Fertility desires and sexual behaviours among women recovering from genital fistula repair in Eldoret, Kenya.

OBJECTIVES: The reproductive desire of women following genital fistula repair surgery is complex, varied and often not addressed, although it carries significant consequences. The aim of this study was to better understand the fertility desires and sexual behaviours of women who recently underwent surgical repair of a genital fistula. METHODS: This is a secondary analysis of a retrospective cohort study designed to assess the effectiveness of Beyond Fistula, a reintegration programme for women recovering from genital fistula surgery in Eldoret, Kenya. One hundred women who participated in the Beyond Fistula programme between 2013 and 2019 were interviewed in person regarding future fertility desire, current sexual behaviour and contraceptive use. RESULTS: Among the 79 reproductive-aged women included in this study, 63.3% reported no future desire for pregnancy. Those that desired another pregnancy were significantly younger (48.3% were 18-29 years old vs. 66.0% were 35 years old or more, p = 0.004), had fewer living children (70% had 0-2 children vs. 56% had 3 or more children, p < 0.001), and a lower level of food insecurity (27.6% reported no to marginal insecurity vs. 14%, p = 0.014). Current sexual activity was marginally different between women who did and did not desire future pregnancy (82.8% vs. 66.0%, p = 0.053). Of the 50 women in our study who did not desire pregnancy, 62.0% were sexually active and of these, only 38.7% were preventing pregnancy. Lack of knowledge and access to methods were most commonly cited as barriers to use. CONCLUSIONS: Many women recovering from genital fistula surgery do not desire pregnancy and are sexually active but are not using a method to prevent pregnancy. The potential for post-surgical reintegration programmes to address education and access to contraception is a vital and unmet need to promote reproductive empowerment in this population of women as they reestablish their lives.

Epilepsy management in pregnant HIV+ women in sub-Saharan Africa, clinical aspects to consider: a scoping review.

BACKGROUND: Since the introduction of highly active antiretroviral therapy (HAART), acquired immune deficiency syndrome (AIDS) related mortality has markedly declined. As HAART is becoming increasingly available, the infection with human immunodeficiency virus (HIV+) in sub-Saharan Africa (SSA) is becoming a chronic condition. While pregnancy in HIV+ women in SSA has always been considered a challenging event for the mother and the fetus, for pregnant HIV+ women also diagnosed with epilepsy (WWE), there are additional risks as HIV increases the odds of developing seizures due to the vulnerability of the central nervous system to other infections, immune dysfunction, and overall metabolic disturbances. In light of a growing proportion of HIV+ WWE on HAART and an increasing number of pregnant women accessing mother-to-child transmission of HIV programs through provision of HAART in SSA, there is a need to develop contextualized and evidenced-based clinical strategies for the management of epilepsy in this population. In this study, we conduct a literature scoping review to identify issues that warrant consideration for clinical management. RESULT: Twenty-three articles were retained after screening, which covered six overarching clinical aspects: status epilepticus (SE), Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), dyslipidemia, congenital malformation (CM), chronic kidney disease (CKD), and neurological development. No studies for our population of interest were identified, highlighting the need for a cautionary approach to be employed when extrapolating findings. CONCLUSION: High risks of CM and drug interactions with first-line antiepileptic drugs (AEDs) warrant measures to increase the accessibility and choices of safer second-line AEDs. To ensure evidence-based management of epilepsy within this population, the potential high prevalence of SE, CKD, dyslipidemia, and SJS/TEN and the cumulative effect of drug-drug interactions should be considered. Further understanding of the intersections between pregnancy and drug-drug interactions in SSA is needed to ensure evidenced-based management of epilepsy in pregnant HIV+ WWE. To prevent SE, the barriers for AED treatment adherence in pregnant HIV+ women should be explored. Our review underscores the need to conduct cohort studies of HIV+ WWE in reproductive age over time and across pregnancies to capture the cumulative effect of HAART and AED to inform clinical management.

