Rapid situational assessment of people who inject drugs (PWID) in Nairobi and coastal regions of Kenya: a respondent driven sampling survey.

BACKGROUND: A Cross-sectional Rapid Situational Assessment of People Who Inject Drug (PWIDs) applying Respondent Driven sampling techniques (RDS) was used to recruit subjects/participants in a study aimed at assessing HIV prevalence and risk behaviors among injecting drug users in Nairobi and Coastal regions of Kenya. There is paucity of data and information on injecting drug use in sub-Saharan Africa and there is sufficient evidence of existence of the environment for development and growth of injecting drug use. Past studies on PWID and its association to HIV and AIDS that have been conducted in Kenya do not provide sufficient information to support effective planning and comprehensive national response to the HIV and AIDS epidemic. METHODS: A cross-sectional study design was adopted in which a set of initial subjects referred to as 'seeds' were first identified from which an expanding chain of referrals were obtained, with subjects from each wave referring subjects of subsequent waves. The seeds were drawn randomly from the population and interviewed to pick the one with the largest network and other unique characteristics. A maximum of twelve seeds were recruited. The second stage involved conducting assessment visits to the sites to identify potential collaborators that included non-governmental organizations (NGOs), drug treatment centres, health facilities, community based organizations (CBO's) among others. Three NGOs located in the coast region and one in Nairobi region were identified to assist in identifying drug injection locations and potential participants. Key informant interviews (KIIs) and Focus Group Discussions (FGDs) were also conducted using interview guides. RESULTS: A total of 646 individuals (344 in Nairobi and 302 at the coast) were recruited for the study between January and March 2010. Of these 590 (91%) were male and 56 (9%) were female. Findings showed that most PWIDs initiated injecting drug use between the ages of 20-29 years, with the youngest age of initiation being 11 years and oldest age being 53 years. Most commonly injected drug was heroin (98%), with a small (2%) percentage injecting cocaine. Other non-injecting methods such as smoking or combining these two drugs with other drugs such as cannabis or Rohypnol were also common. Most PWIDs used other substances (cigarettes, alcohol, and cannabis) before initiating injecting drug use. The adjusted national HIV prevalence of PWIDs was 18.3% (19.62% unadjusted) with PWIDs in Nairobi region registering 18.33% (20.58% unadjusted) compared PWIDs for Coastal region indicating 18.27% (18.59% - unadjusted). The gender based HIV prevalence showed that women were more at risk of acquiring HIV (44.51%-adjusted) compared to men (15.97%-adjusted). The age specific HIV prevalence showed that PWIDs who initiated injecting at 11-19 years (44.7% adjusted) were most at risk in Nairobi compared to those who initiated injecting at age 20-24 years (23.2% - adjusted) in the coastal region. While all PWIDs continue to be at risk in the two regions, those from the Western parts of Nairobi, Kenya were at a relatively higher risk given their increased propensity for sharing injecting equipment and solutions. CONCLUSIONS: Compared to the national HIV prevalence of (4.9%), the results show that People Who Inject Drugs (PWIDs) are at particularly high risk of infection in Kenya and there is urgent need for intervention (KenPHIA, 2018). This study also showed clear evidence that 70% of PWIDs are primary school educated, engage in high risk injecting and sexual behaviors comprising sharing of injecting equipment, unprotected heterosexual and homosexual sex. Given that initiation of injecting drug use begins early and peaks after formal school years (20-29 years), prevention programmes should be targeted at primary and secondary school students, college and out of school youth. Further, to protect People who inject drugs (PWIDs) from HIV infection, the country should introduce free Needle Syringe Programs (NSP) with provision of condoms and Methadone Assisted Therapy (MAT) as a substitute for drug use.

Male circumcision programmes in Kenya: lessons from the Kenya AIDS Indicator Survey 2007.

