Effect of male partners' involvement and support on reproductive, maternal and child health and well-being in East Africa: A scoping review.

Background and Aims: East African countries have high rates of maternal and child mortality and morbidity. Studies have shown that the involvement of male partners in reproductive health can benefit maternal and child health (MCH). This scoping review aims to provide an overview of the evidence across East Africa that describes male partner involvement and its effect on maternal, reproductive, and child well-being. Methods: Ten databases were searched to identify quantitative data on male's involvement in East Africa. Studies reporting qualitative data, "intention to use" data or only reporting on male partner's education or economic status were excluded. Studies were organized into five a priori categories: antenatal care (ANC), human immunodeficiency virus, breastfeeding, family planning, and intimate partner violence with further categories developed based on studies included. Results: A total of 2787 records were identified; 644 full texts were reviewed, and 96 studies were included in this review. Data were reported on 118,967 mothers/pregnant women and 15,361 male partners. Most of the studies (n = 83) were reported from four countries Ethiopia (n = 49), Kenya (n = 14), Tanzania (n = 12) and Uganda (n = 10). The evidence indicates that male partner involvement and support is associated with improved reproductive, MCH across a wide range of outcomes. However, the studies were heterogeneous, using diverse exposure and outcome measures. Also, male partners' lack of practical and emotional support, and engagement in violent behaviors towards partners, were associated with profound negative impacts on MCH and well-being. Conclusions: The body of evidence, although heterogeneous, provides compelling support for male involvement in reproductive health programs designed to support MCH. To advance research in this field, an agreement is needed on a measure of male partner "involvement." To optimize benefits of male partners' involvement, developing core outcome sets and regional coordination are recommended.

ENhancinG vAGinal dElivery in Greece through educational and behavioral interventions among maternity care providers regarding labor management: the ENGAGE stepped-wedge randomized prospective trial protocol.

BACKGROUND: There is an emerging need to systematically investigate the causes for the increased cesarean section rates in Greece and undertake interventions so as to substantially reduce its rates. To this end, the ability of the participating Greek obstetricians to follow evidence-based guidelines and respond to other educational and behavioral interventions while managing labor will be explored, along with barriers and enablers. Herein discussed is the protocol of a stepped-wedge designed intervention trial in Greek maternity units with the aforementioned goals in mind, named ENGAGE (ENhancinG vAGinal dElivery in Greece). METHODS: Twenty-two selected maternity units in Greece will participate in a multicenter stepped-wedge randomized prospective trial involving 20,000 to 25,000 births, with two of them entering the intervention period of the study each month (stepped randomization). The maternity care units entering the study will apply the suggested interventions for a period of 8-18 months depending on the time they enter the intervention stage of the study. There will also be an initial phase of the study lasting from 8 to 18 months including observation and recording of the routine practice (cesarean section, vaginal birth, and maternal and perinatal morbidity and mortality) in the participating units. The second phase, the intervention period, will include such interventions as the application of the HSOG (the Hellenic Society of Obstetrics and Gynecology) Guidelines on labor management, training on the correct interpretation of cardiotocography, and dealing with emergencies in vaginal deliveries, while the steering committee members will be available to discuss and implement organizational and behavioral changes, answer questions, clarify relevant issues, and provide practical instructions to the participating healthcare professionals during regular visits or video conferences. Furthermore, during the study, the results will be available for the participating units in order for them to monitor their own performance while also receiving feedback regarding their rates. Τhe final 2-month phase of the study will be devoted to completing follow-up questionnaires with data concerning maternal and neonatal morbidities that occurred after the completion of the intervention period. The total duration of the study is estimated at 28 months. The primary outcome assessed will be the cesarean section rate change and the secondary outcomes will be maternal and neonatal morbidity and mortality. DISCUSSION: The study is expected to yield new information on the effects, advantages, possibilities, and challenges of consistent clinical engagement and implementation of behavioral, educational, and organizational interventions described in detail in the protocol on cesarean section practice in Greece. The results may lead to new insights into means of improving the quality of maternal and neonatal care, particularly since this represents a shared effort to reduce the high cesarean section rates in Greece and, moreover, points the way to their reduction in other countries. TRIAL REGISTRATION: NCT04504500 (ClinicalTrials.gov). The trial was prospectively registered. Ethics Reference No: 320/23.6.2020, Bioethics and Conduct Committee, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.

