Academic literature on the topic 'HIV infections – Swaziland'

Swaziland is one of the countries with the highest Human Immune-deficiency Virus (HIV) rates in the world. Consequently, the increased need for care and support for people living with Acquired Immune-deficiency Syndrome (AIDS), as well as orphaned and vulnerable children, is unprecedented. The response to combat the HIV epidemic has been evident in many areas as the country continues its fight against the HIV epidemic. However, efforts to provide care and support - including Anti-Retroviral Therapy (ART), management of opportunistic infections, and community home-based care - have, so far, largely stemmed from the health sector. Housing care and other non-medical support is continuing to lag behind. Lack of proper housing is one of the deprivations suffered by orphaned children and people living with AIDS, which predisposes them to attacks by opportunistic infections and other vulnerabilities and disrupts the continuum of care, whilst at times denying occupants the required privacy. This paper focuses on creating an understanding of why housing care and support for HIV and AIDS affected is lagging behind in Swaziland. It suggests cultural, economic, political and policy issues as the underlying reasons for this, and, therefore, concludes that there is need for bold policy reforms in these areas. In order to create a proper framework for such reforms, the paper reviews the following: 1. The national housing policy's implications on the care and support for people living with HIV and AIDS and the orphaned and vulnerable children; and 2. The current human settlements related responses to HIV and AIDS in Swaziland's rural, peri-urban and urban areas. In this context, urban development planning paradigms and the extent to which HIV and AIDS is being integrated into the development plans are discussed.

Background: In vitro, animal, biological and observational clinical studies suggest that some hormonal methods, particularly depot medroxyprogesterone acetate – DMPA, may increase women’s risk of HIV acquisition. DMPA is the most common contraceptive used in many countries worst affected by the HIV epidemic. To provide robust evidence for contraceptive decision-making among women, clinicians and planners, we are conducting the Evidence for Contraceptive Options and HIV Outcomes (ECHO) study in four countries with high HIV incidence and DMPA use: Kenya, South Africa, Swaziland, and Zambia (Clinical Trials.gov identifier NCT02550067). Study design: We randomized HIV negative, sexually active women 16-35 years old requesting effective contraception and agreeing to participate to either DMPA, the copper T 380A intrauterine device or levonorgestrel implant. Participants attend a contraception support visit after 1 month and quarterly visits thereafter for 12 to 18 months. Participants receive a standard HIV prevention package and contraceptive side-effect management at each visit. The primary outcome is HIV seroconversion. Secondary outcomes include pregnancy, serious adverse events and method discontinuation. The sample size of 7800 women provides 80% power to detect a 50% difference in HIV risk between any of the three method pairs, assuming 250 incident infections per comparison. Ethical considerations: Several WHO consultations have concluded that current evidence on HIV risk associated with DMPA is inconclusive and that a randomized trial is needed to guide policy, counselling and choice. Previous studies suggest that women without a specific contraceptive preference are willing to accept randomization to different contraceptive methods. Stringent performance standards are monitored by an independent data and safety monitoring board approximately every 6 months. The study has been conducted with extensive stakeholder engagement. Conclusions: The ECHO study is designed to provide robust evidence on the relative risks (HIV acquisition) and benefits (pregnancy prevention) between three effective contraceptive methods.

Background: In vitro, animal, biological and observational clinical studies suggest that some hormonal methods, particularly depot medroxyprogesterone acetate – DMPA, may increase women’s risk of HIV acquisition. DMPA is the most common contraceptive used in many countries worst affected by the HIV epidemic. To provide robust evidence for contraceptive decision-making among women, clinicians and planners, we are conducting the Evidence for Contraceptive Options and HIV Outcomes (ECHO) study in four countries with high HIV incidence and DMPA use: Kenya, South Africa, Swaziland, and Zambia (Clinical Trials.gov identifier NCT02550067). Study design: We randomized HIV negative, sexually active women 16-35 years old requesting effective contraception and agreeing to participate to either DMPA, the copper T 380A intrauterine device or levonorgestrel implant. Participants attend a contraception support visit after 1 month and quarterly visits thereafter for up to 18 months. Participants receive a standard HIV prevention package and contraceptive side-effect management at each visit. The primary outcome is HIV seroconversion. Secondary outcomes include pregnancy, serious adverse events and method discontinuation. The sample size of 7800 women provides 80% power to detect a 50% relative increase in HIV risk between any of the three method pairs, assuming 250 incident infections per comparison. Ethical considerations: Several WHO consultations have concluded that current evidence on HIV risk associated with DMPA is inconclusive and that a randomized trial is needed to guide policy, counselling and choice. Previous studies suggest that women without a specific contraceptive preference are willing to accept randomization to different contraceptive methods. Stringent performance standards are monitored by an independent data and safety monitoring board approximately every 6 months. The study has been conducted with extensive stakeholder engagement. Conclusions: The ECHO study is designed to provide robust evidence on the relative risks (HIV acquisition) and benefits (pregnancy prevention) between three effective contraceptive methods.

