research & publications

HIV RESEARCH

Results by County (Approx)
  • 65 results found
  • Healthcare-seeking behaviour of HIV-infected mothers and male partners in Nairobi, Kenya

    Background:

    Healthcare-seeking behaviours of HIV-infected mothers in sub-Saharan Africa are poorly characterized and typically focus on individual health conditions rather than overall health. We conducted a qualitative study to understand how HIV-infected mothers, their male partners, and their HIV-exposed infants seek medical services. We performed 32 in-depth interviews (17 female, 15 male) and four focus group discussions (FGDs) among HIV-infected postpartum women and their male partners in Nairobi, Kenya.


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  • Living with HIV post-diagnosis: a qualitative study of the experiences of Nairobi slum residents

    Background:

    Sub-Saharan Africa (SSA) is the region most affected by the HIV/AIDS pandemic, accounting for over 68% of the total global burden. A total of 1.6 million Kenyans are currently living with HIV and Kenyan adult HIV prevalence is estimated to be at 6.2%, higher than that of the SSA region (4.9%)

    The introduction of antiretroviral therapy (ART) has improved the prognosis of HIV, with the potential to transform it into a chronic condition. Access to ART in low and middle income countries has expanded rapidly, with 6.6 million people now receiving treatment, nearly half of those eligible for treatment. Seventy-two per cent of Kenyan adults and children with advanced HIV infection receive ARV. With ART, the future life opportunities of PLWHA can change, including those related to sexuality and reproduction.


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  • Delivering safer conception services to HIV serodiscordant couples in Kenya: perspectives from healthcare providers and HIV serodiscordant couples

    Background:

    For HIV serodiscordant couples in resource-limited settings, pregnancy is common despite the risk of sexual and/or perinatal HIV transmission. Some safer conception strategies to reduce HIV transmission during pregnancy attempts are available but often not used for reasons including knowledge, accessibility, preference and others. We sought to understand Kenyan health providers’ and HIV serodiscordant couples’ perspectives and experiences with safer conception.


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  • A Community-based Oral Health Promotion Model for HIV Patients in Nairobi, East District in Kenya: a Study Protocol

    BACKGROUND:
    General HIV-related orofacial lesions, most commonly oropharyngeal candidiasis, have a typical clinical appearance and can be recognized by members of the community. Although affected patients often experience pain leading to compromised eating and swallowing, barriers such as social stigma and lack of knowledge regarding available services may prevent them from seeking early care. Educating the community about these lesions through community health workers (CHWs) who are democratically elected community members may encourage individuals affected to seek early oral healthcare in the health facilities. A health facility (HF) is a health centre mainly run by clinical officers (CO), i.e. personnel with a 3-year medical training, and nurses. This study aims to evaluate the effect of a CHW training programme on: i) their knowledge and recognition of HIV-related oral-facial lesions at a community level; and ii) referral of affected patients from the community to the HFs.

  • Stage of HIV presentation at initial clinic visit following a community-based HIV testing campaign in rural Kenya

    Background :

    The Kenyan Ministry of Health and partners implemented a community-based integrated prevention campaign (IPC) in Western Kenya in 2008. The aim of this study was to determine whether the IPC, compared to Voluntary Counselling and Testing (VCT) services, was able to identify HIV positive individuals earlier in the clinical course of HIV infection following testing.


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  • Integrating Tuberculosis and HIV Services in rural Kenya: uptake and outcomes

    Background:

    An estimated 35.3 million persons worldwide were living with the human immunodeficiency virus (HIV) in 2012, while 8.6 million people developed tuberculosis (TB), the majority of them in sub-Saharan Africa. Kenya is one of the world’s 22 high TB burden2 and high HIV burden countries.


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  • When families fail: shifting expectations of care among people living with HIV in Nairobi, Kenya

    Background:

    The availability of free antiretroviral treatment in public health facilities since 2004 has contributed to the increasing biomedicalization of AIDS care in Kenya. This has been accompanied by a reduction of funding for community-based care and support organizations since the 2008 global economic crisis and a consequent donor divestment from HIV projects in Africa. This paper explores the ways that HIV interventions, including support groups, home-based care and antiretroviral treatments have shaped expectations regarding relations of care in the low-income area of Kibera in Nairobi, Kenya, over the last decade.


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  • HIV-associated mortality in the era of antiretroviral therapy scale-up – Nairobi, Kenya, 2015

    Background:

    Declines in HIV prevalence and increases in antiretroviral treatment coverage have been documented in Kenya, but population-level mortality associated with HIV has not been directly measured. In urban areas where a majority of deaths pass through mortuaries, mortuary-based studies have the potential to contribute to our understanding of excess mortality among HIV-infected persons. We used results from a cross-sectional mortuary-based HIV surveillance study to estimate the association between HIV and mortality for Nairobi, the capital city of Kenya.


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  • Automating indicator data reporting from health facility Electronic Medical Reporting (EMR) to a national aggregate data system in Kenya: An Interoperability field-test using OpenMRS and DHIS2

    Background:

    Developing countries are increasingly strengthening national health information systems (HIS) for evidence-based decision-making. However, the inability to report indicator data automatically from electronic medical record systems (EMR) hinders this process. Data are often printed and manually re-entered into aggregate reporting systems. This affects data completeness, accuracy, reporting timeliness, and burdens staff who support routine indicator reporting from patient-level data.


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  • Comprehensive Characterization of Humoral Correlates of Human Immunodeficiency Virus 1 Superinfection Acquisition in High-risk Kenyan Women

    Background:

    HIV-1 superinfection, in which an infected individual acquires a second HIV-1 infection from a different partner, is one of the only settings in which HIV acquisition occurs in the context of a pre-existing immune response to natural HIV infection. There is evidence that initial infection provides some protection from superinfection, particularly after 6 months of initial infection, when development of broad immunity occurs. Comparison of the immune response of superinfected individuals at the time of superinfection acquisition to that of individuals who remain singly infected despite continued exposure can shed light on immune correlates of HIV acquisition to inform prophylactic vaccine design.


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  • The HIV and AIDS Tribunal of Kenya: An Effective Mechanism for the Enforcement of HIV-related Human Rights?

    Abstract

    Established under Section 25 of the HIV Prevention and Control Act of 2006, the HIV and AIDS Tribunal of Kenya is the only HIV-specific statutory body in the world with the mandate to adjudicate cases relating to violations of HIV-related human rights. Yet, very limited research has been done on this tribunal. Based on findings from a desk research and semi-structured interviews of key informants conducted in Kenya, this article analyzes the composition, mandate, procedures, practice, and cases of the tribunal with the aim to appreciate its contribution to the advancement of human rights in the context of HIV. It concludes that, after a sluggish start, the HIV and AIDS Tribunal of Kenya is now keeping its promise to advance the human rights of people living with and affected by HIV in Kenya, notably through addressing barriers to access to justice, swift ruling, and purposeful application of the law. The article, however, highlights various challenges still affecting the tribunal and its effectiveness, and cautions about the replication of this model in other jurisdictions without a full appraisal.


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  • Task-shifting alcohol interventions for HIV+ persons in Kenya: a cost-benefit analysis.