Baseline assessment of cervical cancer screening and treatment capacity in 25 counties in Kenya, 2022.

Background: Cervical cancer is the leading cause of cancer deaths among women in Kenya. In the context of the Global strategy to accelerate the elimination of cervical cancer as a public health problem, Kenya is currently implementing screening and treatment scale-up. For effectively tracking the scale-up, a baseline assessment of cervical cancer screening and treatment service availability and readiness was conducted in 25 priority counties. We describe the findings of this assessment in the context of elimination efforts in Kenya. Methods: The survey was conducted from February 2021 to January 2022. All public hospitals in the target counties were included. We utilized healthcare workers trained in preparation for the scale-up as data collectors in each sub-county. Two electronic survey questionnaires (screening and treatment; and laboratory components) were used for data collection. All the health system building blocks were assessed. We used descriptive statistics to summarize the main service readiness indicators. Results: Of 3,150 hospitals surveyed, 47.6% (1,499) offered cervical cancer screening only, while 5.3% (166) offered both screening and treatment for precancer lesions. Visual inspection with acetic acid (VIA) was used in 96.0% (1,599/1,665) of the hospitals as primary screening modality and HPV testing was available in 31 (1.0%) hospitals. Among the 166 hospitals offering treatment for precancerous lesions, 79.5% (132/166) used cryotherapy, 18.7% (31/166) performed thermal ablation and 25.3% (42/166) performed large loop excision of the transformation zone (LLETZ). Pathology services were offered in only 7.1% (17/238) of the hospitals expected to have the service (level 4 and above). Only 10.8% (2,955/27,363) of healthcare workers were trained in cervical cancer screening and treatment; of these, 71.0% (2,097/2,955) were offering the services. Less than half of the hospitals had cervical cancer screening and treatment commodities at time of survey. The main health system strength was presence of multiple screening points at hospitals, but frequent commodity stock-outs was a key weakness. Conclusion: Training, commodities, and diagnostic services are major gaps in the cervical cancer program in Kenya. To meet the 2030 elimination targets, the national and county governments should ensure adequate financing, training, and service integration, especially at primary care level.

Costs and cost drivers of comprehensive sexual reproductive health services to female sex workers in Kenya.

BACKGROUND: Comprehensive sexual reproductive health (SRH) programs for female sex workers (FSW) offering clinical, behavioural, and structural interventions have contributed to declining rates of HIV in this population. However, data on costs and cost drivers is needed to support programs and their donors to better allocate resources, make an investment case for continued funding, and to identify areas of improvement in program design and implementation. We aimed to estimate the annual per-FSW costs of comprehensive services for a standalone FSW program in Kenya. METHODS: We implemented a top-bottom and activity-based costing study of comprehensive FSW services at two drop-in centres (DICs), Mtwapa and Kilifi town, in Kilifi County, Kenya. Service costs were obtained from routinely collected patient data during FSW scheduled and unscheduled visits using Kenyan Ministry of Health records. Costing data were from the program and organization's expenditure reports, cross checked against bank documents and supported by information from in-depth interviews. Data were collected retrospectively for the fiscal year 2019. We obtained approval from the AMREF Research Ethics Committee (AMREF-ESRC P862/2020). RESULTS: In 2019, the unit cost of comprehensive services was 105.93 USD per FSW per year, roughly equivalent to 10,593 Kenya shillings. Costs were higher at Mtwapa DICs compared to Kilifi town DIC; 121.90 USD and 89.90 USD respectively. HIV counselling and testing cost 63.90 USD per person, PrEP was 34.20 USD and family planning was 9.93 USD. Of the total costs, staff salaries accounted for about 60%. Adjusted for inflation, costs in 2024 would be approximately 146.60. CONCLUSION: Programs should strive to maximize the number of FSW served to benefit from economies of scale. Given that personnel costs contribute most to the unit costs, programs should consider alternative designs which reduce personnel and other costs.