Socioeconomic differences in caesarean section - are they explained by medical need? An analysis of patient record data of a large Kenyan hospital.

BACKGROUND: Caesarean section (C-section) rates are often low among the poor and very high among the better-off in low- and middle-income countries. We examined to what extent these differences are explained by medical need in an African context. METHODS: We analyzed electronic records of 12,209 women who gave birth in a teaching hospital in Kenya in 2014. C-section rates were calculated by socioeconomic position (SEP), using maternal occupation (professional, small business, housewife, student) as indicator. We assessed if women had documented clinical indications according to hospital guidelines and if socioeconomic differences in C-section rates were explained by indication. RESULTS: Indication for C-section according to hospital guidelines was more prevalent among professionals than housewives (16% vs. 9% of all births). The C-section rate was also higher among professionals than housewives (21.1% vs. 15.8% [OR 1.43; 95%CI 1.23-1.65]). This C-section rate difference was largely explained by indication (4.7 of the 5.3 percentage point difference between professionals and housewives concerned indicated C-sections, often with previous C-section as indication). Repeat C-sections were near-universal (99%). 43% of primary C-sections had no documented indication. Over-use was somewhat higher among professionals than housewives (C-section rate among women without indication: 6.6 and 5.5% respectively), which partly explained socioeconomic differences in primary C-section rate. CONCLUSIONS: Socioeconomic differences in C-section rates can be largely explained by unnecessary primary C-sections and higher supposed need due to previous C-section. Prevention of unnecessary primary C-sections and promoting safe trial of labor should be priorities in addressing C-section over-use and reducing inequalities. Unnecessary primary C-sections and ubiquitous repeat C-sections drive overall C-section rates and C-section inequalities.

Uptake of three doses of HPV vaccine by primary school girls in Eldoret, Kenya; a prospective cohort study in a malaria endemic setting.

BACKGROUND: All women are potentially at risk of developing cervical cancer at some point in their life, yet it is avoidable cause of death among women in Sub- Saharan Africa with a world incidence of 530,000 every year. It is the 4th commonest cancer affecting women worldwide with over 260,000 deaths reported in 2012. Low resource settings account for over 75% of the global cervical cancer burden. Uptake of HPV vaccination is limited in the developing world. WHO recommended that 2 doses of HPV vaccine could be given to young girls, based on studies in developed countries. However in Africa high rates of infections like malaria and worms can affect immune responses to vaccines, therefore three doses may still be necessary. The aim of this study was to identify barriers and facilitators associated with uptake of HPV vaccine. METHODS: A cross-sectional survey was conducted at Eldoret, Kenya involving 3000 girls aged 9 to 14 years from 40 schools. Parents/guardians gave consent through a questionnaire. RESULTS: Of all 3083 the school girls 93.8% had received childhood vaccines and 63.8% had a second HPV dose, and 39.1% had a third dose. Administration of second dose and HPV knowledge were both strong predictors of completion of the third dose. Distance to the hospital was a statistically significant risk factor for non-completion (P: 0.01). CONCLUSIONS: Distance to vaccination centers requires a more innovative vaccine-delivery strategy and education of parents/guardians on cervical screening to increase attainment of the HPV vaccination.

Determinants of breast cancer early detection for cues to expanded control and care: the lived experiences among women from Western Kenya.