    BACKGROUND:

    Among HIV+ patients, alcohol use is a highly prevalent risk factor for both HIV transmission and poor adherence to HIV treatment. The large-scale implementation of effective interventions for treating alcohol problems remains a challenge in low-income countries with generalized HIV epidemics. It is essential to consider an intervention's cost-effectiveness in dollars-per-health-outcome, and the long-term economic impact -or "return on investment" in monetary terms.

    METHODS:

    We conducted a cost-benefit analysis, measuring economic return on investment, of a task-shifted cognitive-behavioral therapy (CBT) intervention delivered by paraprofessionals to reduce alcohol use in a modeled cohort of 13,440 outpatients in Kenya. In our base-case, we estimated the costs and economic benefits from a societal perspective across a six-year time horizon, with a 3% annual discount rate. Costs included all costs associated with training and administering task-shifted CBT therapy. Benefits included the economic impact of lowered HIV incidence as well as the improvements in household and labor-force productivity. We conducted univariate and multivariate probabilistic sensitivity analyses to test the robustness of our results.

    RESULTS:

    Under the base case, total costs for CBT rollout was $554,000, the value of benefits were $628,000, and the benefit-to-cost ratio was 1.13. Sensitivity analyses showed that under most assumptions, the benefit-to-cost ratio remained above unity indicating that the intervention was cost-saving (i.e., had positive return on investment). The duration of the treatment effect most effected the results in sensitivity analyses.

    CONCLUSIONS:

    CBT can be effectively and economically task-shifted to paraprofessionals in Kenya. The intervention can generate not only reductions in morbidity and mortality, but also economic savings for the health system in the medium and long term. The findings have implications for other countries with generalized HIV epidemics, high prevalence of alcohol consumption, and shortages of mental health professionals.


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  • Uptake and Acceptability of Oral HIV Self-Testing among Community Pharmacy Clients in Kenya: A Feasibility Study.

    BACKGROUND:

    While HIV testing and counselling is a key entry point for treatment as prevention, over half of HIV-infected adults in Kenya are unaware they are infected. Offering HIV self-testing (HST) at community pharmacies may enhance detection of undiagnosed infections. We assessed the feasibility of pharmacy-based HST in Coastal Kenya.


    METHODS:

    Staff at five pharmacies, supported by on-site research assistants, recruited adult clients (≥18 years) seeking services indicative of HIV risk. Participants were offered oral HST kits (OraQuick®) at US$1 per test. Within one week of buying a test, participants were contacted for post-test data collection and counselling. The primary outcome was test uptake, defined as the proportion of invited clients who bought tests. Views of participating pharmacy staff were solicited in feedback sessions during and after the study.


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  • Jaboya ("Sex for Fish"): A Qualitative Analysis of Contextual Risk Factors for Extramarital Partnerships in the Fishing Communities in Western Kenya.

    Extramarital partnerships exacerbate high HIV prevalence rates in many communities in sub-Saharan Africa. We explored contextual risk factors and suggested interventions to reduce extramarital partnerships among couples in the fishing communities on Lake Victoria, Kenya. We conducted 12 focus group discussions with 9-10 participants each (N = 118) and 16 in-depth interviews (N = 16) with fishermen and their spouses. Couples who participated were consented and separated for simultaneous gender-matched discussions/interviews. Interview topics included courtship and marriage, relationship and sexual satisfaction, extramarital relationships and how to intervene on HIV risks. Coding, analysis, and interpretation of the transcripts followed grounded theory tenets that allow analytical themes to emerge from the participants. Our results showed that extramarital partnerships were perceived to be widespread and were attributed to factors related to sexual satisfaction such as women needing more foreplay before intercourse, discrepancies in sexual desire, and boredom with the current sexual repertoire.


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  • A rapid assessment of post-disclosure experiences of urban HIV-positive and HIV-negative school-aged children in Kenya

    Abstract

    There has been limited involvement of HIV-negative children in HIV disclosure studies; most studies conducted on the effects of disclosure on children have been with HIV-positive children and HIV-positive mother-child dyads. Seven HIV-positive and five HIV-negative children participated in a larger study conducted to understand the lived experiences of HIV-positive parents and their children during the disclosure process in Kenya. In this study, the experiences of these 12 children after receiving disclosure of their own and their parents' illnesses respectively are presented. Each child underwent an in-depth qualitative semi-structured digitally recorded interview. The recorded interviews were transcribed and loaded into NVivo8 for phenomenological data analysis. Five themes emerged from the data, indicating that HIV-positive and negative children appear to have differing post-disclosure experiences revolving around acceptance of illness, stigma and discrimination, medication consumption, sexual awareness, and use of coping mechanisms. Following disclosure, HIV-negative children accepted their parents' illnesses within a few hours to a few weeks; HIV-positive children took weeks to months to accept their own illnesses. HIV-negative children knew of high levels of stigma and discrimination within the community; HIV-positive children reported experiencing indirect incidences of stigma and discrimination. HIV-negative children wanted their parents to take their medications, stay healthy, and pay their school fees so they could have a better life in the future; HIV-positive children viewed medication consumption as an ordeal necessary to keep them healthy. HIV-negative children wanted their parents to speak to them about sexual-related matters; HIV-positive children had lingering questions about relationships, use of condoms, marriage, and childbearing options. All but one preadolescent HIV-positive child had self-identified a person to speak with for social support. When feeling overwhelmed by their circumstances, the children self-withdrew and performed positive activities (e.g., praying, watching TV, listening to the radio, singing, dancing) to help themselves feel better. Many HIV-affected families have a combination of HIV-positive and negative siblings within the household. Pending further studies conducted with larger sample sizes, the results of this study should assist healthcare professionals to better facilitate disclosure between HIV-positive parents and their children of mixed HIV statuses. 


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  • Community Perceptions of Community Health Workers (CHWs) and Their Roles in Management for HIV, Tuberculosis and Hypertension in Western Kenya.

    Given shortages of health care providers and a rise in the number of people living with both communicable and non-communicable diseases, Community Health Workers (CHWs) are increasingly incorporated into health care programs. We sought to explore community perceptions of CHWs including perceptions of their roles in chronic disease management as part of the Academic Model Providing Access to Healthcare Program (AMPATH) in western Kenya. In depth interviews and focus group discussions were conducted between July 2012 and August 2013. Study participants were purposively sampled from three AMPATH sites: Chulaimbo, Teso and Turbo, and included patients within the AMPATH program receiving HIV, tuberculosis (TB), and hypertension (HTN) care, as well as caregivers of children with HIV, community leaders, and health care workers. Participants were asked to describe their perceptions of AMPATH CHWs, including identifying the various roles they play in engagement in care for chronic diseases including HIV, TB and HTN.


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  • Uptake and linkage into care over one year of providing HIV testing and counselling through community and health facility testing modalities in urban informal settlement of Kibera, Nairobi Kenya.

    BACKGROUND:

    We examine the uptake of HIV Testing and Counselling (HTC) and linkage into care over one year of providing HTC through community and health facility testing modalities among people living in Kibera informal urban settlement in Nairobi Kenya.


    METHODS:

    We analyzed program data on health facility-based HIV testing and counselling and community- based testing and counselling approaches for the period starting October 2013 to September 2014. Univariate and bivariate analysis methods were used to compare the two approaches with regard to uptake of HTC and subsequent linkage to care. The exact Confidence Intervals (CI) to the proportions were approximated using simple normal approximation to binomial distribution method.