Postpartum recovery after severe maternal morbidity in Kilifi, Kenya: a grounded theory of recovery trajectories beyond 42 days.

INTRODUCTION: The burden of severe maternal morbidity is highest in sub-Saharan Africa, and its relative contribution to maternal (ill) health may increase as maternal mortality continues to fall. Women's perspective of their long-term recovery following severe morbidity beyond the standard 42-day postpartum period remains largely unexplored. METHODS: This woman-centred, grounded theory study was nested within the Pregnancy Care Integrating Translational Science Everywhere (PRECISE) study in Kilifi, Kenya. Purposive and theoretical sampling was used to recruit 20 women who experienced either a maternal near-miss event (n=11), potentially life-threatening condition (n=6) or no severe morbidity (n=3). Women were purposively selected between 6 and 36 months post partum at the time of interview to compare recovery trajectories. Using a constant comparative approach of line-by-line open codes, focused codes, super-categories and themes, we developed testable hypotheses of women's postpartum recovery trajectories after severe maternal morbidity. RESULTS: Grounded in women's accounts of their lived experience, we identify three phases of recovery following severe maternal morbidity: 'loss', 'transition' and 'adaptation to a new normal'. These themes are supported by multiple, overlapping super-categories: loss of understanding of own health, functioning and autonomy; transition in women's identity and relationships; and adaptation to a new physical, psychosocial and economic state. This recovery process is multidimensional, potentially cyclical and extends far beyond the standard 42-day postpartum period. CONCLUSION: Women's complex needs following severe maternal morbidity require a reconceptualisation of postpartum recovery as extending far beyond the standard 42-day postpartum period. Women's accounts expose major deficiencies in the provision of postpartum and mental healthcare. Improved postpartum care provision at the primary healthcare level, with reach extended through community health workers, is essential to identify and treat chronic mental or physical health problems following severe maternal morbidity.

Women's health and rights in the twenty-first century.

In the twenty-first century, the complex relationship between women's health and rights has been influenced by a range of interconnected challenges, including gender inequity, reproductive health disparities, maternal mortality and morbidity, and women's inability to access life-saving, high-quality healthcare services including family planning. Going forward, the world needs to find ways to implement the unfinished agenda of the International Conference on Population and Development (ICPD) 1994 and the Sustainable Development Goals (SDGs), thus prioritizing health and rights for women and girls as essential not only to their survival but also to their progress, agency and empowerment. It is also important to consider the interconnection between women's health and rights and climate change, with its disproportionate impact on the well-being of girls and women, and to address the impact and opportunities afforded by digital technologies. By embracing a holistic approach, societies might be able to advance the cause of women's health and rights in a more inclusive and sustainable manner.

Two decades of research capacity strengthening and reciprocal learning on sexual and reproductive health in East Africa - a point of (no) return.

As the world is facing challenges such as pandemics, climate change, conflicts, and changing political landscapes, the need to secure access to safe and high-quality abortion care is more urgent than ever. On 27th of June 2023, the Swedish government decided to cut funding resources available for developmental research, which has played a fundamental role in the advancement of sexual and reproductive health and rights (SRHR) globally, including abortion care. Withdrawal of this funding not only threatens the fulfilment of the United Nations sustainable development goals (SDGS) - target 3.7 on ensuring universal access to SRHR and target 5 on gender equality - but also jeopardises two decades of research capacity strengthening. In this article, we describe how the partnerships that we have built over the course of two decades have amounted to numerous publications, doctoral graduates, and important advancements within the field of SRHR in East Africa and beyond.

Main findings: The two-decade long collaboration between Sweden and East Africa, funded by the Swedish government, has resulted in important partnerships, research findings, and advancements within sexual and reproductive health and rights in East Africa.Added knowledge: The Swedish government is now cutting funding for development research, which jeopardises the progress made so far.Global health impact for policy and action: Governments need to prioritise women's sexual and reproductive health and rights.

Sexual satisfaction, an indicator of sexual health and well-being? Insights from STI/HIV prevention research in European men who have sex with men.