BACKGROUND: Estimately, 70-80% of cancer cases are diagnosed in late stages in Kenya with breast cancer being a common cause of mortality among women where late diagnosis is the major ubiquitous concern. Numerous studies have focused on epidemiological and health policy dynamics essentially underestimating the determining factors that shape people's choices and cues to health care service uptake. The study sought to evaluate the knowledge, attitude and health seeking behavior towards breast cancer and its screening in a quest to explain why women present for prognosis and treatment when symptomatic pointers are in advanced stages, impeding primary prevention strategies. METHODS: Eight focus groups (6-10 members per group) and four key informant interviews were conducted among adult participants from rural and urban settings. Sessions were audio-recorded and transcribed. A thematic analysis of the data was based on the concepts of the health belief model. Data analysis was conducted using NVIVO10. RESULTS: Most women perceived breast cancer as a fatal disease and conveyed fear of having early screening. Rural women preferred self-prescribed medications and the use of alternative medicine for long periods before presenting for professional care on suspicion that the lump is cancerous. Accessibility to equipped health facilities, lack of information to establish effective follow-up treatment and low-income status were underscored as their major health seeking behavior barriers whereas, urban women identified marital status as their main barrier. Key informant interviews revealed that health communication programs emphasized more on communicable diseases. This could in part explain why there is a high rate of misconception and suspicion about breast cancer among rural and urban women in the study setting. CONCLUSIONS: Creating breast cancer awareness alongside clear guidelines on accessing screening and treatment infrastructure is critical. It was evident, a diagnosis of breast cancer or lump brings unexpected confrontation with mortality; fear, pain, cultural barriers, emotional and financial distress. Without clear referral channels to enable those with suspicious lumps or early stage disease to get prompt diagnosis and treatment, then well-meaning awareness will not necessarily contribute to reducing morbidity and mortality.

First look: a cluster-randomized trial of ultrasound to improve pregnancy outcomes in low income country settings.

BACKGROUND: In high-resource settings, obstetric ultrasound is a standard component of prenatal care used to identify pregnancy complications and to establish an accurate gestational age in order to improve obstetric care. Whether or not ultrasound use will improve care and ultimately pregnancy outcomes in low-resource settings is unknown. METHODS/DESIGN: This multi-country cluster randomized trial will assess the impact of antenatal ultrasound screening performed by health care staff on a composite outcome consisting of maternal mortality and maternal near-miss, stillbirth and neonatal mortality in low-resource community settings. The trial will utilize an existing research infrastructure, the Global Network for Women's and Children's Health Research with sites in Pakistan, Kenya, Zambia, Democratic Republic of Congo and Guatemala. A maternal and newborn health registry in defined geographic areas which documents all pregnancies and their outcomes to 6 weeks post-delivery will provide population-based rates of maternal mortality and morbidity, stillbirth, neonatal mortality and morbidity, and health care utilization for study clusters. A total of 58 study clusters each with a health center and about 500 births per year will be randomized (29 intervention and 29 control). The intervention includes training of health workers (e.g., nurses, midwives, clinical officers) to perform ultrasound examinations during antenatal care, generally at 18-22 and at 32-36 weeks for each subject. Women who are identified as having a complication of pregnancy will be referred to a hospital for appropriate care. Finally, the intervention includes community sensitization activities to inform women and their families of the availability of ultrasound at the antenatal care clinic and training in emergency obstetric and neonatal care at referral facilities. DISCUSSION: In summary, our trial will evaluate whether introduction of ultrasound during antenatal care improves pregnancy outcomes in rural, low-resource settings. The intervention includes training for ultrasound-naïve providers in basic obstetric ultrasonography and then enabling these trainees to use ultrasound to screen for pregnancy complications in primary antenatal care clinics and to refer appropriately. TRIAL REGISTRATION: Clinicaltrials.gov (NCT # 01990625).

Impact of Beyond Fistula programming on economic, psychosocial and empowerment outcomes following female genital fistula repair: A retrospective study.