SUMMARYSwaziland has the highest prevalence of human immunodeficiency virus (HIV) in the world. Attrition (loss to follow-up and mortality) in people living with HIV/AIDS (PLWHA) already on treatment is a major challenge, undermining achievements of the antiretroviral treatment (ART) programme in Swaziland. The contributing factors to attrition in the Swazi context are unclear. This study aims to (1) estimate attrition from the ART programme 12 months after ART initiation in Swaziland, and (2) determine the predictors of attrition in PLWHA treated with ART in Swaziland. A retrospective cohort study using national baseline data was conducted. A competing-risk Cox proportional hazard regression was used to determine the predictors of attrition. We estimated 10·3% (95% confidence interval 10·1–10·6) attrition in 16 423 participants that initiated ART in 2012. Attrition was significantly associated with sex, age, district, treatment supporter at initiation, co-infection of HIV and TB, functional status, WHO clinical stage, and ownership of facility. Our study can form a base of policies, plans, and service delivery strategies for preventing and controlling attrition in Swaziland.

Introduction. Our objective is to understand how HIV infection increases the risk of progression from latent tuberculosis (TB) to active disease. We understand now that immunity is a balance of competing immune responses by multiple cell types. Since T-lymphocyte production of interferon-gamma (IFN-γ) in response toMycobacterium tuberculosis (Mtb) antigens fails to differentiate disease from latent infection, we applied a comprehensive profiling methodology to define immune biomarkers that reliably predict a patient’s TB risk.Methods. We established a cohort of HIV-infected adults with TB disease from Swaziland. Multiparametric flow cytometry was used to quantify the mycobacterial-specific anti-inflammatory (IL-4 and IL-10) and proinflammatory (IFN-γ) immune response.Results. From 12 HIV-infected Swaziland patients with TB disease, the CD4+, CD8+, Double Negative, and CD56+CD3−lymphocytes increase their IL-4 : IFN-γratio as HIV disease worsens (Spearmanrof −0.59; −0.59; −0.60; and −0.59, resp.;p<0.05). Similarly, HIV severity is associated with an increased IL-10 : IFN-γratio (Spearmanrof −0.76;p=0.01).Conclusion. As HIV disease progresses, both the adaptive and innate branches skew away from an inflammatory and towards anti-inflammatory phenotype.

Background: HIV and AIDS remains a pandemic that has greatly affected many regions and countries in the world. Africa is the hardest hit region by tthis disease while southern Africa appears to be the melting pot for HIV and AIDS. The HIV and AIDS pandemic remains the greatest sustainable human development and public health challenge for Swaziland. Swaziland is the world’s worst affected country with the youth the most vulnerable group to HIV and AIDS due to many factors.Objectives:’Methods: This study investigated the behavioral factors that contributed to the transmission of HIV and AIDS among female youth of Mbabane in Swaziland and to suggest measures that could encourage positive female youth behavior change in order to mitigate the spread and impacts of the pandemic. The study used a qualitative research approach in order to gain an in-depth experience of female youths in Mabane. Data were collected using a questionnaire, which were distributed to 210 randomly sampled females aged 16 to 24 years in Mbabane and who attended Mbabane Public Health Unit. The Behavior Change Communication (BCC) theoretical framework was usedin order to contextualize the study.Results: Most respondents were female-single youth (64%), almost half (45%) had a high school education and most were unemployed (57%) with little or no source of income. The majority (88%) were sexually active and the main sources of HIV/AIDS transmission was through sex. For many (52%) health facilities were their main source of HIV and AIDS information. The majority (97%) were knowledgeable about HIV and AIDS, but casual sex, inconsistent condom usage and early sexual debut among others were still prevalent indicating resistance to behavior change.Conclusion: The findings indicated that though the majority of the respondents had knowledge of HIV and AIDS, positive behavior change remained a challenge. Most respondents (88%) had one sexual partner with 38% reporting condom use during their last sexual encounter. HIV/AIDS awareness was widespread. However, there were still characteristics of resistance to behavior change, because there was evidence of underestimation of HIV risk through engagement in behavior, which contributed to HIV infection and spread.Behavioral change measures using the BCC model is proposed.Keywords: BCC Model, behavior change, HIV, AIDS, youth, Swaziland.

Background: Over one-quarter of the adult population in Swaziland is estimated to be HIV positive. Men’s use of sexual health (SH) services has significant implications for HIV prevention. This study aimed to understand Swazi men’s health-seeking behaviours in relation to SH and HIV services. Methods: A household survey was conducted in Manzini (n = 503), complemented by 23 semi-structured interviews and two focus group discussions (with a total of 10 participants). Results: One-third of male survey participants used SH services in the past year, most commonly HIV testing (28%). Service users were more likely to be sexually active (aOR 3.21, 95% CI: 1.81–5.68 for those with one partner; and aOR 2.35, 95% CI: 1.25–4.41 for those with multiple partners) compared with service non-users. Service users were less likely to prefer HIV services to be separated from other healthcare services (aOR 0.50, 95% CI: 0.35–0.71), or to agree with travelling further for their HIV test (aOR 0.52, 95% CI: 0.33–0.82) compared with non-users, after controlling for age-group and education. Men avoided SH services because they feared being stigmatised by STI/HIV testing, are uncomfortable disclosing SH problems to female healthcare providers, and avoided HIV testing by relying on their wife’s results as a proxy for their own status. Informal providers, such as traditional healers, were often preferred because practitioners were more often male, physical exams were not required and appointments and payment options were flexible. Conclusion: To improve men’s uptake of SH services, providers and services need to be more sensitive to men’s privacy concerns, time restrictions and the potential stigma associated with STI/HIV testing.