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  • A Qualitative Investigation of the Impact of a Livelihood Intervention on Gendered Power and Sexual Risk Behaviors Among HIV-Positive Adults in Rural Kenya.

    Despite the recognized links between food insecurity, poverty, and the risk of HIV/AIDS, few randomized trials have evaluated the impact of livelihood interventions on HIV risk behaviors. The current study draws upon data collected from a qualitative process evaluation that was embedded into a pilot randomized controlled trial that tested whether a multisectoral agricultural intervention (Shamba Maisha) affected the HIV-related health of HIV-positive adults in rural Kenya.


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  • Economic Context and HIV Vulnerability in Adolescents and Young Adults Living in Urban Slums in Kenya: A Qualitative Analysis Based on Scarcity Theory.

    Abstract

    Urban slum adolescents and young adults have disproportionately high rates of HIV compared to rural and non-slum urban youth. Yet, few studies have examined youth's perceptions of the economic drivers of HIV. Informed by traditional and behavioral economics, we applied a scarcity theoretical framework to qualitatively examine how poverty influences sexual risk behaviors among adolescents and young adults. Focus group discussions with one hundred twenty youth in Kenyan's urban slums were transcribed, coded, and analyzed using interpretive phenomenology.



  • Should HIV testing for all pregnant women continue? Cost-effectiveness of universal antenatal testing compared to focused approaches across high to very low HIV prevalence settings.

    INTRODUCTION:

    HIV testing is the entry point for the elimination of mother-to-child transmission of HIV. Decreasing external funding for the HIV response in some low- and middle-income countries has triggered the question of whether a focused approach to HIV testing targeting pregnant women in high-burden areas should be considered. This study aimed at determining and comparing the cost-effectiveness of universal and focused HIV testing approaches for pregnant women across high to very low HIV prevalence settings.


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  • Multiple HPV infections in female sex workers in Western Kenya: implications for prophylactic vaccines within this sub population.

    BACKGROUND:

    Whilst the imputed role of High Risk (HR) HPV infection in the development of cervical lesions and cancer has been established, the high number of HPV genotypes that Female Sex workers (FSW) harbour warrants that the synergistic effects of potential HR (pHR) and HR HPV genotypes be elucidated to assess the potential impact of prophylactic vaccines. This population in Kenya also harbours a number of other vaginal infections and STIs, including bacterial vaginosis (BV), trichomonas vaginalis (TV) and candida spp. The aims of this cross-sectional analysis in Kenya are to explore the epidemiology of abnormal cytology and the pairing of pHR/HPV genotypes in HIV-negative and HIV-infected FSW.


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  • Dengue and Chikungunya Virus Infections among Young Febrile Adults Evaluated for Acute HIV-1 Infection in Coastal Kenya.

    BACKGROUND: 

    Fever is common among patients seeking care in sub-Saharan Africa (sSA), but causes other than malaria are rarely diagnosed. We assessed dengue and chikungunya virus infections among young febrile adults evaluated for acute HIV infection (AHI) and malaria in coastal Kenya.


    METHODS:

    We tested plasma samples obtained in a cross-sectional study from febrile adult patients aged 18-35 years evaluated for AHI and malaria at urgent care seeking at seven health facilities in coastal Kenya in 2014-2015. Dengue virus (DENV) and chikungunya virus (CHIKV) were amplified using quantitative real-time reverse-transcription polymerase chain reaction. We conducted logistic regression analyses to determine independent predictors of dengue virus infection.


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  • Risk Factors for Hypoxia and Tachypnea Among Adolescents with Vertically-Acquired HIV in Nairobi.

    BACKGROUND:

    Chronic lung diseases are increasingly recognized complications of vertically-acquired HIV among adolescents in sub-Saharan Africa and may manifest with hypoxia or tachypnea. We sought to determine the prevalence of and risk factors for hypoxia and tachypnea among adolescents with vertically-acquired HIV in Nairobi, Kenya.


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  • Association between menopause and unprotected sex in high-risk HIV-positive women in Mombasa, Kenya.

    OBJECTIVE:

    Many HIV-positive women now live well beyond menopause. Postmenopausal women are no longer at risk for pregnancy, and some studies suggest they may use condoms less often than premenopausal women. This study tests the hypothesis that, in HIV-positive women who report trading sex for cash or in-kind payment, unprotected sex is more common at postmenopausal visits compared to premenopausal visits.


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  • "They make money off of us": a phenomenological analysis of consumer perceptions of corruption in Kenya's HIV response system.

    BACKGROUND:

    Problems with misallocation and redirection of critical resources and benefits intended for PLHIV are not uncommon in Kenya. This study explores corruption in Kenya's HIV response system and the implications for health outcomes from the perspective of people living with HIV (PLHIV). Although they might not be directly responsible for health care fund management, PLHIV and their advocacy efforts have been central to the development of HIV system response and they have a vested interest in ensuring proper governance.

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  • Changes in Male Circumcision Prevalence and Risk Compensation in the Kisumu, Kenya Population 2008-2013.

    BACKGROUND:

    Three randomized controlled trials (RCT) showed that voluntary medical male circumcision (VMMC) reduces the risk of female to male HIV transmission by approximately 60%. However, data from communities where VMMC programs have been implemented are needed to assess changes in circumcision prevalence and whether men and women compensate for perceived reductions in risk by increasing their HIV risk behaviors.

  • "A Baby Was an Added Burden": Predictors and Consequences of Unintended Pregnancies for Female Sex Workers in Mombasa, Kenya: A Mixed-Methods Study.

    INTRODUCTION:

    Female sex workers (FSW) have high rates of unintended pregnancy, sexually transmitted infections including HIV, and other adverse sexual and reproductive health outcomes. Few services for FSWs include contraception. This mixed-methods study aimed to determine the rate, predictors and consequences of unintended pregnancy among FSWs in Mombasa, Kenya.


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  • Couple interdependence impacts HIV-related health behaviours among pregnant couples in southwestern Kenya: a qualitative analysis.

    INTRODUCTION:

    HIV infection is frequently transmitted within stable couple partnerships. In order to prevent HIV acquisition in HIV-negative couples, as well as improve coping in couples with an HIV-positive diagnosis, it has been suggested that interventions be aimed at strengthening couple relationships, in addition to addressing individual behaviours. However, little is known about factors that influence relationships to impact joint decision-making related to HIV.


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  • Alcohol Use and Associations With Biological Markers and Self-Reported Indicators of Unprotected Sex in Human Immunodeficiency Virus-Positive Female Sex Workers in Mombasa, Kenya.

    BACKGROUND:

    Studies of alcohol use and sexual behavior in African populations have primarily been cross-sectional, used nonvalidated measures of alcohol use, or relied on self-reported sexual risk endpoints. Few have focused on human immunodeficiency virus (HIV)-positive women.


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  • Understanding Barriers to Scaling Up HIV-Assisted Partner Services in Kenya.

    Assisted partner services (APS) are more effective than passive referral in identifying new cases of HIV in many settings. Understanding the barriers to the uptake of APS in sub-Saharan Africa is important before its scale up. In this qualitative study, we explored client, community, and healthcare worker barriers to APS within a cluster randomized trial of APS in Kenya.