OBJECTIVE: To retrospectively assess changes in economic status, psychosocial status and empowerment among women who participated in Beyond Fistula reintegration programming following fistula repair. METHODS: We conducted a retrospective study among 100 Beyond Fistula program participants capturing sociodemographic characteristics, obstetric and fistula history, program participation, and our primary outcomes: economic status, psychosocial status, and empowerment via quantitative survey at two time points: before program participation and currently. Data were collected from November 2020 to July 2021 from 2013 to 2019 program participants. We compared outcomes across these two time points using paired t tests or McNemar's tests. RESULTS: The proportion of individuals owning property (28.0% vs. 38.0%, P = 0.006), having a current source of income (19.0% vs. 56.0%, P < 0.001), and saving or investing income (11.0% vs. 37.0%, P < 0.001) increased significantly from pre- to post-programming. We also identified statistically significant increases from pre- to post-programming in self-esteem (5.0 [IQR 4.0-5.0] vs. 5.0 [IQR 5.0-5.0], P < 0.001), reintegration (53.0 [IQR 43.0-69.0] vs. 65.0 [IQR 51.0-72.0], P < 0.001) and level of input into household economic decision making (2.0 [SD 1.0] vs. 2.3 [SD 1.0], P = 0.004). CONCLUSION: Beyond Fistula programming likely improved economic status, psychosocial status, and empowerment of participants. Post-surgical interventions incorporating a holistic approach can advance recovery through supporting psychosocial and economic wellbeing and should be offered to women undergoing genital fistula repair.

A combined community- and facility-based approach to improve pregnancy outcomes in low-resource settings: a Global Network cluster randomized trial.

BACKGROUND: Fetal and neonatal mortality rates in low-income countries are at least 10-fold greater than in high-income countries. These differences have been related to poor access to and poor quality of obstetric and neonatal care. METHODS: This trial tested the hypothesis that teams of health care providers, administrators and local residents can address the problem of limited access to quality obstetric and neonatal care and lead to a reduction in perinatal mortality in intervention compared to control locations. In seven geographic areas in five low-income and one middle-income country, most with high perinatal mortality rates and substantial numbers of home deliveries, we performed a cluster randomized non-masked trial of a package of interventions that included community mobilization focusing on birth planning and hospital transport, community birth attendant training in problem recognition, and facility staff training in the management of obstetric and neonatal emergencies. The primary outcome was perinatal mortality at ≥28 weeks gestation or birth weight ≥1000 g. RESULTS: Despite extensive effort in all sites in each of the three intervention areas, no differences emerged in the primary or any secondary outcome between the intervention and control clusters. In both groups, the mean perinatal mortality was 40.1/1,000 births (P = 0.9996). Neither were there differences between the two groups in outcomes in the last six months of the project, in the year following intervention cessation, nor in the clusters that best implemented the intervention. CONCLUSIONS: This cluster randomized comprehensive, large-scale, multi-sector intervention did not result in detectable impact on the proposed outcomes. While this does not negate the importance of these interventions, we expect that achieving improvement in pregnancy outcomes in these settings will require substantially more obstetric and neonatal care infrastructure than was available at the sites during this trial, and without them provider training and community mobilization will not be sufficient. Our results highlight the critical importance of evaluating outcomes in randomized trials, as interventions that should be effective may not be. TRIAL REGISTRATION: ClinicalTrials.gov NCT01073488.

Stillbirths: the vision for 2020.

Stillbirth is a common adverse pregnancy outcome, with nearly 3 million third-trimester stillbirths occurring worldwide each year. 98% occur in low-income and middle-income countries, and more than 1 million stillbirths occur in the intrapartum period, despite many being preventable. Nevertheless, stillbirth is practically unrecognised as a public health issue and few data are reported. In this final paper in the Stillbirths Series, we call for inclusion of stillbirth as a recognised outcome in all relevant international health reports and initiatives. We ask every country to develop and implement a plan to improve maternal and neonatal health that includes a reduction in stillbirths, and to count stillbirths in their vital statistics and other health outcome surveillance systems. We also ask for increased investment in stillbirth-related research, and especially research aimed at identifying and addressing barriers to the aversion of stillbirths within the maternal and neonatal health systems of low-income and middle-income countries. Finally, we ask all those interested in reducing stillbirths to join with advocates for the improvement of other pregnancy-related outcomes, for mothers and their offspring, so that a united front for improved pregnancy and neonatal care for all will become a reality.