Thesis (MTh)--Stellenbosch University, 2012.<br>ENGLISH ABSTRACT: This thesis critically analyses the appropriateness and effectiveness of the ABC model in the HIV/AIDS prevention within the context of Swaziland. According to Louw (2008:423), the ABC model stands for the following: A = Abstinence, B = Be faithful and C = use Condoms. According to Green and Herling (2007:1) the ABC model has gained the attention of many countries. The attempt of this model in HIV prevention was to “aim at empowering people through value-based programs to basically abstain from sex as long as possible, to be faithful to one intimate partner and to use condoms correctly and consistently” (De la Porte 2006:79). The assessment of the HIV/AIDS virus in 1983-1984 came as a shock. It was difficult for the church to know at that time how to respond. Some of the responses pointed to the virus as punishment of God. Gradually the church started to become involved in the pandemic. From a Christian spirituality perspective it was argued that the so called ABC model could be viewed as a means of remedy within a prevention approach. The cultural issues as well as human sexuality factors have been discovered to be an obstacle in the ABC model in playing a progressive role in Swaziland. The cultural factors that prevent the ABC model from accomplishing effective results are listed in the final report of (Whiteside et al. 2006: 18-19): bunganwa (having multiple sexual partners; a cultural practice of male married and unmarried to have many girlfriends); kungenwa (levirate or wife inheritance); a widow is given in marriage to marry the brother of her deceased husband without the consent of the women which exposes women to the HIV virus. This practice is done without the consent of the women. Kujuma (occasional overnight visits between unmarried lovers); kuhlanta (a young girl bearing the children of her infertile sister); kushenda (extramarital relationships); kulamuta (a man having a sexual relationship with a younger sister of his wife); and sitsembu (polygamy, one man with more than one wife); this is a common cultural practice found in many African countries due to gender inequality (Chitando 2009:26). This has led to Swaziland being seriously affected by the HIV/AIDS virus (Rupiya 2006:66). The high rate of infection is frightening in a small country with a population of 1 million. As Bishop M, Mabuza, the Anglican bishop indicated, the nation‟s existence is threatened. (Rosenow 2011: 32). Therefore the researcher proposed a pastoral model which gives dignity to human and adds the spiritual dimension of healing in the pastoral care and counselling. There is an urgent need for church leaders to be empowered to face the HIV/AIDS with knowledge that the pandemic is not a punishment for promiscuous people. The theology of sexuality emphasises the responsibility in every sexual engagement for people to be conscious to whatever decision they take.<br>AFRIKAANSE OPSOMMING: In hierdie navorsing word die toepaslikheid en effektiwiteit van die ABC model in die voorkoming van MIV/Vigs binne die konteks van Swaziland krities ontleed. Volgens Louw (2008:423) staan ABC (in Engels) vir: A = Onthouding, B = Getrouheid aan een maat en C = Die gebruik van kondome. Die navorser, ‟n geordende predikant van die Evangeliese Lutherse Kerk, bespreek die erns van die voorkoms van die MIV/Vigs-infeksie in Swaziland. Empiries is bewys dat Swaziland een van die lande in Sub-Sahara en die wêreld is met die hoogste infeksiekoers (Rupiya 2006:66). Dit is ernstig in ‟n klein landjie soos Swaziland met ‟n bevolking van slegs 1 129 000. Die pandemie het ‟n impak op alle gemeenskappe in die land en bied‟n groot uitdaging vir die Kerk in Swaziland. Die vraag is hoe die Kerk, in haar pastorale bediening, die ABC model kan gebruik om die globale poging te steun om te verhoed dat MIV/Vigs versprei. Hoe kan die konsep van die ABC model toegepas word sodat die Kerk, as hulpgewende gemeenskap, kan sorg vir die siele van die gemeentelede (cura animarum) en effektief inligting omtrent die ABC model kan versprei en uitreik na MIV-positiewe mense? Die navorser stel voor dat daar verandering moet kom in die gesindheid van die Kerk en dat daar ‟n herkonseptualisasie van die voorkomingstrategie en die Skrifverklaring van menslike seksualiteit moet wees. Die Kerke in Swaziland moet hulle houding verander. Daar moet baie meer openlikheid wees sodat sosio-kulturele kwessies openlik bespreek kan word. Daar moet ‟n kritiese herbepaling wees van die tradisies en die kerkbeleid rondom menslike seksualiteit en hoe dit betrekking het op die MIV/Vigs-pandemie.

