping. Further, we explored the presence of resistant minor variants in individual's viral populations and find that the identification of minor resistant variants in individuals exposed to nevirapine through PMTCT correlates with the time since exposure. We conclude that HIV resistance genotyping is now a viable prospect for resource limited setting with a high burden of HIV infections and that UDPS approaches are at least as sensitive as the currently used Sanger-based sequencing approaches. Further, the development of Seq2Res has provided a sensitive, easy to use and scalable technology that facilitates the routine use of UDPS for HIV drug resistance genotyping.