Community based weighing of newborns and use of mobile phones by village elders in rural settings in Kenya: a decentralised approach to health care provision.

BACKGROUND: Identifying every pregnancy, regardless of home or health facility delivery, is crucial to accurately estimating maternal and neonatal mortality. Furthermore, obtaining birth weights and other anthropometric measurements in rural settings in resource limited countries is a difficult challenge. Unfortunately for the majority of infants born outside of a health care facility, pregnancies are often not recorded and birth weights are not accurately known. Data from the initial 6 months of the Maternal and Neonatal Health (MNH) Registry Study of the Global Network for Women and Children's Health study area in Kenya revealed that up to 70% of newborns did not have exact weights measured and recorded by the end of the first week of life; nearly all of these infants were born outside health facilities. METHODS: To more completely obtain accurate birth weights for all infants, regardless of delivery site, village elders were engaged to assist in case finding for pregnancies and births. All elders were provided with weighing scales and mobile phones as tools to assist in subject enrollment and data recording. Subjects were instructed to bring the newborn infant to the home of the elder as soon as possible after birth for weight measurement.The proportion of pregnancies identified before delivery and the proportion of births with weights measured were compared before and after provision of weighing scales and mobile phones to village elders. Primary outcomes were the percent of infants with a measured birth weight (recorded within 7 days of birth) and the percent of women enrolled before delivery. RESULTS: The recorded birth weight increased from 43 ± 5.7% to 97 ± 1.1. The birth weight distributions between infants born and weighed in a health facility and those born at home and weighed by village elders were similar. In addition, a significant increase in the percent of subjects enrolled before delivery was found. CONCLUSIONS: Pregnancy case finding and acquisition of birth weight information can be successfully shifted to the community level.

Comparison of conventional cervical cytology versus visual inspection with acetic acid among human immunodeficiency virus-infected women in Western Kenya.

OBJECTIVE: This study aimed to determine the accuracy of visual inspection with acetic acid (VIA) versus conventional Pap smear as a screening tool for cervical intraepithelial neoplasia/cancer among human immunodeficiency virus (HIV)-infected women. MATERIALS AND METHODS: A total of 150 HIV-infected women attending the Moi Teaching and Referral Hospital HIV clinic in Eldoret underwent conventional Pap smear, VIA, colposcopy, and biopsy. Both VIA and Pap smears were done by nurses, whereas colposcopy and biopsy were done by a physician. Receiver operating characteristic analysis was conducted to compare the accuracies between VIA and Pap smear in sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: Among the study participants: VIA was abnormal in 55.3% (83/150, 95% confidence interval [CI] = 47.0%-63.5%); Pap smear showed atypical squamous cells of undetermined significance or worse in 43.7% (59/135, 95% CI = 35.2%-52.5%) and 10% (15/150) of the Pap smears were unsatisfactory. Of the abnormal Pap smears, 3% (2/59) had atypical squamous cells of undetermined significance, 7% (4/59) had high-grade atypical squamous cells, 60% (35/59) had low-grade squamous intraepithelial lesions, 29% (17/59) had high-grade squamous intraepithelial lesions, and 2% (1/59) was suspicious for cervical cancer. Using cervical intraepithelial neoplasia 2 or higher disease on biopsy as an end point, VIA has a sensitivity of 69.6% (95% CI = 55.1%-81.0%), specificity of 51.0% (95% CI = 41.5%-60.4%), PPV of 38.6% (95% CI = 28.8%-49.3%), and NPV of 79.1% (95% CI = 67.8%-87.2%). For conventional Pap smear, sensitivity was 52.5% (95% CI = 42.1%-71.5%), specificity was 66.3% (95% CI = 52.0%-71.2%), PPV was 39.7% (95% CI = 27.6%-51.8%), and NPV was 76.8% (95% CI = 67.0%-85.6%). CONCLUSIONS: Visual inspection with acetic acid is comparable to Pap smear and acceptable for screening HIV-infected women in resource-limited settings such as Western Kenya.