This research focuses on vulnerable children in Swaziland, the country with the highest level of adult HIV prevalence in the world, where nearly 25 percent of children will be orphaned by 2010. It investigates the experiences of relatively poor urban children growing up in the epidemic and the coping strategies the children and their adult carers adopt. Through the lens of both children and adult carers, it explores the ways sexual knowledge is gained and used by older children in the context of HIV/AIDS as well as the experience of coping with widespread bereavement. In this way, it adds to the literature on childhoods in the 'South' and the increasing recognition of the heterogeneity of children's lived experiences. Rather than being seen as passive, the agency of both vulnerable children and their adult carers emerges as they seek to improve their livelihoods. The way this agency connects with government, NGO and community structures is revealed by showing the opportunities for and constraints on gaining access to education and health-care. The interwoven roles of government, international donors, NGOs and civil society is explored by assessing the relative merits of supporting vulnerable children by either welfare assistance to poor families or new forms of 'community' care structures or institutionalised residential care. The critical importance of relationships and power relations between key actors in different organisations and the effect this has on implementation of interventions for children is discussed as well as the relevance of these findings to vulnerable children in other settings.

Thesis (MPhil)--Stellenbosch University, 2013.<br>ENGLISH ABSTRACT: World Health Organisation (WHO) and UNAIDS named male circumcision as a key intervention in halting the spread of HIV in Africa. Several countries in sub-Saharan Africa with low levels of male circumcision (MC) and high HIV prevalence are scaling up MC services, Swaziland being one of them. Despite the circumcisions done in Swaziland it seems there is no significant decrease in HIV prevalence which might be due to various reasons. One of the reasons noted was the behaviour of men after circumcision because of the belief of total of immunity. This has led to an increase in high risk behaviour, increased promiscuity, multiple partners, more unsafe sex and failure to use condoms, thereby defeating the own stated purpose. Objectives: 1) To identify the knowledge, attitude and practices (KAP) of circumcised men towards safe sex. 2) To establish the existing knowledge of the relationship between circumcision and HIV prevention. 3) To establish whether men in Swaziland take part in riskier sexual behaviour after or before being circumcised. 4) To make recommendations for the counseling programme. Methodology: A cross-sectional analytical study whereby both qualitative and quantitative methods of data collection was used. Simple random sampling was used to select circumcised men from Mankayane hospital, Mankayane and Holy Rosary high schools and a total of 90(60 adults and 30 teenagers) filled in self- administered questionnaires and also took part in focus group discussions. Purposive sampling was used to choose the MC Counsellors and in-depth interviews were done to complement the information on knowledge, attitudes and practices of men towards safe sex before, during and after circumcision. An observation checklist was also used to check what they included in their counselling sessions. Results: The responses solicited from the men who participated in this study show that there is basic knowledge with regards to safe sex and the value of MC in the prevention of HIV. The pattern in the data however shows that those that were the most recent to undergo medical circumcision had the most varied opinions on the extent to which MC protect one from HIV. There was mixed attitude towards safe sex after circumcision, some wanting to maximise their satisfaction without using protection. The data also points to a pattern were the men have a high relationship turnover and this was more discernible among the teenagers who suggest that the relationships are not built on commitment but possible experimentation. While the study did not have control that tracked uncircumcised men for comparative purposes, the findings point to inconsistent use of condoms among men which heightens the risk of HIV transmission. The results point to a well-structured programme of counseling followed by MC counselors. Conclusion: The study was able to satisfy the aim and objectives. The research process was designed to collect the necessary data and be analysed in a manner that answered the research question. The research target population and subsequent sample represented the geographical scope of the study. The research tools were designed to be easy for the respondents to use. The distribution and collection method was designed to give the respondents less hassle as possible. This had a positive impact on the response rate, which increased the validity of the data collected. Both the literature review and primary research findings affirm that MC without behaviour change is not the panacea for prevention of HIV.<br>AFRIKAANSE OPSOMMING: Die Wêreldgesondheidsorganisasie (WGO) en UNAIDS het manlike besnydenis as ’n belangrike intervensie uitgewys om die verspreiding van MIV in Afrika te stuit. Verskeie lande in Afrika suid van die Sahara met lae vlakke van manlike besnydenis (MB) en hoë vlakke van MIV is tans besig om MB-dienste uit te brei, en Swaziland is geen uitsondering nie. Ondanks die besnydenis wat in Swaziland gedoen word, blyk daar egter geen beduidende afname in MIV te wees nie. Dít kan aan verskillende redes toegeskryf word. Een daarvan is mans se gedrag ná besnyding vanweë hul oortuiging dat hul geheel en al immuun is. Dit het tot ’n toename in hoërisikogedrag, meer promiskuïteit, veelvuldige bedmaats, meer onveilige seks en ’n gebrek aan kondoomgebruik gelei, wat uiteraard die doel verydel. Oogmerke: 1) Om besnyde mans se kennis, houdings en praktyke met betrekking tot veilige seks te bepaal. 2) Om bestaande kennis oor die verband tussen besnydenis en MIV-voorkoming te bepaal. 3) Om vas te stel of mans in Swaziland voor of ná besnyding geneig is tot meer riskante seksuele gedrag. 4) Om aanbevelings te doen vir die MB-beradingsprogram. Metodologie: ’n Deursnee- analitiese studiebenadering met sowel kwalitatiewe as kwantitatiewe datainsamelingsmetodes is gevolg. Met behulp van eenvoudige ewekansige steekproefneming is mans van Mankayane-hospitaal en tienerseuns van Mankayane- en Holy Rosary-hoërskool gekies. Altesaam 90 respondente (60 volwassenes en 30 tieners) het vraelyste op hul eie ingevul en ook aan fokusgroepbesprekings deelgeneem. Doelbewuste steekproefneming is gebruik om ’n groep MB-beraders te kies, met wie daar diepteonderhoude gevoer is om die inligting oor mans se kennis, houdings en praktyke met betrekking tot veilige seks voor, gedurende en ná besnyding aan te vul. ’n Waarnemingskontrolelys is ook gebruik om af te merk wat die beraders by hul beradingsessies insluit. Resultate: Die antwoorde van die mans wat aan hierdie studie deelgeneem het, toon basiese kennis met betrekking tot veilige seks en die waarde van MB in die voorkoming van MIV. Die patroon in die data toon egter dat diegene wat mees onlangs mediese besnydenis ondergaan het, die mees uiteenlopende menings het oor die mate waarin MB jou teen MIV beskerm. Daar is ’n gemengde houding oor veilige seks ná besnyding: Party mans jaag eenvoudig so veel moontlik bevrediging na, sonder enige beskerming. Die data dui ook op ’n patroon van ’n hoë verhoudingsomset onder die respondente. Dít was veral waarneembaar onder die tieners, wat te kenne gee dat hul verhoudings nie op toewyding gegrond is nie, maar eerder moontlike eksperimentasie. Hoewel die studie geen kontrolegroep met onbesnyde mans vir vergelykende doeleindes gehad het nie, dui die bevindinge op inkonsekwente kondoomgebruik onder mans, wat op sy beurt die risiko van MIV-oordrag verhoog. Die resultate dui voorts daarop dat MB-beraders ’n goed gestruktureerde beradingsprogram volg. Gevolgtrekking: Die studie het in sy doel en oogmerke geslaag. Die navorsingsproses was ontwerp om die nodige data in te samel en te ontleed ten einde die navorsingsvraag te beantwoord. Die navorsing steikenpopulasie en gevolglike steekproef was verteenwoordigend van die geografiese studiebestek. Die navorsingsinstrumente was ontwerp vir maklike gebruik deur respondente. Die verspreidings- en insamelingsmetode is gekies om so min moontlik moeite vir respondente te veroorsaak. Dít het ’n positiewe impak op die reaksiesyfer gehad, wat weer die geldigheid van die ingesamelde data verhoog het. Sowel die literatuuroorsig as die primêre navorsingsbevindinge bevestig dat MB sonder gedragsverandering allermins ’n ‘wondermiddel’ vir MIV-voorkoming is.