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  • Outcomes of prevention of mother to child transmission of the human immunodeficiency virus-1 in rural Kenya--a cohort study.

    Success in prevention of mother-to-child transmission (PMTCT) raises the prospect of eliminating pediatric HIV infection. To achieve global elimination, however, strategies are needed to strengthen PMTCT interventions. This study aimed to determine PMTCT outcomes and identify challenges facing its successful implementation in a rural setting in Kenya.


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  • Identifying the Gaps: An Assessment of Nurses' Training, Competency, and Practice in HIV Care and Treatment in Kenya.

    Given the burden of HIV and the critical shortage of health workers in Kenya, in 2011 the National AIDS and STI Control Program recommended shifting HIV care and treatment tasks to nurses in settings without physicians and clinical officers in order to decentralize and scale-up HIV services. In September 2013, ICAP at Columbia University conducted a survey with nurses in four health facilities in eastern Kenya to assess preparedness for task shifting. Findings indicated gaps in nurses' training, perceived competency, and practice in HIV care and treatment. Further investment in nurse capacity building is needed to bridge the gaps and prepare more nurses to provide high-quality, comprehensive HIV care and treatment services to curb the epidemic in Kenya.


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  • Using Health Commodity Management Platform (HCMP) Improve Laboratory Commodity Reporting Rates in Kenya

    Background:

    Accurate quantification, timely reporting and requisition of HIV rapid test kits (RTKs) has been a perennial challenge for the health system in Kenya. We introduced an online reporting system for HIV RTKs in Nakuru County in October 2013 to streamline the reporting, requisition and monitor consumption of HIV RTKs We report here the process used in setting up this system and how data was collected and used to monitor stock levels.


    Methodology: The Sub-County medical laboratory technologists (SCMLTs were trained on the online commodity reporting and requisition platform, the report submission process and individual tracking of the reports. This was a day-to-day training and mentorship provided by the project laboratory technical officers to ensure timely and accurate submission of reports. After the launch of the system data on reporting rates, stock levels, commodity consumption, timeliness and accuracy of reporting was collected from October 2013 to May 2015.


    Results

    Prior to the launch of the platform, the average reporting rate was 66%. The reporting rate in October 2013, when the online platform was launched, was 83%. Within a year of introduction, commodity reporting rates improved to 100%.


    Conclusion:

    The new system allows real-time visualization of data by the supply side upon entry by the consumer. This has led to improved reporting rates, timely redistribution of kits to facilities that are facing stock outs, better monitoring of kit consumption by administrators as well as monitoring of the number of people tested across the region.



  • Use of data for decision making for epidemic Control

    Background

    Due to the difference in the data management practices between the MOH and implementing partners including the thoroughness of scrutiny and querying of reports by the later, there have been discordance between partner and MOH data in the District health information systems DHIS. More often than not the MOH has disowned data presented by partners as it seems better than what is in the DHIS.


    Objective System strengthening for informed decision making in HIV programming through District Health Information Systems data accuracy.


    Methods

    EGPAF working with the MOH introduced a monthly DHIS data concordance meeting to harmonize discrepancies witnessed between the two systems. EGPAF Monitoring &Evaluation team together with County health records department developed the DHIS concordance data review schedule to be implemented monthly. Seven indicators were initially tracked per facility a cross the supported sub-counties. This was later on scaled up to all the indicators in MOH 731, 711 & 717. At the end of the month and according to the prepared schedule, the sub-county Health Records Information Officer was invited to come with the original copies of the three reports. This was followed by , a meeting between the supporting M&E officer and the HRIO to compare indicators in the two systems and make corrections on the discrepancies identified in real time.


    Findings

    Since January 2016 to date, there has been increased concordance in the data with over 99% of the indicators achieving 100% concordance. There has also been increased ownership of data and enhanced relationships between the M&E departments between partners in the county due to increased contact time between them

    .

    Conclusion: There is need to embrace DHIS concordance meetings among county health partners for ownership and concordance of their data systems for informed decision making. This has demonstrated promising results and can be emulated by the rest of Counties faced with similar challenges.


    Implication: The cost of the intervention is one day per diem and transport reimbursement for the HRIOs from far flung sub-counties and only lunch allowance for the ones within the headquarters. This totals to Kshs 30,000 for the four supported sub-counties.


  • Innovations in commodity management coordination and decision-making at national and county level through use of DHIS2

    Background:

    The flow of information is critical to the effective management of health commodity supply chains. Within NASCOP, the presence of multiple vertical commodity information systems resulted in duplication and lack of full pipeline visibility. Variances in patient numbers across service and commodity data have also been identified. To address these weaknesses, various NASCOP programs - ART, lab, nutrition - decided to integrate commodity reporting into one national system, DHIS2, based on previous successful use in family planning and malaria programs.


    Objectives: To enable NASCOP team harmonize commodity data into one platform to allow for greater visibility at national and county level; facilitate decision-making and timely sharing of strategic information with stakeholders.


    Methods:

    A core team comprising NASCOP, other programs, KEMSA, HIS unit, UoN and implementing partners was constituted in 2015. Several consensus meetings were held to clarify requirements, develop a plan of action and undertake a proof of concept to ascertain the viability of incorporating NASCOP's decentralized hierarchy structure for commodity reporting into DHIS2. Development work was initiated involving the design and upload of commodity reporting tools, development of national and county dashboards, incorporation of data validation rules to enhance data quality, supply chain indicators for performance analysis and automation of facility ordering to inform resupply. The system was pre-tested in 3 counties (Tharaka-Nithi, Nakuru and Kiambu) by staff drawn from national and county levels.


    Results:

    The pilot counties were able to visualize their full list of facilities providing HIV services. Input facility data was immediately visible at facility, sub-county, county and national levels, enabling generation of reports on patient and test numbers, and stock status. Disparities in facility mapping between counties and the national program were rectified through the hierarchy implementation in DHIS2. With service and commodity data available in DHIS, county health management teams found it easier to triangulate data; and make commodity management decisions e.g. need for commodity redistribution, creation of additional central and satellite sites. The use of a common platform provided an opportunity for a team approach to commodity management coordination at county level, incorporating health records information officers, CASCOs, laboratory, nutrition and pharmacy coordinators.


    Conclusions, recommendations and implications:

    Integration of HIV reporting in DHIS2 will standardize and improve commodity information management, increase visibility of commodity information and enhance use of data for decision-making at all levels for HIV commodity security and improved patient outcomes. This new system is going to help counties to manage their commodities in line with decentralization of HIV commodity management and devolution of health services; enabling closer collaboration between the national and county levels. Strengthening the link between KEMSA systems and DHIS2 is required for visibility of upstream and downstream stocks to minimize disruption in commodity supply. With increased visibility of information such as service and workload data, opportunities for further decentralization of HIV services can be identified.


  • Innovations in commodity management coordination and decision-making at national and county level through use of DHIS2

    Background:

    The flow of information is critical to the effective management of health commodity supply chains. Within NASCOP, the presence of multiple vertical commodity information systems resulted in duplication and lack of full pipeline visibility. Variances in patient numbers across service and commodity data have also been identified. To address these weaknesses, various NASCOP programs - ART, lab, nutrition - decided to integrate commodity reporting into one national system, DHIS2, based on previous successful use in family planning and malaria programs.