Retrospective review of predisposing factors and surgical outcomes in obstetric fistula patients at a single teaching hospital in Western Kenya.

OBJECTIVE: We examined success rates and complications of obstetric fistula (OF) surgical repairs in association with patient and fistula characteristics, including sociocultural and socioeconomic determinants of health. A better understanding of these associations will help guide surgical management and prevent predisposing factors. METHODS: We reviewed the medical records of 86 patients who underwent OF repair at Moi Teaching and Referral Hospital in Kenya between 1999 and 2007. RESULTS: Women with OF presented for repair with a variety of concurrent conditions. Seventy-eight percent had laboured for at least 24 hours; 29% had undergone previous unsuccessful surgery. Of the women who presented at postoperative follow-up, 54% still complained of incontinence. Persistent incontinence was associated with larger, more complicated fistulas and having had previous failed attempts at surgical repair. CONCLUSION: The association of factors such as duration of labour with OF reflects the limited availability of obstetrical care in Western Kenya. There is a significant difference in postoperative success of fistula repair between women with large fistulas or those who had previous failed surgery and other patients. This reflects the importance of primary and secondary prevention.

A novel ED-based sexual assault centre in western Kenya: description of patients and analysis of treatment patterns.

BACKGROUND: The aim of this study was to establish the feasibility of a Kenyan emergency department (ED)-based sexual assault centre; and to improve knowledge of the characteristics of sexual assault in the region. METHODS: The Center for Assault Recovery-Eldoret (CAR-E) was established to provide timely, culturally sensitive treatment of Kenyan sexual assault survivors using a standardised evaluation/treatment protocol. A retrospective review of charts of all sexual assault survivors attending CAR-E from May 2007-May 2008 was performed. Simple descriptive statistics, t tests, and OR were calculated. RESULTS: CAR-E treated 321 survivors over 13 months. Patients' mean age was 15.9 years; 50% were younger than 14years old. Survivors were predominately female and single. Most knew their assailant. Younger age was associated with increased likelihood of genital trauma. Only 43% of assaults were reported to the police. Sexually transmitted infection prophylaxis was given per protocol to 84% eligible; emergency contraception to 64%; and HIV prophylaxis to 63%. Only 44% received counselling. Survivors were more likely to get sexually transmitted infection and HIV prophylaxis, and emergency contraception if they had genital injury. CONCLUSIONS: Development of an ED-based sexual assault centre at a referral hospital in Kenya using a standardised history, physical, and treatment protocol was feasible, and high rates of prophylaxis were provided. Based on characteristics of people who have been assaulted, community prevention efforts should concentrate on decreasing the societal acceptability of rape. In conjunction with improvement of protocols at the centre under consideration, development of similar centres in sub-Saharan African ED should be encouraged.

Mothers of adolescent girls and Human Papilloma Virus (HPV) vaccination in Western Kenya.

INTRODUCTION: human papilloma virus (HPV) which is preventable is the main cause of cervical cancer and it targets mostly young adolescents. The study was to determine the practice desire, attitude and knowledge of mothers of adolescent girls on HPV vaccination in Western Kenya. METHODS: this was a descriptive cross-sectional study design. Data was obtained using semi-structured questionnaires and analyzed using both descriptive and inferential statistics at 95% confidence level using the SPSS software version 22. A p-value ≤ 0.05 was considered statistically significant. RESULTS: ninety five percent of the mothers had intentions to vaccinate their daughters and also had a positive attitude and their response to HPV vaccination was significantly lower than those without intentions p=0.02, 95% CI, OR=0.48 (0.90-0.89). Vaccination against HPV was low at 9.4% with a mean age of 34 years. Our results found a high level of cervical cancer awareness (85.0%), HPV and vaccine awareness respectively (62.0%, and 64.0%). "Vaccination of my daughters will prompt early sexual activity and the cost of HPV vaccination being a barrier to vaccination" had a statistically significant influence on the practice of vaccination. Negative attitude to daughters´ early onset of sexual activity significantly reduced up take while positive attitude to cost of HPV vaccine significantly increased up take of HPV vaccination with p value of 0.007 and 0.04 respectively. CONCLUSION: awareness of HPV and HPV vaccine prevention is low among mothers of adolescent girls in Western Kenya. There was a positive attitude and high desire towards the use of HPV vaccination therefore a need for awareness, policy and unify efforts to reduce cervical cancer burden.