INTRODUCTION: Although sexual health has been holistically defined to include sexual satisfaction, it has been largely absent in health services and sexual and reproductive health and rights programmes in many parts of the world. We propose sexual satisfaction as a useful indicator, as one of the proxy measures for sexual health and well-being and as a component of well-being in general. METHODS: The Sialon II project is a multicentre biological and behavioural cross-sectional community-based survey implemented across 13 European cities during 2013-2014 among men who have sex with men. Sexual satisfaction was explored using one single item: 'How satisfied are you with your sex life?' A multivariable multilevel logistic random-intercept model was estimated to identify factors associated with reporting positive sexual satisfaction versus negative sexual satisfaction. RESULTS: Age, the number of partners and self-reported HIV status were not significantly associated with sexual satisfaction in the multivariate model. Participants reporting an insertive role or reported both an insertive and receptive role during the last anal intercourse were more likely to be sexually satisfied, compared with a receptive role. Participants reporting anal intercourse with a condom were more likely to be satisfied than those declaring no anal intercourse in the last 6 months, but no significant association was found compared with anal intercourse without condom. Knowledge of HIV-serostatus concordance with the last sexual partner was positively correlated with sexual satisfaction. Having had sexual intercourse with non-steady partners only in the last 6 months was negatively correlated. The more positive participants perceived their work/school, parents and friends/acquaintances' attitudes towards gay or bisexual persons, the higher the odds they were satisfied with their sexual life. CONCLUSION: Using a single item on sexual satisfaction in a bio-behavioural study, our analysis has shown that it is associated with individual, interpersonal and social/structural factors and has proven its usefulness as a sexual health indicator among men who have sex with men.

Corrigendum: Microbiota dynamics, metabolic and immune interactions in the cervicovaginal environment and their role in spontaneous preterm birth.

[This corrects the article DOI: 10.3389/fimmu.2023.1306473.].

Factors associated with late diagnosis of cervical cancer at two national referral hospitals, Kenya 2017: A case control study.

Background: Cervical cancer is the leading cause of cancer mortality among women in Kenya. Two thirds of cervical cancer cases in Kenya are diagnosed in advanced stages. We aimed to identify factors associated with late diagnosis of cervical cancer, to guide policy interventions. Methods: An unmatched case control study (ratio 1:2) was conducted among women aged ≥ 18 years with cervical cancer at Kenyatta National and Moi Teaching and Referral Hospitals. We defined a case as patients with International Federation of Gynecology and Obstetrics (FIGO) stage ≥ 2A and controls as those with stage ≤ 1B. A structured questionnaire was used to document exposure variables. We calculated adjusted odds ratio (aOR) to identify any associations. Results: We enrolled 192 participants (64 cases, 128 controls). Mean age 39.2 (±9.3) years, 145 (76 %) were married, 77 (40 %) had primary level education, 168 (88 %) had their first pregnancy ≤ 24 years of age, 85 (44 %) were > para 3 and 150 (78 %) used contraceptives. Late diagnosis of cervical cancer was associated with cost of travel to cancer centres > USD 6.1 (aOR 6.43 95% CI [1.30, 31.72]), age > 50 years (aOR 4.71; 95% CI [1.18, 18.80]), anxiety over cost of cancer care (aOR 5.6; 95% CI [1.05, 32.72]) and ultrasound examination during evaluation of symptoms (aOR 4.89; 95% CI [1.07-22.42]). Previous treatment for gynecological infections (aOR 0.10; 95% CI [0.02, 0.47]) was protective against late diagnosis. Conclusion: Cost of seeking care and the quality of the diagnostic process were important factors in this study. Decentralization of care, innovative health financing solutions and clear diagnostic and referral algorithms for women presenting with gynecological symptoms could reduce late-stage diagnosis in Kenya.

Challenges and opportunities for improving access to adolescent and youth sexual and reproductive health services and information in the coastal counties of Kenya: a qualitative study.

