Submitted in fulfillment of the requirements for the degree of Doctor of Philosophy (PhD) Health Science, Durban University of Technology, Durban, South Africa, 2017. / Background: The HIV pandemic has attracted unprecedented scale-up in resources to curb its escalation and manage those afflicted. Although evidence from developing countries suggests that public health systems have been strengthened as a result of scale-up, only anecdotes exist in other countries. Despite scale-up, the prevalence of HIV/AIDS is still high and the resultant mortality and morbidity demands a refocus. Furthermore, the HIV/AIDS epidemic has severely strained vulnerable health systems in developing countries leading to concerns among policy makers about non-HIV priority services. Although anecdotally, it is clear that HIV scale-up has had profound effects on health systems, available evidence does not allow for an assessment of the impact of such effects on health care access, service delivery or medical outcomes for non- HIV conditions. The aim of this study was to determine the impact of HIV/AIDS scale-up on non-HIV priority services in the former Nyanza Province, Kenya. Additionally we determined the benefits and detriments of HIV programmes, and identified the elements of successful HIV programs and their effect on scale-up and last but not least determined the perceptions, attitudes and experiences of health care staff towards scale-up and integration of health care services. The first part of the main sequential study reviewed practices during scale-up by looking at public health facilities within the Province at Nyanza in Kenya. This looked at health management information systems (HMIS) and routine health facility client records for five years, 2009-2013 with a comparison of trends in 2009 to that in 2013. This data was reviewed in order to show trends in delivery of HIV priority and non-HIV services. The second part of the study utilized a prospective cross sectional survey to determine perceptions, attitudes and experiences xi of facility personnel towards HIV/AIDS scale up. Randomly sampled facilities involved in the delivery of any aspects of HIV diagnosis care and treatment were investigated. Self-administered questionnaires and in-depth interviews were used to obtain information on impact of HIV services on non-HIV priority services on health managerial staff in the facilities and key informants who have shaped scale up. We created a qualitative codebook based on three major themes identified from the data: (1) Meaning and importance of HIV scale-up (2) Perspectives of scale-up on service delivery on non-HIV services and (Ministry of State for Planning) Health facility staff awareness. The findings indicate that the interventions that were utilized in the scale-up of HIV in 2009 resulted in significant increases in uptake of the service in 2013 (p<0.01) and total integration of HIV and non-HIV services at all the health facilities thereby contributing to improved health outcomes beyond those specifically addressed by HIV programs. This study has also shown that utilization of both HIV and non-HIV services increased significantly for both years after integrated HIV care was introduced in the health facilities (p<0.01). Notable increases were found for ANC utilization (p=0.09), family planning (p=0.09), screening for tuberculosis and malaria (p<0.01) and provision of support services (p<0.01) to HIV infected people. The scale up of HIV in the region had several human resource policy implications resulting from staff turnover and workload. Stakeholder engagement and sustainability are critical in the sustenance of these initiatives. Strategic alliances between donors, NGOs and the government underpinned the scale-up process. Policies around scale-up and health service delivery were vital in ensuring sustainability of scale- up and service integration. This study has attempted to provide evidence on the impact of HIV scale-up on non-HIV service delivery in three different settings, in two different time periods and it therefore concludes that the evidence is mixed with most of the impact being positive with some aspects that still needs development. It is critical to pursue the integration of HIV and non- HIV services in a strategic and systematic manner so as to maximize the public health impact of these efforts. The proposed model, best practices and practices requiring improvement will be communicated to the relevant ministries to ensure its integration into policy. / D

AbstractAnalysing the Impact of Stigma and Discrimination on the Linkages Across the Continuum of HIV Services for Men who have Sex with Men: A Realist ApproachBackground and Aim The world has now entered the third decade of the AIDS epidemic. Men who have sex with men (MSM) continue to be disproportionately affected by HIV/AIDS. Haiti still struggles in its response to this ongoing crisis throughout the continuum of services: disease prevention, treatment, and HIV related stigma, prejudice, and discrimination. Much of the information reported on people living with HIV has come from the general population, but only a few parts of some of those studies have focused on MSM. Therefore, the overall aim of this dissertation was to analyse the impact of stigma and discrimination on the continuum of HIV services for MSM in order to ascertain why, how and under which circumstances MSM are engaged, linked and retained along the care continuum.Methods For this dissertation, data were collected via literature review, electronic medical records, participant observations, focus groups and semi structured interviews with medical students, health care workers and MSM. Using a realist approach based on mixed methods design we sought to address the influence of HIV and sexual stigma on the continuum of HIV services and to identify key mechanisms emerging from the context and leading to the outcomes. Quantitative social and medical data were gathered and analysed to produce descriptive and analytic statistics and qualitative data were analysed thematically regarding the objectives.FindingsResults indicated that MSM experienced stigma in multiple and overlapping layers. MSM described stigmatizing experiences stemming from religious sources, communities, family and friends, and from the medical establishment. From the social construction of heteronormativity in the society, several social and cultural factors, gender norms lie behind the stigma associated with sexual orientation and HIV. Moreover, medical students and healthcare givers still carry discriminatory attitudes towards them despite tailored interventions. Our analysis showed that current service delivery models are less than optimal in linking and retaining MSM, resulting in loss to follow-up in the continuum of care and failure to fully realize the health and prevention benefits. However, multi-level, contextual-based and socially accountable interventions can produce stigma mitigation through personal, health systems’ and contextual mechanisms for better engagement, adherence and retention throughout the continuum.ConclusionsThe results within this dissertation are intended to inform health professionals in the planning and implementation of interventions for better continuum outcomes in Haiti and similar contexts. This thesis provides insight and contextual information for a socially accountable framework of adapted interventions. To end the AIDS epidemic by 2030, Haiti, the Caribbean region and the entire world urgently need to defy expectations to reach the left behind.KeywordsHIV; Continuum of HIV Services; Stigma; Discrimination; Realist Evaluation; Context-Mechanism-Outcome; Social Accountability / Doctorat en Sciences de la santé Publique / info:eu-repo/semantics/nonPublished