Thesis (MPhil)--Stellenbosch University, 2013.<br>ENGLISH ABSTRACT: Since the beginning of the HIV epidemic in the early 1980s, men who have sex with men (MSM) have been disproportionately affected by the virus. Sex between men is the main route of transmission of HIV in some parts of the world. In some other places it is a secondary route of transmission. Worldwide, MSM are classified as most-at-risk populations because of their higher risk of HIV transmission. Although sex between men occurs in most societies, its existence, importance in HIV prevention are frequently denied. Often, these men are neglected in HIV prevention interventions. Sexual acts between men have often been condemned and sometimes criminalized. In some countries, penalties for those accused of sexual acts between men are among the severest available. Elsewhere, even where same-sex behaviour is not illegal, there is frequently unofficial persecution by the authorities or discrimination against or stigmatisation of those men known or thought to be having sexual relations with other men. For these reasons, in many parts of the world, sex between men is hidden or secretive. This makes an assessment of its extent, and of the various types of sexual acts that occur, even more difficult. As a result of being neglected, there has been generally lack of research and services directed towards MSM. In sub-Saharan Africa, for instance, it was only over 10 years ago, in 2001, when the first behavioural survey among MSM was conducted. However, few countries have conducted such studies and MSM’s specific health needs, especially for HIV prevention, are still not being met. In most countries, like Swaziland, the HIV prevalence is still generalized. Although Swaziland bears the burden the highest HIV prevalence in the world at 26% for the age group 15-49 (UNAIDS, 2010), interventions to MSM and other most-at-risk populations are limited. The study’s main aim was to identify the prevention needs of MSM in Swaziland. A total of 50 MSM were interviewed in order to find information. In addition, five key informants who were managers of HIV prevention programmes were also interviewed. It was established that there is a gap between the MSM’s needs and the interventions currently available. There were factors that put MSM at risk for HIV infection that were identified by the study. It was established that some of the HIV prevention did not meet the specific needs and expectations of MSM. Knowledge on some HIV risk behaviours and some prevention strategies targeting MSM was limited.<br>AFRIKAANSE OPSOMMING: Sedert die begin van die MIV-epidemie in die vroeë 1980's, het die mans wat seks het met mans (MSM) is buite verhouding beïnvloed deur die virus. Seks tussen mans is die belangrikste roete van die oordrag van MIV in sommige dele van die wêreld. In sommige ander plekke is dit is 'n sekondêre roete van oordrag. Wêreldwyd, MSM word geklassifiseer as die meeste-at-Risk bevolking as gevolg van hul hoër risiko van MIV-oordrag. Alhoewel seks tussen mans in die meeste samelewings voorkom, word dikwels sy bestaan, belang in MIV-voorkoming geweier. Dikwels word hierdie manne verwaarloos in MIV-voorkoming intervensies. Seksuele dade tussen mans dikwels veroordeel en soms gekriminaliseer. In sommige lande, strawwe vir diegene wat beskuldig word van seksuele dade tussen mans is onder die ergste beskikbaar. Elders, selfs waar van dieselfde geslag gedrag nie onwettig is nie, is daar dikwels nie-amptelike vervolging deur die owerhede of diskriminasie of stigmatisering van daardie manne wat bekend is of gedink word om seksuele verhoudings met ander mans. Vir hierdie redes, seks tussen mans, in baie dele van die wêreld is verborge of geheimsinnig. Dit maak 'n assessering van die omvang, en van die verskillende tipes van seksuele dade wat plaasvind, nog moeiliker. As 'n gevolg van verwaarloos, is daar gewoonlik gebrek aan navorsing en dienste gerig op MSM. In sub-Sahara Afrika, byvoorbeeld, dit was net meer as 10 jaar gelede, in 2001, toe die eerste gedrags-opname onder MSM is uitgevoer. Egter, het 'n paar lande uitgevoer sodanige studies en MSM se spesifieke gesondheid behoeftes, veral vir MIV-voorkoming, is nog steeds nie bereik word nie. In die meeste lande, soos Swaziland, die voorkoms van MIV is nog steeds algemene. Hoewel Swaziland dra die las om die hoogste voorkoms van MIV in die wêreld op 26% vir die ouderdomsgroep 15-49 (UNAIDS, 2010), intervensies MSM en ander die meeste-op-risiko bevolkings is beperk. Die studie se hoofdoel was om die voorkoming van MSM te identifiseer in Swaziland. 'N totaal van 50 MSM is ondervra ten einde inligting te vind. Daarbenewens is ook vyf sleutel informante wat bestuurders van die voorkoming van MIV-programme ondervra. Daar is vasgestel dat daar is 'n gaping tussen die MSM se behoeftes en die intervensies wat tans beskikbaar is. Daar is faktore wat sit MSM 'n risiko vir MIV-infeksie wat deur die studie geïdentifiseer is. Daar is vasgestel dat sommige van die MIV-voorkoming het nie voldoen aan die spesifieke behoeftes en verwagtinge van MSM. Kennis op 'n aantal MIV-risiko gedrag en 'n paar voorkoming strategieë fokus MSM is beperk.