    Objectives:

    To enable NASCOP team harmonize commodity data into one platform to allow for greater visibility at national and county level; facilitate decision-making and timely sharing of strategic information with stakeholders.


    Methods:

    A core team comprising NASCOP, other programs, KEMSA, HIS unit, UoN and implementing partners was constituted in 2015. Several consensus meetings were held to clarify requirements, develop a plan of action and undertake a proof of concept to ascertain the viability of incorporating NASCOP's decentralized hierarchy structure for commodity reporting into DHIS2. Development work was initiated involving the design and upload of commodity reporting tools, development of national and county dashboards, incorporation of data validation rules to enhance data quality, supply chain indicators for performance analysis and automation of facility ordering to inform resupply. The system was pre-tested in 3 counties (Tharaka-Nithi, Nakuru and Kiambu) by staff drawn from national and county levels.


    Results:

    The pilot counties were able to visualize their full list of facilities providing HIV services. Input facility data was immediately visible at facility, sub-county, county and national levels, enabling generation of reports on patient and test numbers, and stock status. Disparities in facility mapping between counties and the national program were rectified through the hierarchy implementation in DHIS2. With service and commodity data available in DHIS, county health management teams found it easier to triangulate data; and make commodity management decisions e.g. need for commodity redistribution, creation of additional central and satellite sites. The use of a common platform provided an opportunity for a team approach to commodity management coordination at county level, incorporating health records information officers, CASCOs, laboratory, nutrition and pharmacy coordinators.


    Conclusions, recommendations and implications:

    Integration of HIV reporting in DHIS2 will standardize and improve commodity information management, increase visibility of commodity information and enhance use of data for decision-making at all levels for HIV commodity security and improved patient outcomes. This new system is going to help counties to manage their commodities in line with decentralization of HIV commodity management and devolution of health services; enabling closer collaboration between the national and county levels. Strengthening the link between KEMSA systems and DHIS2 is required for visibility of upstream and downstream stocks to minimize disruption in commodity supply. With increased visibility of information such as service and workload data, opportunities for further decentralization of HIV services can be identified.


  • Innovations in commodity management coordination and decision-making at national and county level through use of DHIS2

    Background:

    The flow of information is critical to the effective management of health commodity supply chains. Within NASCOP, the presence of multiple vertical commodity information systems resulted in duplication and lack of full pipeline visibility. Variances in patient numbers across service and commodity data have also been identified. To address these weaknesses, various NASCOP programs - ART, lab, nutrition - decided to integrate commodity reporting into one national system, DHIS2, based on previous successful use in family planning and malaria programs.


    Objectives: To enable NASCOP team harmonize commodity data into one platform to allow for greater visibility at national and county level; facilitate decision-making and timely sharing of strategic information with stakeholders.


    Methods:

    A core team comprising NASCOP, other programs, KEMSA, HIS unit, UoN and implementing partners was constituted in 2015. Several consensus meetings were held to clarify requirements, develop a plan of action and undertake a proof of concept to ascertain the viability of incorporating NASCOP's decentralized hierarchy structure for commodity reporting into DHIS2. Development work was initiated involving the design and upload of commodity reporting tools, development of national and county dashboards, incorporation of data validation rules to enhance data quality, supply chain indicators for performance analysis and automation of facility ordering to inform resupply. The system was pre-tested in 3 counties (Tharaka-Nithi, Nakuru and Kiambu) by staff drawn from national and county levels.


    Results:

    The pilot counties were able to visualize their full list of facilities providing HIV services. Input facility data was immediately visible at facility, sub-county, county and national levels, enabling generation of reports on patient and test numbers, and stock status. Disparities in facility mapping between counties and the national program were rectified through the hierarchy implementation in DHIS2. With service and commodity data available in DHIS, county health management teams found it easier to triangulate data; and make commodity management decisions e.g. need for commodity redistribution, creation of additional central and satellite sites. The use of a common platform provided an opportunity for a team approach to commodity management coordination at county level, incorporating health records information officers, CASCOs, laboratory, nutrition and pharmacy coordinators.


    Conclusions, recommendations and implications:

    Integration of HIV reporting in DHIS2 will standardize and improve commodity information management, increase visibility of commodity information and enhance use of data for decision-making at all levels for HIV commodity security and improved patient outcomes. This new system is going to help counties to manage their commodities in line with decentralization of HIV commodity management and devolution of health services; enabling closer collaboration between the national and county levels. Strengthening the link between KEMSA systems and DHIS2 is required for visibility of upstream and downstream stocks to minimize disruption in commodity supply. With increased visibility of information such as service and workload data, opportunities for further decentralization of HIV services can be identified.



  • Improved demand and utilization of key population data through visual presentation towards enhanced quality of service (Dashboard)

    Background:

    International Medical Corps runs Tekeleza Drop in Centers (DiCEs) which are also friendly key population clinics offering a combination of HIV prevention interventions including HIV testing, care and treatment services. The DiCES generate monthly data using different indicators and have so far registered an average of 1,500 patients currently on HIV care and treatment. The current data aggregation tools have many data elements being reported which are vital for programming however there is little demand and utilization of these data by the healthcare providers for assessing program performance and making decisions for quality improvement instigating for a simplified way of presenting data. This initiative was meant to transform the data into a visual form for easy integration and utilization.


    Methodology:

    Data officers and healthcare providers were trained on Data Demand and Information Use and data analysis. Specific indicators were selected for performance monitoring including number of HIV +ve patients linked to care, number started on Antiretroviral Therapy (ART), trends of patients currently on care and currently on ART, IPT coverage, client retention rates among others. A retrospective data analysis was done from January 2015 using the program data and District health information system. Facilities dashboard ware created whereby performance was presented using bar graphs, pie charts, line graphs and pivot tables. The data was presented and discussed at the monthly multidisciplinary team meetings and quarterly data review meetings from where action plans for poorly performing indicators were formulated. The charts and the action plans were displayed on the notice boards for all to access.


    Results: The performance trend of the DiCEs was seen at a glance. DiCEs staffs were able to interpret indicators on the standard reporting tools. There was easy identification of poorly performing indicators and action planning for improvement. Regular demand for data increased.


    Conclusion and Recommendation:

    Visual analytics enables raw data to be presented in a way that is meaningful and that generates more value. A system of frequent analysis and presentation of data visually makes it easy to understand and interpret indicator performance. This is recommended to be rolled out in all health facilities.