OBJECTIVE: To provide guidance for male circumcision programmes in Kenya by estimating the population of uncircumcised men and investigating the association between circumcision and infection with the human immunodeficiency virus (HIV), with particular reference to uncircumcised, HIV-uninfected men. METHODS: Data on men aged 15 to 64 years were derived from the 2007 Kenya AIDS Indicator Survey, which involved interviews and blood collection to test for HIV and herpes simplex virus 2 (HSV-2). The prevalence of HIV infection and circumcision in Kenyan provinces was calculated and the demographic characteristics and sexual behaviour of circumcised and uncircumcised, HIV-infected and HIV-uninfected men were recorded. FINDINGS: The national prevalence of HIV infection in uncircumcised men was 13.2% (95% confidence interval, CI: 10.8-15.7) compared with 3.9% (95% CI: 3.3-4.5) among circumcised men. Nyanza province had the largest estimated number of uncircumcised, HIV-uninfected men (i.e. 601 709), followed by Rift Valley, Nairobi and Western Province, respectively, and most belonged to the Luo ethnic tribe. Of these men, 77.8% did not know their HIV status and 33.2% were HSV-2-positive. In addition, 65.3% had had unprotected sex with a partner of discordant or unknown HIV status in the past 12 months and only 14.7% consistently used condoms with their most recent partner. However, only 21.8% of the uncircumcised, HIV-uninfected men aged 15 to 19 years were sexually active. CONCLUSION: The Kenyan male circumcision strategy should focus on the provinces with the highest number of uncircumcised, HIV-uninfected men and target young men before or shortly after sexual debut.

A venue-based approach to reaching MSM, IDUs and the general population with VCT: a three study site in Kenya.

A venue-based HIV prevention study which included Voluntary Counseling and Testing (VCT) was conducted in three diverse areas of Kenya-Malindi, Nanyuki and Rachounyo. Aims of the study were to: (1) assess the acceptability of VCT for the general population, men who have sex with men (MSM), and injecting drug users (IDUs) within the context of a venue-based approach; (2) determine if there were differences between those agreeing and not agreeing to testing; and (3) study factors associated with being HIV positive. Approximately 98% of IDUs and 97% of MSM agreed to VCT, providing evidence that populations with little access to services and whose behaviors are stigmatized and often considered illegal in their countries can be reached with needed HIV prevention services. Acceptability of VCT in the general population ranged from 60% in Malindi to 48% in Nanyuki. There were a few significant differences between those accepting and declining testing. Notably in Rachuonyo and Malindi those reporting multiple partners were more likely to accept testing. There was also evidence that riskier sexual behavior was associated with being HIV positive for both men in Rachounyo and women in Malindi. Overall HIV prevalence was higher among the individuals in this study compared to individuals sampled in the 2008-2009 Kenya Demographic and Health Survey, indicating the method is an appropriate means to reach the highest risk individuals including stigmatized populations.

Evidence of high-risk sexual behaviors among injection drug users in the Kenya PLACE study.

BACKGROUND: Injection drug users (IDUs) in resource poor settings are at high risk for HIV transmission through unsafe needle-sharing and sexual practices. We report on the injecting and sexual behavior of a sample of IDUs from Malindi, Kenya. METHODS: A Priority for Local AIDS Control Efforts (PLACE) study was conducted from April to May 2010 to identify areas where HIV transmission is most likely to occur and specific venues where people meet new sexual partners. Community informants (n=202) listed 157 unique venues from which 29 were randomly selected using a systematic fixed interval sampling strategy with probability of selection proportional to venue size. Twenty patrons and four workers were interviewed at each venue. Drug use practices were elicited in a staff-administered interview. RESULTS: Between 40% and 50% of IDUs reported needle-sharing, taking drugs from a common reservoir, using a ready-made solution without boiling, and not exchanging a used for a new syringe in the past month. Most could inconsistently or never get new syringes. In multivariate logistic regression models controlling for age, education, residence, and poverty status, IDUs were twice as likely as non-IDUs to report multiple partners in the past year (OR 1.94, 95% CI 1.26-3.00, p<.01) and multiple new partners in the past year (OR 2.11, 95% CI 1.30-3.42, p<.01). CONCLUSIONS: High prevalence of multiple sexual partnerships and risky injecting behaviors among IDUs and unavailability of new injecting needles are likely facilitating HIV transmission in Malindi, Kenya.