Thesis (PhD)--Stellenbosch University, 2014.<br>ENGLISH ABSTRACT: This study aims to understand the processes and factors that explain the framing of HIV and AIDS policy in Botswana, South Africa and Swaziland. Africa remains the global epicentre of the HIV and AIDS epidemic with Southern Africa remaining the most affected region in the world. The investigation centres on the HIV and AIDS policymaking discourses and dynamics leading to the securitisation of the epidemic in the three countries. The central focus of the study covers the timeframe of the leadership of President Mogae in Botswana, President Mbeki in South Africa and King Mswati III in Swaziland. This period is important as it characterises the HIV and AIDS epidemic being elevated onto the political agenda of the respective countries. This dissertation relies on two strands of theoretical literature namely, public policy theory and securitisation theory to help explain the framing of policy decision-making that leads to the process of securitisation of the HIV and AIDS epidemic in the three countries. This study is a multiple case study within the qualitative research paradigm. This research is based on three case studies: Botswana, South Africa and Swaziland. As far as data collection is concerned, this study drew on primary sources of data, which consisted of documents obtained during the fieldwork from various stakeholders such as such as official government documents, as well as official documents from international and domestic HIV and AIDS organisations. Twenty semi-structured interviews were also conducted between 2007 and 2008 with various stakeholders including government officials, representatives of domestic and international HIV and AIDS organisations operating in the respective countries, researchers from think tanks and academics. In addition, eleven exploratory interviews were also conducted as part of the fieldwork process. Furthermore this study also relied on various secondary sources of data such as scholarly articles and books, official documents and legislation and newspaper articles. The preliminary results collected and analysed in this study suggest that Botswana, South Africa and Swaziland have all demonstrated a degree of formal commitment to adopting international guidelines to combat the epidemic. The thesis shows that while all three countries may share the burden of the epidemic, each presents a different political, social and cultural identity with different institutional architects (both foreign and domestic) that determined the nature of the response policy to the epidemic. The study shows that each of the three case studies presents an example of differing degrees of securitisation attempts: i) Botswana - successful securitisation; ii) South Africa - unsuccessful securitisation; and iii) Swaziland - partial securitisation because different actors and audiences are positioned at varying points along a spectrum of securitisation. This degree of securitisation can be linked to the acceptance of international ideas and the prevailing global discourse regarding the HIV and AIDS epidemic and the openness to forming collaborative agreements between state and non-state actors in each of the three countries.<br>AFRIKAANSE OPSOMMING: Hierdie studie poog om ’n begrip te ontwikkel van die prosesse en faktore wat verklaar hoe beleid rondom MIV en VIGS in Botswana, Suid-Afrika en Swaziland geraam word. Die Afrikavasteland is nog steeds die wêreld se MIV en VIGS-episentrum en die Suider-Afrika-streek loop die mees gebuk onder die epidemie. Die ontleding sentreer op die MIV en VIGS beleidsdiskoerse en die dinamieke wat aanleiding gee tot die beveiliging van die epidemie in die drie lande. Die kollig val op die tyd toe President Mogae van Botswana, President Mbeki van Suid-Afrika en Koning Mswati III van Swaziland aan bewind was. Hierdie periode is van belang omdat dit die tyd was toe MIV en VIGS op die drie lande se politieke agendas geplaas is. Die proefskrif gebruik literatuur uit twee teoretiese velde, naamlik openbare beleidsteorie en sekuriteitsteorie, om te verklaar hoe daar op bepaalde beleide besluit word, hoe dit geraam word, en die proses waarvolgens MIV en VIGS gevolglik in die drie lande beveilig word. Die studie is ’n meervuldige gevallestudie binne die kwalitatiewe navorsingsparadigma. Die navorsing is op drie gevallestudies gebaseer, te wete Botswana, Suid-Afrika en Swaziland. Ten opsigte van data-insameling, het die studie van primêre databronne gebruik gemaak bestaande uit bewysstukke wat van verskeie belangegroepe verkry is. Hierdie stukke beslaan amptelike regeringsdokumente en amptelike dokumentasie van internasionale sowel as nasionale MIV en VIGS-organisasies. Daar is ook met verskeie belangegroepe onderhoude gevoer. Die belangegroepe het bestaan uit regeringsamptenare, die verteenwoordigers van nasionale en internasionale MIV en VIGS-organisasies betrokke in die drie lande, akademici, en kundiges by navorsingsinstansies. Twintig semi-gestruktureerde onderhoude is in 2007 en 2008 gevoer. Boonop is daar as deel van die empiriese navorsing 11 verkenningsonderhoude gevoer. Die studie het ook van verskeie sekondêre databronne soos vakwetenskaplike artikels en boeke, amptelike dokumentasie, wetaktes en koerantartikels gebruik gemaak. Die voorlopige bevindinge dui dat Botswana, Suid-Afrika en Swaziland elkeen hulself tot ’n mate formeel tot internasionale riglyne verbind het om die epidemie te beveg. Die proefskrif bewys dat ofskoon al drie lande swaar aan die las van die epidemie dra, daar by elkeen verskillende politieke, maatskaplike en kulturele identiteite, asook institusionele argitekte (plaaslik sowel as buitelands) bestaan wat die aard van die beleidsrespons bepaal het. Die studie dui verskillende grade van beveiliging by elkeen van die gevallestudies: i) Botswana – suksesvolle beveiliging; ii) Suid-Afrika – onsuksesvolle beveiliging; en iii) Swaziland – gedeeltelike beveiliging. Hierdie grade van beveiliging kan verklaar word aan die hand van die mate waartoe daar by elkeen van die lande aanvaarding was van internasionale denke en diskoers oor die MIV en VIGS-epidemie en of samewerking tussen staats- en nie-staatsakteurs bewerkstellig is.