BACKGROUND: Globally, adolescents and youth experience high unmet need for sexual and reproductive health (SRH) information and services. In Kenya, evidence shows that more than half of teenage pregnancies are unintended and that half of all new HIV infections occur in people ages 15-24-year-olds, with the majority of those being female. The coastal counties in Kenya record a relatively high adolescent pregnancy rate and higher rates of unmet need for contraception for all women of reproductive age compared to the national average. This study focused on gaining a deeper understanding of the existing challenges to and opportunities for accessing SRH information and services among adolescents and youth (AY) at the Kenyan coast. METHODS: Using qualitative methods, this study conducted thirty-six focus group discussions with adolescents, youth, and community health volunteers across all the six coastal counties in Kenya. The sample included adolescents aged 10-14 years in school (male and female), adolescents aged 15-19 years not in education (male and female), youths aged 20-24 years (mix of both male and female), and community health volunteers who were conveniently sampled. Thematic analysis was used to examine the data and report the study results. RESULTS: The barriers to accessing AYSRH identified in the study are individual factors (feelings of shame, lack of information, and fear of being judged) parental factors, healthcare worker and health institution factors, teacher/educators factors, and broader contextual factors such as culture, religion, poverty, and illiteracy. Factors that facilitate access to AYSRH information and services included, supportive parenting and culture, AYSRH sessions in schools, peer support, supportive health institutions, gender inclusivity, and digital technology. CONCLUSIONS: AYSRH information and services at the Kenyan coast is strongly influenced by a range of individual, social, cultural, and economic factors. Improving access to AYSHR necessitates meaningful AY engagement, provision of youth-friendly services, use of digital technology as alternative pathways for sharing SRH information, strengthening parent-AY relationships, embracing peer-to-peer support, and the adoption of gender-inclusive approaches in AYSRH programming.

Prevalence and correlates of depressive disorders in commercially sexual exploited children: A cross-sectional study in Mombasa, Kenya.

BACKGROUND: Commercial sexual exploitation of children (CSEC) is a global concern and is among the common forms of sexual violence against children. In Kenya, about 32 % of girls and 16 % of boys experience sexual violence before the age of 18 years. While much has been written about the impact of child sexual exploitation, there's little on the prevalence of depressive disorders among CSE children. OBJECTIVES: This study was conducted to assess the prevalence and correlates of depressive disorders among CSE children in Mombasa, Kenya. PARTICIPANTS AND SETTING: The study was conducted among CSE children (10-17 years) in Mombasa County. METHODS: A cross-sectional study conducted between May 2021 and June 2022. A total of 409 CSE children were enrolled, using a case management approach. Data was collected using the child identification tool and the Patient Health Questionnaire (PHQ-9), at the first counselling session to determine the prevalence of depression levels. RESULTS: Of the 409 children, 367 (90 %) were girls while 42 (10 %) were boys. The mean age was 15 years (10-17) (SD = 1.4, t = 0.765). In 286 (70 %) 'Depression unlikely' was recorded, while 123 (30 %) 'Depression likelihood.' Prevalence of mild to severe depression was significantly higher in girls than boys (p = 0.002). Other determinants of depression were having a primary level of education (p = 0.03) and being an orphan. (p = 0.03). CONCLUSION: It is important to prioritize mental health interventions such as screening and early diagnosis of mental health among CSE children in order to prevent and manage both short and long term effects.

Women in Health and their Economic, Equity and Livelihood statuses during Emergency Preparedness and Response (WHEELER) protocol: a mixed methods study in Kenya.

INTRODUCTION: Kenya reported its first COVID-19 case on 13 March 2020. Pandemic-driven health system changes followed and unforeseen societal, economic and health effects reported. This protocol aims to describe the methods used to identify the gender equality and health equity gaps and possible disproportional health and socioeconomic impacts experienced by paid and unpaid (community health volunteer) female healthcare providers in Kilifi and Mombasa Counties, Kenya during the COVID-19 pandemic. METHODS AND ANALYSIS: Participatory mixed methods framed by gender analysis and human-centred design will be used. Research implementation will follow four of the five phases of the human-centred design approach. Community research advisory groups and local advisory boards will be established to ensure integration and the sustainability of participatory research design. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Institutional Scientific and Ethics Review Committee at the Aga Khan University and the University of Manitoba.This study will generate evidence on root cultural, structural, socioeconomic and political factors that perpetuate gender inequities and female disadvantage in the paid and unpaid health sectors. It will also identify evidence-based policy options for future safeguarding of the unpaid and paid female health workforce during emergency preparedness, response and recovery periods.