  • Benefits and Costs of Integrating Sexual-Reproductive Health and HIV Services in Kenya and Swaziland (Integra)

    There are many well-established reasons that support the rationale for integrating or linking sexual and reproductive health (SRH) and HIV services in developing countries with generalized HIV epidemics - primarily in sub-Saharan Africa. Yet the evidence base for the impact of integrated service delivery on health outcomes and costs remains weak. Partly this is a result of methodological difficulties. There is an emerging body of literature addressing the challenges of using randomized controlled trials to assess the impact of public health interventions. Particularly in cases such as the Integra Initiative, where the causal chain (between intervention and outcome) is long, and where there are is a broad range of outcomes that need to be explored, and where there is already some a degree of integration occurring in some clinic settings, attempting to conduct a randomized controlled trial is not appropriate. Consistent with evaluation designs described by Habicht and colleagues, the Integra design includes evaluation of performance and impact to try to make two types of causal inference: adequacy and plausibility. Evaluation of adequacy will assess whether the expected changes in provision, service utilisation and cost-effectiveness have occurred in intervention facilities. Evaluation of impact will assess the plausibility that changes in service, health and behavioral outcomes are due to the Integra Initiative. The case for such plausibility will be built from the following strands of evidence:

    •Comparing findings in 'intervention' facilities with those in facilities chosen as 'comparison' sites prior to the evaluation

    •Exploring a dose-response relationship between the measured extent of integration and the study outcomes

    •Measuring changes in performance over time, to demonstrate a logical sequence between the intervention (integration) and outcomes

    •Measuring change in each step of the logic model - a prerequisite for any attribution to the intervention

    •Triangulating findings from a mix of research methods to capture a range of perspectives and insights from different disciplines.

    The study will employ a controlled pre- and post-test quasi-experimental, or non-randomized, design and utilizes multiple research methods (cohort study, community survey, clinic assessments, costing tools and qualitative interviews). Since the research is being conducted in real-life health delivery settings where programmatic contamination is possible due to ongoing health programme interventions over the study period, the control group will be referred to as a 'comparison group', for which outcomes will be compared over time up to two years after implementation.


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  • A Review Of Health Risk Behavior Among Adolescents Living With HIV In Sub-Saharan Africa.

    Background:

    Sub-Saharan Africa (SSA) is home to an estimated 1.2 million HIV infected adolescents aged 15-19 years and 3.2 million HIV infected children below 15 years. The adolescence developmental stage is often characterized by a marked rise in propensity for risk taking and yet for adolescents living with HIV, their engagement in health risk behaviour (HRB) presents significant challenges for treatment, management and achieving the control of HIV. To this end, sub-optimal outcomes such as poor medical adherence and low retention in HIV care have been linked to some HRBs such as the use of alcohol and other drugs. However, the burden of HRBs among adolescents living with HIV in the SSA context is not fully quantified or documented; which may have implications for optimizing healthcare services targeting this sub-population.


    Objectives:

    The overall goal of the study is to investigate the current level of research on forms and burden of HRB among HIV infected adolescents in SSA. Specifically, we set out to: i) To identify and summarize the characteristics of studies that quantify HRB among adolescents living with HIV in SSA ii) To summarize the main forms of HRB assessed among adolescents living with HIV in SSA iii) To quantify the general burden of HRB among HIV infected adolescents in SSA.


    Methods:

    Four databases of PubMed, Embase, PsycINFO and Applied Social Sciences Index & Abstracts were systematically searched for empirical studies published until 30th April 2016, and that quantified HRB among HIV infected adolescents (10-19 years) in SSA. Guidelines for preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used to summarize the results and the quality of eligible studies was appraised using the quality assessment tool for systematic reviews of observational studies (QATSO). A random effects model was used to estimate the pooled effect after assessing heterogeneity by the I2 statistic of the DerSimonian and Laird method.


    Results:

    A total of 14 eligible articles were retrieved from the 1,693 initially identified articles. Risky sexual behaviour, alcohol and drugs use were the most frequently documented HRBs. Overall, Condom non-use behaviour was estimated at 65.7% (95% CI: 52.8-77.6%), engagement in risky sexual partnerships at 31.1% (95% CI: 12.9-52.9%), transactional sex at 20.1% (95% CI: 9.2-33.8%) and sexual violence at 19.9% (95% CI: 14.8-25.5%) among the HIV infected adolescents. The median age of first sexual debut ranged between 14.7 and 17 years. Other prevalent forms of behaviour were problem alcohol drinking and sex under the influence of drugs or alcohol mainly among the males.


    Conclusion, recommendation and implications:

    Health risk behaviour such as risky sexual behaviour and substance use is highly problematic among HIV infected adolescents in SSA and this potentially attributes to a number of challenges in treatment, care and management of HIV. This study points to the urgent need for further research on HRB as well as age-appropriate interventions which effectively address the behavioural and health needs of HIV affected adolescents.



  • Community HIV testing as the best approach for Fisher Folks- case of Tekeleza Drop in Center- Homabay County

    Background:

    Fisherfolk are among populations at high risk of HIV infection. They are vulnerable to HIV acquisition and transmission due to their behaviors including: exchange of fish for sex, time away from home and transactional sex. Fisherfolk feel conflicted between going fishing; their main livelihood activity and creating time for health care services (MARPS Surveillance report 2012). To compound this further, the vast distances to health facilities, and challenging terrain presents serious challenges to them accessing health care services. International Medical Corps has established static Key Population Drop in Centers (DiCEs). Services offered at these DiCEs include HIV testing services, Sexually Transmitted Infection (STI) screening and treatment, cervical cancer screening and condom distribution. HIV testing is an entry point to HIV prevention and management. It is difficult to target fisherfolk due to their migratory nature. As a result, innovative approaches have been employed in order to take services directly to them.


    Methodology:

    With funding from CDC, and in collaboration with the Ministry of Health International Medical Corps established Tekeleza: a HIV-prevention program targeting Key and Priority populations in Homa Bay county. Outreach services were used as strategy to reach out to the fisher folks and offer them a Comprehensive Health Package (CHP) including HIV testing services at the community level. In March 2016, services were offered both at the DiCEs and within the community in Mbita Sub-county. Community door-to-door testing was done at the beaches where fisherfolk operate. Those who came to the DiCE for services including family planning, STI treatment and cervical cancer screening were offered HTS.


    Results:

    A larger number of fisherfolk were reached at community level with the door-to-door approach (1982 Females and 2488 males) than at the static DiCEs (70 males and 74 females). In addition, the positivity rates recorded at the community were 4.4% (72 females and 124 males) while the positivity for those tested at the DiCE was 11.8% (6 males and 11 females).


    Conclusion:

    Community HIV testing among fisher fork increases knowledge of HIV status. This in turn reduces the HIV burden and plays a role in the prevention and management of HIV. There is therefore need to take HIV testing services closer to dynamic populations.

  • Uptake and Acceptability of Oral HIV Self-Testing Among Community Pharmacy Clients in Coastal Kenya

    Background:

    While HIV testing and counselling is a key entry point for treatment as prevention, over half of HIV-infected adults in Kenya are unaware they are infected. Up to a half of patients in developing country settings seek care in community pharmacies. Offering HIV self-testing (HST) at community pharmacies may enhance testing coverage, detect undiagnosed infections, and normalize HIV testing.


    Objectives:

    We aimed to determine HST uptake and factors associated with uptake among at-risk pharmacy clients, assess acceptability and willingness to pay, and document experiences and views of participating pharmacy staff


    Methods:

    Existing staff at five purposively selected community pharmacies in Coastal Kenya invited adults (≥18 years) seeking products indicative of HIV risk. On-site research assistants administered HIV pre-test counselling and pre-test questionnaires. Participants were offered oral HST kits (OraQuick®) at KSh 100. Within one week of buying a test, participants were contacted for post-test questionnaires and counselling. The primary outcome was test uptake, defined as the proportion of eligible clients who bought tests. Through group discussions mid- and end-study, we solicited the views and experiences of pharmacy service providers.