Knowledge of Cervical Cancer and Acceptability of Prevention Strategies Among Human Papillomavirus-Vaccinated and Human Papillomavirus-Unvaccinated Adolescent Women in Eldoret, Kenya.

Cervical cancer is a critical public health concern in sub-Saharan Africa. Adolescents are key targets in primary prevention strategies. Following a human papillomavirus (HPV) vaccination initiative (Gardasil) in Eldoret, Kenya, the knowledge and source of information of cervical cancer and acceptance of prevention strategies among vaccinated and unvaccinated adolescents were evaluated. A cross-sectional comparative study enrolled 60 vaccinated and 120 unvaccinated adolescent women. Institutional ethical approval was obtained and signed consent was obtained from the parents. Data collection was performed using interviewer-administered questionnaires derived from factual statements based on information from print material used for community sensitization on cervical cancer. The median age of the participants was 14.0 years (interquartile range [IQR] = 13.0-15.0). Of 60 vaccinated adolescents, 56 (93.3%) had heard of the HPV vaccine compared with 6 (5%) of unvaccinated participants (p < 0.001). Of 60 vaccinated participants, 58 (96.7%) had heard of cervical cancer compared with 61 (50.8%) unvaccinated participants (p < 0.001). Both cohorts identified the school as the main source of information for cervical cancer. The two groups also showed similarity in their selection of cervical cancer prevention strategies acceptable to them such as delaying sexual debut, limiting number of sexual partners, and use of condoms for protection against sexually transmitted infections. Of 120 unvaccinated participants, 63.7% expressed willingness to be vaccinated. Exposure to the HPV vaccine was associated with a higher knowledge of cervical cancer. The adolescents predominantly rely on the school for health information. Both cohorts of adolescents showed remarkable acceptability for cervical cancer prevention strategies.

Effects of malaria/helminthic coinfections on cervical cancer progression among sub Saharan African women on highly active antiretroviral therapy: A scoping review.

In Africa, the HIV prevalence in rural areas has begun to reach levels estimated within urban settings, where women are also more at risk for both malaria and intestinal parasitic infections. The objective of this review is to assess whether concomitant infections with malaria and/or helminthic diseases have an impact on cervical disease progression in women on HAART. This scoping review was conducted in August 2018. To conduct this scoping review, we searched the relevant studies in electronic databases such as PUBMED, Global Health, EMBASE, CINAHL and SCOPUS published in the year between 1960 and 2018 using the following search terms HAART AND malaria OR Helminth and Female OR women. Eight studies qualified for this review. The literature underscores the need for women on HAART with multiple co-infections to use adjuncts to retain immune recovery and undetectable HIV viral load, to reduce risk of cervical disease progression. A trend for higher risk of CIN3+ in HIV+ women reporting recent malarial infection was observed in one study. Given the public health impact of synergistic interactions between malaria and helminthic infections in HIV/HPV co-infected women on HAART, it is urgent that these interactions are elucidated.

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

[This corrects the article DOI: 10.1186/s13027-016-0114-5.].

A code of ethics for the fistula surgeon.