HIV infection persists in Swaziland with the highest prevalence of the disease globally – 1 in 4 Swazis aged 15-49 are HIV-positive. Women have a higher rate of infection than men (31.1% of women are HIV-positive, whereas 19.7% of men are HIV-positive). The difference in prevalence between the sexes raises some concerns, particularly due to the possibility of vertical transmission from mothers to infants because the average number of children ever born per woman is 2.28 for all women and 3.58 children for married women. This research aimed to determine if there was a significant difference regarding the knowledge and personal beliefs about HIV transmission between men and women. Obtaining correct knowledge regarding the transmission of HIV and where to get tested for HIV is vital to preventing further transmission of the disease. The Demographic and Health Surveys Program (DHS) gathered data in 2006-2007 to determine the baseline knowledge of individuals about the transmission of HIV. Comparisons of data collected from Swazi men (n = 4,156) and women (n = 4,987) concerning their knowledge and beliefs about HIV were made in order to obtain descriptive statistics, including chi-square to determine the presence or absence of significance (p-values) and percent differences between the sexes. Statistical Package for the Social Sciences (SPSS) software was utilized to perform all statistical analyses using both the chi-square and percent difference functions. Data was weighted accordingly prior to analyses being run in SPSS. Questions regarding the individuals’ personal beliefs about the transmission of HIV were included on surveys for both sexes, specifically addressing the following: 1) the outward appearance of those who are HIV-positive (96.1% of women and 95.7% of men believed healthy-looking individuals can be infected with HIV; p = 0.336, % difference = 0.3999, χ2 = 0.926), 2) the role (or lack thereof) of mosquitoes in transmitting HIV (65.7% of women and 66.1% of men believed mosquitoes cannot transmit HIV; p = 0.688, % difference = 0.3999, χ2 = 0.161), 3) supernatural involvement in the transmission of HIV (92.3% of women and 91.7% of men believed supernatural means do not contribute to the spread of HIV; p = 0.292, % difference = 0.5999, χ2 = 1.112), 4) and the ability of HIV to be spread via food intake (82.2% of women and 82.3% of men believe they cannot becoming infected with HIV by sharing food with an HIV-positive individual; p = 0.901, % difference = 0.0999, χ2 = 0.016). Despite no statistically significant differences between the beliefs about HIV transmission held by both men and women, the data indicated only 51.9% of women and 51.4% of men possess comprehensively correct knowledge about the transmission of HIV. Furthermore, although 91.8% of women knew where to get tested for HIV, only 78.1% of men knew where to get tested for HIV. However, an encouraging 73.8% of women and 71.8% of men between the ages of 18 and 19 stated they believed adolescents between the ages of 12 and 14 should be taught proper condom use to prevent HIV infection. Comprehensive adolescent and adult sex education programs are indicated to ensure all adolescents and sexually active men and women possess correct knowledge about the transmission of HIV and where to seek assistance for HIV testing and treatment.