    Results:

    From Nov 2015 to Apr 2016, 467 clients were invited to participate; 178 (38%) were enrolled and completed the pre-test questionnaire; 164 (35%) bought a test; and 153 (33%) completed a post-test questionnaire. HST uptake was 35% [95% CI 31-39%]; higher among clients seeking HIV testing compared to those seeking other index products (84% vs.11%, p<0.001). Acceptability was high among both clients and service providers, but concerns about pre-test counselling were raised. Almost all testers reported the test procedure was easy or very easy, that they would like to use the method again in future, and that they were likely or very likely to recommend it to others. Demand for HST kits persisted beyond the study end and participating pharmacy service providers were eager to continue offering the service. Only 2% of clients declined the test because of inability to pay, and only 1% cited affordability as a main disadvantage.


    Conclusions, recommendations and implications:

    Acceptability of pharmacy HST was high among both clients and service providers. A much higher uptake among clients seeking HIV testing suggests that a client-initiated approach is the most feasible in this setting. Official implementation of pharmacy self-testing will meet the apparent unmet need and facilitate quality improvement and monitoring. Pharmacy HST providers should be equipped to provide pre-test counselling and self-testers should have access to counselling support before, during and after testing.



  • Outcomes of follow up of discordant couples in an urban setting

    Background

    A report by UNAIDS 2005 indicated that there were between 23.8% to 28.9% sero conversions among previously HIV negative partners in discordant relationship. In Kenya, according to Kenya AIDS Indicator Survey 2012, 45% of HIV-infected individuals were in a discordant relationship. The provision of services tailored to meet the needs of discordant couples is critical in the fight against new HIV-infections among high risk populations. This provides an opportunity to intensify prevention counseling and interventions including prompt ART initiation among HIV-infected partners which ultimately results in low HIV-transmission. University of Maryland, Baltimore through its PACT program supports HIV service delivery in 48 facilities in Nairobi County and has introduced discordant couple groups in 19 facilities where HIV prevention interventions are provided.


    Objectives

    The aim of the study was to determine the outcomes among the discordant couples enrolled in PACT-supported facilities.


    Methodology

    Discordant couples were identified mainly through testing of partners of patients enrolled in care and during couple counselling sessions. Services offered include annual HIV testing of negative partners, counseling on positive health dignity and prevention intervention including STI screening, condom use and family planning and initiation of ART among positive partners. Regular support group meetings were held during which the clients shared their experiences. Longitudinal follow-up was done through use of customized discordant couple registers. A retrospective analysis of data was conducted to determine the outcome amongst couples enrolled between Jan-March 2013 and who had been followed up for at least 12 months.


    Results

    Overall, as at March 2016, 1,263 discordant couples had been enrolled in the program of whom 1014 (80%) remained active and continued to attend the support group meetings and 664 (64%) of the negative partner had received a HIV test in the last 12 months. Among those active 993 (98%) of HIV-infected partners were on antiretroviral therapy. For the 249 couples that had fallen out of the program, 80 (32%) had separated, 75 (30%) transferred out, only 21 (8%) of the HIV negative partners seroconverted and were therefore enrolled in care, 24 (10%) died and 49 (20%) were lost to follow-up.


    Conclusion, recommendations and implications

    Longitudinal follow up of discordant couples, with focus on both HIV negative and Positive, is important for positive outcomes. This ensures good adherence, Correct and consistent use of condoms, STI screening to avoid infection and yearly testing of the Negative partner.



  • HIV Type 1 Transmission Networks Among Men Having Sex with Men and Heterosexuals in Kenya

    We performed a molecular phylogenetic study on HIV-1 polymerase sequences of men who have sex with men (MSM) and heterosexual patient samples in Kenya to characterize any observed HIV-1 transmission networks. HIV-1 polymerase sequences were obtained from samples in Nairobi and coastal Kenya from 84 MSM, 226 other men, and 364 women from 2005 to 2010. Using Bayesian phylogenetics, we tested whether sequences clustered by sexual orientation and geographic location. In addition, we used trait diffusion analyses to identify significant epidemiological links and to quantify the number of transmissions between risk groups. Finally, we compared 84 MSM sequences with all HIV-1 sequences available online at GenBank. Significant clustering of sequences from MSM at both coastal Kenya and Nairobi was found, with evidence of HIV-1 transmission between both locations. Although a transmission pair between a coastal MSM and woman was confirmed, no significant HIV-1 transmission was evident between MSM and the comparison population for the predominant subtype A (60%). However, a weak but significant link was evident when studying all subtypes together. GenBank comparison did not reveal other important transmission links. Our data suggest infrequent intermingling of MSM and heterosexual HIV-1 epidemics in Kenya.


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  • Experiences of Kenyan healthcare workers providing services to men who have sex with men: qualitative findings from a sensitivity training programme

    Introduction:

    Men who have sex with men (MSM) in Kenya are at high risk for HIV and may experience prejudiced treatment in health settings due to stigma. An on-line computer-facilitated MSM sensitivity programme was conducted to educate healthcare workers (HCWs) about the health issues and needs of MSM patients.


    Methods:

    Seventy-four HCWs from 49 ART-providing health facilities in the Kenyan Coast were recruited through purposive sampling to undergo a two-day MSM sensitivity training. We conducted eight focus group discussions (FGDs) with programme participants prior to and three months after completing the training programme. Discussions aimed to characterize HCWs’ challenges in serving MSM patients and impacts of programme participation on HCWs’ personal attitudes and professional capacities.


    Results:

    Before participating in the training programme, HCWs described secondary stigma, lack of professional education about MSM, and personal and social prejudices as barriers to serving MSM clients. After completing the programme, HCWs expressed greater acknowledgement of MSM patients in their clinics, endorsed the need to treat MSM patients with high professional standards and demonstrated sophisticated awareness of the social and behavioural risks for HIV among MSM.


    Conclusions:

    Findings provide support for this approach to improving health services for MSM patients. Further efforts are needed to broaden the reach of this training in other areas, address identified barriers to HCW participation and evaluate programme effects on patient and HCW outcomes using rigorous methodology


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  • Men who have sex with men sensitivity training reduces homoprejudice and increases knowledge among Kenyan healthcare providers in coastal Kenya

    Introduction:

    Healthcare workers (HCWs) in Africa typically receive little or no training in the healthcare needs of men who have sex with men (MSM), limiting the effectiveness and reach of population-based HIV control measures among this group. We assessed the effect of a web-based, self-directed sensitivity training on MSM for HCWs (www.marps-africa.org), combined with facilitated group discussions on knowledge and homophobic attitudes among HCWs in four districts of coastal Kenya.


    Methods:

    We trained four district ‘‘AIDS coordinators’’ to provide a two-day training to local HCWs working at antiretroviral therapyproviding facilities in coastal Kenya. Self-directed learning supported by group discussions focused on MSM sexual risk practices, HIV prevention and healthcare needs. Knowledge was assessed prior to training, immediately after training and three months after training. The Homophobia Scale assessed homophobic attitudes and was measured before and three months after training.