Vesicovaginal fistulas from obstructed labor no longer exist in wealthy industrialized countries. In the impoverished countries of sub-Saharan Africa and south Asia obstetric fistulas continue to be a prevalent clinical problem. As many as 3.5 million women may suffer from this condition and few centers exist that can provide them with competent and compassionate surgical repair of their injuries. As this situation has become more widely known in the industrialized world, increasing numbers of surgeons have begun traveling to poor countries to perform fistula operations. To date, these efforts have been carried out largely by well-intentioned individuals, acting alone. An international community of fistula surgeons who share common goals and values is still in the process of being created. To help facilitate the development of a common ethos and to improve the quality of care afforded to women suffering from obstetric fistulas, we propose a Code of Ethics for fistula surgeons that embraces the fundamental principles of beneficence, non-maleficence, respect for personal autonomy, and a dedication to the pursuit of justice.

Pattern of Ureteric Pathology Presenting to a Fistula Centre in Western Kenya.

BACKGROUND: Ureteric pathology arises from surgical misadventures, trauma, and congenital anomalies. Early detection and treatment is of the essence. OBJECTIVES: To determine the types/etiology and outcome of ureteric pathology presenting to Gynocare Fistula Centre, Eldoret, Kenya. METHODS: Descriptive retrospective study that evaluated patients presenting with ureteric pathology at Gynocare between 1st January 2012 and 31st December 2016. We pulled out patient charts and extracted and analyzed relevant data using STATA 13E statistical software. RESULTS: We analyzed 33 charts, and their age ranged from 10 to 58 years. Annual proportion for 2012, 2013, 2014, 2015, and 2016 was 2.5%, 2.8%, 1.2%, 1.4%, and 3.0% respectively among all the fistula patients treated in the hospital. All the patients presented with urinary incontinence, and 7 (21.2%) had flank pain. Iatrogenic injuries contributed 84.8% (28), and 3 (9.1%) were congenital while trauma and infection had 1 each. Of those resulting from surgical misadventures, 17 (60.7%) were from obstetric while 11 (39.2%) were from gynecological surgery. All the injuries were in the distal third of the ureter; 5 were bilateral; and 11 were left sided while 17 were right-sided. Repair and/or reimplantation was successful in 31 (93.93%) of the patients. CONCLUSION: Highest proportion of ureteric pathologies was accounted for by iatrogenic causes and surgical repair and/or reimplantation has a high success rate.

Public health approach to prevent cervical cancer in HIV-infected women in Kenya: Issues to consider in the design of prevention programs.

Women living with HIV in Africa are at increased risk to be co-infected with Human Papilloma Virus (HPV), persistent high risk (HR) HPV infection and bacterial vaginosis (BV), which compounds HPV persistence, thereby increasing the risk for cervical dysplasia. New guidance from WHO in 2014 advocating for a "screen and treat" approach in resource poor settings is becoming a more widely recommended screening tool for cervical cancer prevention programs in such contexts. This review article summarizes the risk factors to be considered when designing a primary and secondary cervical prevention program in a post-vaccination era for HIV-infected women in Kenya. This review article is based on our prior research on the epidemiology of pHR/HR-HPV genotypes in HIV-infected women and CIN 2 + in Kenya and other sub-Saharan contexts. In order to contextualize the findings, a literature search was carried out in March 2017 by means of four electronic databases: PUBMED, EMBASE, SCOPUS, and PROQUEST. Risk factors for potential (pHR)/HR HPV acquisition, including CD4 count, HAART initiation, Female Sex Worker status (FSW) and BV need to be considered. Furthermore, there may be risk factors for abnormal cytology, including FSW status, multiple potential (p)HR/HR HPV genotypes, which may require that HIV-infected women be subjected to screening at more frequent intervals than the three year recommended by the WHO. The quadruple synergistic interaction between HIV, HPV and BV and its related cervicitis may need to be reflected within a larger prevention framework at the community level. The opportunities brought forth by the roll out of HAART could lead to task shifting of HIV-HPV-BV care to nurses, which may increase access in poorly-served areas.