Estimating HIV incidence among adults in Kenya and Uganda: a systematic comparison of multiple methods.

BACKGROUND: Several approaches have been used for measuring HIV incidence in large areas, yet each presents specific challenges in incidence estimation. METHODOLOGY/PRINCIPAL FINDINGS: We present a comparison of incidence estimates for Kenya and Uganda using multiple methods: 1) Epidemic Projections Package (EPP) and Spectrum models fitted to HIV prevalence from antenatal clinics (ANC) and national population-based surveys (NPS) in Kenya (2003, 2007) and Uganda (2004/2005); 2) a survey-derived model to infer age-specific incidence between two sequential NPS; 3) an assay-derived measurement in NPS using the BED IgG capture enzyme immunoassay, adjusted for misclassification using a locally derived false-recent rate (FRR) for the assay; (4) community cohorts in Uganda; (5) prevalence trends in young ANC attendees. EPP/Spectrum-derived and survey-derived modeled estimates were similar: 0.67 [uncertainty range: 0.60, 0.74] and 0.6 [confidence interval: (CI) 0.4, 0.9], respectively, for Uganda (2005) and 0.72 [uncertainty range: 0.70, 0.74] and 0.7 [CI 0.3, 1.1], respectively, for Kenya (2007). Using a local FRR, assay-derived incidence estimates were 0.3 [CI 0.0, 0.9] for Uganda (2004/2005) and 0.6 [CI 0, 1.3] for Kenya (2007). Incidence trends were similar for all methods for both Uganda and Kenya. CONCLUSIONS/SIGNIFICANCE: Triangulation of methods is recommended to determine best-supported estimates of incidence to guide programs. Assay-derived incidence estimates are sensitive to the level of the assay's FRR, and uncertainty around high FRRs can significantly impact the validity of the estimate. Systematic evaluations of new and existing incidence assays are needed to the study the level, distribution, and determinants of the FRR to guide whether incidence assays can produce reliable estimates of national HIV incidence.

Factors associated with HIV infection in married or cohabitating couples in Kenya: results from a nationally representative study.

BACKGROUND: In order to inform prevention programming, we analyzed HIV discordance and concordance within couples in the Kenya AIDS Indicator Survey (KAIS) 2007. METHODS: KAIS was a nationally representative population-based sero-survey that examined demographic and behavioral indicators and serologic testing for HIV, HSV-2, syphilis, and CD4 cell counts in 15,853 consenting adults aged 15-64 years. We analyzed interview and blood testing data at the sexual partnership level from married or cohabitating couples. Multivariable regression models were used to identify factors independently associated with HIV discordant and concordant status. RESULTS: Of 3256 couples identified in the survey, 2748 (84.4%) had interview and blood testing data. Overall, 3.8% of couples were concordantly infected with HIV, and in 5.8% one partner was infected, translating to 338,000 discordant couples in Kenya. In 83.6% of HIV-infected Kenyans living in married or cohabitating couples neither partner knew their HIV status. Factors independently associated with HIV-discordance included young age in women (AOR 1.5, 95% CI: 1.2-1.8; p<0.0001), increasing number of lifetime sexual partners in women (AOR 1.5, 95% CI: 1.3-1.8; p<0.0001), HSV-2 infection in either or both partners (AOR 4.1, 95% CI: 2.3-7.2; p<0.0001), and lack of male circumcision (AOR 1.6, 95% CI: 1.0-2.5; p = 0.032). Independent factors for HIV-concordance included HSV-2 infection in both partners (AOR 6.5, 95% CI: 2.3-18.7; p = 0.001) and lack of male circumcision (AOR 1.8, 95% CI: 1.0-3.3; p = 0.043). CONCLUSIONS: Couple prevention interventions should begin early in relationships and include mutual knowledge of HIV status, reduction of outside sexual partners, and promotion of male circumcision among HIV-uninfected men. Mechanisms for effective prevention or suppression of HSV-2 infection are also needed.