    Results:

    Seventy-four HCWs (68% female; 74% clinical officers or nurses; 84% working in government facilities) from 49 health facilities were trained, of whom 71 (96%) completed all measures. At baseline, few HCWs reported any prior training on MSM anal sexual practices, and most HCWs had limited knowledge of MSM sexual health needs. Homophobic attitudes were most pronounced among HCWs who were male, under 30 years of age, and working in clinical roles or government facilities. Three months after training, more HCWs had adequate knowledge compared to baseline (49% vs. 13%, McNemar’s test pB0.001); this was most pronounced in those with clinical or administrative roles and in those from governmental health providers. Compared to baseline, homophobic attitudes had decreased significantly three months after training, particularly among HCWs with high homophobia scores at baseline, and there was some evidence of correlation between improvements in knowledge and reduction in homophobic sentiment.


    Conclusions:

    Scaling up MSM sensitivity training for African HCWs is likely to be a timely, effective and practical means to improve relevant sexual health knowledge and reduce personal homophobic sentiment among HCWs involved in HIV prevention, testing and care in sub-Saharan Africa.


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  • Changes in Sexual Risk Behavior in the Mombasa Cohort: 1993–2007

    The Mombasa Cohort is an open cohort study following HIV-seronegative women reporting transactional sex. Established in 1993, the cohort provides regular HIV counseling and testing at monthly visits. Over time, HIV acquisition risk has declined steadily in this cohort. To evaluate whether this decline may reflect changes in sexual risk behavior, we investigated trends in condom use and partner numbers among women who participated in the Mombasa Cohort between 1993 and 2007. Multinomial logistic regression and generalized estimating equations were used to evaluate the association of calendar time and follow-up time with key risk behaviors, after adjustment for potential confounding factors. At enrollment visits by 1,844 women, the adjusted probability of never using condoms decreased over time, from 34.2% to 18.9%. Over 23,911 follow-up visits, the adjusted probabilities of reporting >2 partners decreased from 9.9% to 4.9% and inconsistent condom use decreased from 7.9% to 5.3% after ≥12 cohort visits. Important predictors of risk behavior were work venue, charging low fees for sex, and substance abuse. Women with a later sexual debut had less risky behavior. Although sexual risk has declined among women participating in the Mombasa Cohort, HIV acquisition continues to occur and interventions to promote and reinforce safer sex are clearly needed.


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  • Engaging young adult clients of community pharmacies for HIV screening in Coastal Kenya: a cross-sectional study

    Background

    Adults in developing countries frequently use community pharmacies as the first and often only source of care. The objective of this study was to assess the success of pharmacy referrals and uptake of HIV testing by young adult clients of community pharmacies in the context of a screening programme for acute HIV-1 infection (AHI).


    Methods

    We requested five pharmacies to refer clients meeting predefined criteria (ie, 18–29 years of age and requesting treatment for fever, diarrhoea, sexually transmitted infection (STI) symptoms or body pains) for HIV-1 testing and AHI screening at selected clinics. Using multivariable logistical regression, we determined client characteristics associated with HIV-1 test uptake.


    Results

    From February through July 2013, 1490 pharmacy clients met targeting criteria (range of weekly averages across pharmacies: 4–35). Of these, 1074 (72%) accepted a referral coupon, 377 (25%) reported at a study clinic, 353 (24%) were HIV-1 tested and 127 (9%) met criteria for the AHI study. Of those tested, 14 (4.0%) were HIV-1 infected. Test uptake varied significantly by referring pharmacy and was higher for clients who presented at the pharmacy without a prescription versus those with a prescription, and for clients who sought care for STI symptoms.


    Conclusions

    About a quarter of targeted pharmacy clients took up HIV-1 testing. Clients seeking care directly at the pharmacy (ie, without a prescription) and those with STI symptoms were more likely to take up HIV-1 testing. Engagement of adult pharmacy clients for HIV-1 screening may identify undiagnosed individuals and offers opportunities for HIV-1 prevention research.


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  • Association between Participant Self-Report and Biological Outcomes Used to Measure Sexual Risk Behavior in HIV-1-Seropositive Female Sex Workers in Mombasa, Kenya

    Background

    Few studies have examined the association between self-reported sexual risk behaviors and biological outcomes in HIV-1-seropositive African adults.


    Methods

    We conducted a prospective cohort study in 898 HIV-1-seropositive women who reported engaging in transactional sex in Mombasa, Kenya. Primary outcome measures included detection of sperm in genital secretions, pregnancy, and sexually transmitted infections (STIs). Because three outcomes were evaluated, data are presented with odds ratios [OR] and 96.7% confidence intervals [CI] to reflect that we would reject a null hypothesis if a p-value were ≤0.033 (Simes’ methodology).


    Results

    During 2,404 person-years of follow-up, self-reported unprotected intercourse was associated with significantly higher likelihood of detecting sperm in genital secretions (OR 2.32, 96.7% CI 1.93, 2.81), and pregnancy (OR 2.78, 96.7% CI 1.57, 4.92), but not with detection of STIs (OR 1.20, 96.7% CI 0.98, 1.48). At visits where women reported being sexually active, having >1 sex partner in the past week was associated with lower likelihood of detecting sperm in genital secretions (OR 0.74, 96.7% CI 0.56, 0.98). This association became non-significant after adjustment for reported condom use (adjusted OR 0.81, 96.7% CI 0.60, 1.08).


    Conclusions

    Combining behavioral and biological outcomes, which provide complementary information, is advantageous for understanding sexual risk behavior in populations at risk for transmitting HIV-1. The paradoxical relationship between higher numbers of sex partners and less frequent identification of sperm in genital secretions highlights the potential importance of context-specific behavior, such as condom use dependent on partner type, when evaluating sexual risk behavior.


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  • Most adults seek urgent healthcare when acquiring HIV-1 and are frequently treated for malaria in coastal Kenya

    Background:

    Acute HIV-1 infection (AHI) may present with symptoms for which urgent healthcare is sought. However, little is known about healthcare seeking around the time of HIV-1 seroconversion in sub-Saharan Africa.


    Methods:

    Review of clinical, counselling, treatment and laboratory records of previously HIV-1 seronegative at-risk adults, followed at monthly or 3-monthly visits, who seroconverted and enrolled in an AHI cohort. All HIV-seronegative plasma samples were tested for p24 antigen (p24) and stored preseroconversion samples for HIV-1 RNA (RNA). Factors associated with malaria treatment while acquiring HIV-1 were evaluated in multiple logistic regression.


    Results: Sixty men and 12 women (95% of 75 seroconverters) were evaluated, including 43 (60%) with either p24-positive or RNA-positive or HIV-1 discordant rapid antibodies prior to seroconversion. Prior to diagnosis, 54 patients (75%) reported fever and 50 (69%) sought urgent care for symptomatic illness, including 23 (32%) who sought care in a nonresearch setting. Twenty-nine patients (40%) received presumptive malaria treatment. Only 24% of febrile patients were tested for malaria parasites. All documented smear results were negative. Malaria treatment was strongly associated with fever [adjusted odds ratio (aOR): 46, 95% confidence interval (CI): 3–725] and nonresearch setting (aOR: 5, 95% CI: 3–64). AHI was suspected in six (12%) patients who presented for urgent care during research evaluation.


    Conclusions: The majority of adults with AHI seek urgent healthcare. These individuals are often presumptively treated for malaria. Improved recognition of AHI in adults presenting for care may offer opportunities for optimizing HIV prevention strategies.


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