Pattern and determinants of contraceptive use among the muslim women in Wajir and Lamu counties in Kenya: a cross-sectional study.

BACKGROUND: Improving access to family planning (FP) is associated with positive health benefits that includes averting nearly a third of all maternal deaths and 10% of childhood deaths. Kenya has made great strides in improving access to family planning services. However, amid this considerable progress, regional variation has been noted which begs the need for a clearer understanding of the the patterns and determinants that drive these inconsistencies. METHODS: We conducted a cross-sectional study that involved 663 Muslim women of reproductive age (15-49 years) from Wajir and Lamu counties in Kenya between March and October 2018.The objective of this study was to understand patterns and determinants of contraceptive use in two predominantly Muslim settings of Lamu and Wajir counties that have varying contraceptive uptake. Eligible women were interviewed using a semi-structured questionnaire containing socio-demographic information and history of family planning use. Simple and multiple logistic regression were used to identify determinants of family planning use. The results were presented as Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR) ratios at 95% confidence interval. A p-value of 0.05 was considered statistically significant. RESULTS: Of the 663 Muslim women of reproductive age consenting to participate in the study, 51.5%, n = 342 and 48.5%, n = 321 were from Lamu and Wajir County, respectively. The prevalence of women currently using contraceptive was 18.6% (n = 123). In Lamu, the prevalence was 32.8%, while in Wajir, it was 3.4%. The determinants of current contraceptive use in Lamu include; marital status, age at marriage, employment status, discussion with a partner on FP, acceptability of FP in culture, and willingness to obtain information on FP. While in Wajir, determinants of current contraceptive use were education, and the belief that family planning is allowed in Islam. CONCLUSIONS: Our study found moderately high use of contraceptives among Muslim women of reproductive age in Lamu county and very low contraceptive use among women in Wajir. Given the role of men in decision making, it is critical to design male involvement strategy particularly in Wajir where the male influence is very prominent. It is critical for the government to invest in women and girls' education to enhance their ability to make informed decisions; particularly in Wajir where FP uptake is low with low education attainment. Further, our findings highlight the need for culturally appropriate messages and involvement of religious leaders to demystify the myths and misconception around family planning and Islam particularly in Wajir.

Pregnancy-related mortality up to 1 year postpartum in sub-Saharan Africa: an analysis of verbal autopsy data from six countries.

OBJECTIVE: To compare the causes of death for women who died during pregnancy and within the first 42 days postpartum with those of women who died between >42 days and within 1 year postpartum. DESIGN: Open population cohort (Health and Demographic Surveillance Systems). SETTING: Ten Health and Demographic Surveillance Systems (HDSS) in The Gambia, Kenya, Malawi, Tanzania, Ethiopia and South Africa. POPULATION: 2114 deaths which occurred within 1 year of the end of pregnancy where a verbal autopsy interview was conducted from 2000 to 2019. METHODS: InterVA5 and InSilicoVA verbal autopsy algorithms were used to attribute the most likely underlying cause of death, which were grouped according to adapted International Classification of Diseases-Maternal Mortality categories. Multinomial regression was used to compare differences in causes of deaths within 42 days versus 43-365 days postpartum adjusting for HDSS and time period (2000-2009 and 2010-2019). MAIN OUTCOME MEASURES: Cause of death and the verbal autopsy Circumstances of Mortality Categories (COMCATs). RESULTS: Of 2114 deaths, 1212 deaths occurred within 42 days postpartum and 902 between 43 and 365 days postpartum. Compared with deaths within 42 days, deaths from HIV and TB, other infectious diseases, and non-communicable diseases constituted a significantly larger proportion of late pregnancy-related deaths beyond 42 days postpartum, and health system failures were important in the circumstances of those deaths. The contribution of HIV and TB to deaths beyond 42 days postpartum was greatest in Southern Africa. The causes of pregnancy-related mortality within and beyond 42 days postpartum did not change significantly between 2000-2009 and 2010-2019. CONCLUSIONS: Cause of death data from the extended postpartum period are critical to inform prevention. The dominance of HIV and TB, other infectious and non-communicable diseases to (late) pregnancy-related mortality highlights the need for better integration of non-obstetric care with ante-, intra- and postpartum care in high-burden settings.