付記する学位プログラム名: グローバル生存学大学院連携プログラム<br>Kyoto University (京都大学)<br>0048<br>新制・課程博士<br>博士(医学)<br>甲第20266号<br>医博第4225号<br>新制||医||1021(附属図書館)<br>京都大学大学院医学研究科医学専攻<br>(主査)教授 小泉 昭夫, 教授 中山 健夫, 教授 髙折 晃史<br>学位規則第4条第1項該当

Multilevel models account for different levels of aggregation that may be present in the data. Researchers are sometimes faced with the task of analysing data that are collected at different levels such that attributes about individual cases are provided as well as the attributes of groupings of these individual cases. Data with multilevel structure is common in the social sciences and other fields such as epidemiology. Ignoring hierarchies in data (where they exist) can have damaging consequences to subsequent statistical inference. This study applied multilevel models from frequentist and Bayesian perspectives to the Swaziland Demographic and Health Survey (SDHS) data. The first model fitted to the data was a Bayesian generalised linear mixed model (GLMM) using two estimation techniques: the Integrated Laplace Approximation (INLA) and Monte Carlo Markov Chain (MCMC) methods. The study aimed at identifying determinants of HIV in Swaziland and as well as comparing the different statistical models. The outcome variable of interest in this study is HIV status and it is binary, in all the models fitted the logit link was used. The results of the analysis showed that the INLA estimation approach is superior to the MCMC approach in Bayesian GLMMs in terms of computational speed. The INLA approach produced the results within seconds compared to the many minutes taken by the MCMC methods. There were minimal differences observed between the Bayesian multilevel model and the frequentist multilevel model. A notable difference observed between the Bayesian GLMMs and the the multilevel models is that of differing estimates for cluster effects. In the Bayesian GLMM, the estimates for the cluster effects are larger than the ones from the multilevel models. The inclusion of cluster level variables in the multilevel models reduced the unexplained group level variation. In an attempt to identify key drivers of HIV in Swaziland, this study found that age, age at first sex, marital status and the number of sexual partners one had in the last 12 months are associated with HIV serostatus. Weak between cluster variations were found in both men and women.<br>Thesis (M.Sc.)-University of KwaZulu-Natal, Pietermaritzburg, 2012.

Text in English<br>The aim of the study was to describe the competencies of midwives during the provision of immediate postnatal care (PNC) with the intention of adapting and linking international best practice guidelines as well as a conceptual framework for the implementation of PNC in Swaziland. A quantitative cross-sectional design study was conducted to investigate the competencies of midwives during the provision of immediate postnatal care services to mothers and their infants. A systematic random sampling technique was used to select eighty-eight (88) midwives and six (6) senior midwives to participate in the study. Data collection was done using structured questionnaires. Quantitative data was complemented by data that was generated from open-ended questions at the end of the questionnaires. Data analysis was conducted using IBM SPSS Statistics version 22.0 software. The study highlighted that all the midwives who participated in this study had the relevant qualification. Of the respondents, 70.5% were state-certified midwives with a second registered certificate, 27.3% had bachelor’s degrees, while 2.3% had an advanced midwifery certificate. The study found no difference between the type of qualification of midwives and the knowledge of PNC interventions to be offered to mothers immediately post-delivery across different qualifications held by the midwives (Kruskal-Wallis test: x2=5.498, df=2, p=0.064). Gaps were identified in their knowledge and practices. There were discrepancies in the level of knowledge and practices regarding maternal vital sign assessment immediately after delivery (within 30 minutes). It was noted that these vital signs, i.e. blood pressure (12.5%), temperature (50.0%), pulse (54.5%), respiration (63.6%) were not taken after delivery. It was also noted that 15.0%, 58.0%, 64.8% of the respondents were not aware of the importance of assessing newborns for APGAR, skin-to-skin contact and drying the neonate. The study found that there were no postnatal care guidelines in Swaziland. The findings of the study led to the adaption and linkage of the latest international evidence-based guidelines and a conceptual framework for the implementation of immediate PNC to mothers and their infants in Swaziland.<br>Health Studies<br>D. Litt. et Phil. (Health Studies)

HIV prevention efforts across sub-Saharan Africa are increasingly focused on engaging men, for their own health and that of their partners and families. We examined whether and how HIV risk and protective factors are changing among men in Eswatini (formerly Swaziland)—a country with a substantial HIV burden. The study is part of the Population Council’s implementation science research portfolio on the DREAMS Partnership1, a large-scale initiative to reduce new HIV infections among adolescent girls and young women (AGYW) and their partners.