P16 expression and recurrent cervical intraepithelial neoplasia after cryotherapy among women living with HIV.

Background: The expression of p16 protein, a surrogate marker for high-risk human papillomavirus (hrHPV), is associated with cervical dysplasia. We evaluated correlates of p16 expression at treatment for high-grade cervical lesions and its utility in predicting the recurrence of cervical intraepithelial lesions grade 2 or higher (CIN2+) following cryotherapy among women with HIV. Methods: This is a subgroup analysis of women with HIV in Kenya with baseline cervical biopsy-confirmed CIN2+ who were randomized to receive cryotherapy and followed every six-months for two-years for biopsy-confirmed recurrence of CIN2+. P16 immunohistochemistry was performed on the baseline cervical biopsy with a positive result defined as strong abnormal nuclear expression in a continuous block segment of cells (at least 10-20 cells). Results: Among the 200 women with CIN2+ randomized to cryotherapy, 160 (80%) had a baseline cervical biopsy specimen available, of whom 94 (59%) were p16-positive. p16 expression at baseline was associated with presence of any one of 14 hrHPV genotypes [Odds Ratio (OR) = 3.2; 95% Confidence Interval (CI), 1.03-9.78], multiple lifetime sexual partners (OR = 1.6; 95% CI, 1.03-2.54) and detectable plasma HIV viral load (>1,000 copies/mL; OR = 1.43; 95% CI, 1.01-2.03). Longer antiretroviral therapy duration (≥2 years) at baseline had lower odds of p16 expression (OR = 0.46; 95% CI, 0.24-0.87) than <2 years of antiretroviral therapy. Fifty-one women had CIN2+ recurrence over 2-years, of whom 33 (65%) were p16-positive at baseline. p16 was not associated with CIN2+ recurrence (Hazard Ratio = 1.35; 95% CI, 0.76-2.40). Conclusion: In this population of women with HIV and CIN2+, 41% of lesions were p16 negative and baseline p16 expression did not predict recurrence of cervical neoplasia during two-year follow up.

Health facilities preparedness to deliver maternal and newborn health care in Kilifi and Kisii Counties, Kenya.

INTRODUCTION: Health facility preparedness is essential for delivering quality maternal and newborn care, minimizing morbidity and mortality by addressing delays in seeking skilled care, reaching appropriate facilities, and receiving emergency care. A rapid assessment of 23 government health facilities in Kilifi and Kisii counties identified poor maternal and newborn indicators in 16 facilities. The Access to Quality Care through Extending and Strengthening Health Systems (AQCESS) project supported these facilities with training, equipment, and referral linkages. This study focuses on facility preparedness of the 16 facilities to deliver maternal and newborn health services, specifically delays two and three at the end of the project implementation. METHODS: A descriptive cross-sectional study was carried-out on behalf of AQCESS project team by respective county ministry of health in-charge of reproductive maternal newborn and child health programs and trained nurses and medical doctors from Aga Khan health services in December 2019. The study evaluated the accessibility and reliability of drugs, commodities, equipment, personnel, basic necessities (such as water and electricity), and guidelines using validated World Health Organization service availability and readiness assessment tool. The findings of the assessment are presented through frequency and percentage analysis, along with a comparative analysis between the two counties. RESULTS: All the 16 facilities assessed offered routine antenatal care (ANC) and normal delivery, but only two provided comprehensive emergency obstetric and newborn care (CEmONC). Most essential medicines, commodities, and required equipment were available. BEmONC and CEmONC guidelines were present in Kilifi, not in Kisii. One staff member was available 24/7 for cesarean section (CS) in each county, with one anesthetist in Kilifi. Electricity was accessible in all facilities, but only half had secondary power supply. Facilities offering CS had backup generators. CONCLUSION: The Facilities assessed had necessary drugs, commodities, equipment, and requirements, but staffing and guidelines were limited. Kilifi outperformed Kisii in most indicators. Additional support is needed for infrastructure and human resources to deliver quality maternal and newborn health services. Continuous monitoring will facilitate resource allocation based on facility needs.

The impact of COVID-19 mitigation measures on sexual and reproductive health in low- and middle-income countries: a rapid review.

Pandemic mitigation measures can have a negative impact on access and provision of essential healthcare services including sexual and reproductive health (SRH) services. This rapid review looked at the literature on the impact of COVID-19 mitigation measures on SRH and gender-based violence (GBV) on women in low- and middle-income countries (LMIC) using WHO rapid review guidance. We looked at relevant literature published in the English language from January 2020 to October 2021 from LMICs using WHO rapid review methods. A total of 114 articles were obtained from PubMed, Google Scholar and grey literature of which 20 met the eligible criteria. Our review found that there was an overall reduction in; (a) uptake of services as shown by lower antenatal, postnatal and family planning clinic attendance, (b) service delivery as shown by reduced health facility deliveries, and post abortion care services and (c) reproductive health outcomes as shown by an increase in incidence of GBV especially intimate partner violence. COVID-19 mitigation measures negatively impact SRH of women in LMICs. Findings from this review could inform policy makers in the health sector to recognise the potential adverse effects of COVID-19 responses on SRH in the country, and therefore implement mitigation measures.

Integrating human papillomavirus testing as a point-of care service using GeneXpert platforms: Findings and lessons from a Kenyan pilot study (2019-2020).

BACKGROUND: Globally, cervical cancer is a major public health problem, with about 604,000 new cases and over 340,000 deaths in 2020. In Kenya, it is the leading cause of cancer deaths, with over 3,000 women dying in 2020 alone. Both the Kenyan cancer screening guidelines and the World Health Organization's Global Cervical Cancer Elimination Strategy recommend human papillomavirus (HPV) testing as the primary screening test. However, HPV testing is not widely available in the public healthcare system in Kenya. We conducted a pilot study using a point of care (POC) HPV test to inform national roll-out. METHODS: The pilot was implemented from October 2019 to December 2020, in nine health facilities across six counties. We utilized the GeneXpert platform (Cepheid, Sunnyvale, CA, USA), currently used for TB, Viral load testing and early infant diagnosis for HIV, for HPV screening. Visual inspection with acetic acid (VIA) was used for triage of HPV-positive women, as recommended in national guidelines. Quality assurance (QA) was performed by the National Oncology Reference Laboratory (NORL), using the COBAS 4800 platform (Roche Molecular System, Pleasanton, CF, USA). HPV testing was done using either self or clinician-collected samples. We assessed the following screening performance indicators: screening coverage, screen test positivity, triage compliance, triage positivity and treatment compliance. Test agreement between local GeneXpert and central comparator high-risk HPV (hrHPV) testing for a random set of specimens was calculated as overall concordance and kappa value. We conducted a final evaluation and applied the Nominal Group Technique (NGT) to identify implementation challenges and opportunities. KEY FINDINGS: The screening coverage of target population was 27.0% (4500/16,666); 52.8% (2376/4500) were between 30-49 years of age. HPV positivity rate was 22.8% (1027/4500). Only 10% (105/1027) of HPV positive cases were triaged with VIA/VILI; 21% (22/105) tested VIA/VILI positive, and 73% (16/22) received treatment (15 received cryotherapy, 1 was referred for biopsy). The median HPV testing turnaround time (TAT) was 24 hours (IQR 2-48 hours). Invalid sample rate was 2.0% (91/4500). Concordance between the Cepheid and COBAS was 86.2% (kappa value = 0.71). Of 1042 healthcare workers, only 5.6% (58/1042) were trained in cervical cancer screening and treatment, and only 69% (40/58) of those trained were stationed at service provision areas. Testing capacity was identifed as the main challenge, while the community strategy was the main opportunity. CONCLUSION: HPV testing can be performed on GeneXpert as a near point of care platform. However, triage compliance and testing TAT were major concerns. We recommend strengthening of the screening-triage-treatment cascade and expansion of testing capacity, before adoption of a GeneXpert-based HPV screening among other near point of care platforms in Kenya.