All-cause and cause-specific mortality rates for Kisumu County: a comparison with Kenya, low-and middle-income countries.

BACKGROUND: Understanding the magnitude and causes of mortality at national and sub-national levels for countries is critical in facilitating evidence-based prioritization of public health response. We provide comparable cause of death data from Kisumu County, a high HIV and malaria-endemic county in Kenya, and compared them with Kenya and low-and-middle income countries (LMICs). METHODS: We analyzed data from a mortuary-based study at two of the largest hospital mortuaries in Kisumu. Mortality data through 2019 for Kenya and all LMICs were downloaded from the Global Health Data Exchange. We provided age-standardized rates for comparisons of all-cause and cause-specific mortality rates, and distribution of deaths by demographics and Global Burden of Disease (GBD) classifications. RESULTS: The all-cause age-standardized mortality rate (SMR) was significantly higher in Kisumu compared to Kenya and LMICs (1118 vs. 659 vs. 547 per 100,000 population, respectively). Among women, the all-cause SMR in Kisumu was almost twice that of Kenya and double the LMICs rate (1150 vs. 606 vs. 518 per 100,000 population respectively). Among men, the all-cause SMR in Kisumu was approximately one and a half times higher than in Kenya and nearly double that of LMICs (1089 vs. 713 vs. 574 per 100,000 population). In Kisumu and LMICs non-communicable diseases accounted for most (48.0 and 58.1% respectively) deaths, while in Kenya infectious diseases accounted for the majority (49.9%) of deaths. From age 10, mortality rates increased with age across all geographies. The age-specific mortality rate among those under 1 in Kisumu was nearly twice that of Kenya and LMICs (6058 vs. 3157 and 3485 per 100,000 population, respectively). Mortality from injuries among men was at least one and half times that of women in all geographies. CONCLUSION: There is a notable difference in the patterns of mortality rates across the three geographical areas. The double burden of mortality from GBD Group I and Group II diseases with high infant mortality in Kisumu can guide prioritization of public health interventions in the county. This study demonstrates the importance of establishing reliable vital registry systems at sub-national levels as the mortality dynamics and trends are not homogeneous.

Bisexual and Bidirectional: Assessing the Potential for HIV Bridging in Mozambique.

African men who have sex with men (MSM) frequently, and often concurrently, have female partners, raising concerns about HIV sexual bridging. We explored potential HIV transmission in Mozambique from and to female partners of MSM focusing on preferred anal sex role and circumcision status. Data collected in a respondent-driven sampling study of MSM in 2011 in Maputo and Beira. Men who had oral or anal sex with other men 12 months prior completed a questionnaire and consented for HIV testing. Statistical analysis explored demographic/risk characteristics and associations among circumcision status, anal sex with men, sexual positions during anal sex with men and vaginal or anal sex with women. We identified 326 MSM in Maputo and 237 in Beira with both male and female partners 3 months before the study. Of these, 20.8% in Maputo and 36.0% in Beira had any receptive anal sex with men 12 months prior, including 895 unprotected sexual acts with males in Maputo and 692 in Beira. Uncircumcised and exclusively insertive males, 27.7% of the sample in Maputo and 33.6% in Beira, had the most unprotected sex with females: 1159 total acts in Maputo and 600 in Beira. Sexual bridging between MSM and women likely varies geographically and is probably bi-directional, occurring within a generalized epidemic where HIV prevalence is higher among reproductive-age women than MSM. Prevention strategies emphasizing correct and consistent condom use for all partners and circumcision for bisexual men should be considered.

Prevalence of HIV and Associated Risk Factors Among Long Distance Truck Drivers in Inchope, Mozambique, 2012.

This is the first integrated biological and behavioral surveillance survey among long-distance truck drivers (LDTD) in Mozambique. Using modified time-location sampling in 2012 at a key transportation junction (Inchope), we enrolled 327 male LDTD. HIV prevalence was 15.4 % (95 % confidence interval : 11.4-19.4 %, n = 318 tested). Among HIV-positive LDTD, 83.7 % did not know their status. One-third of LDTD had never tested for HIV and three-quarters had not received free condoms, lubricants or HIV literature in the past 12 months. In that same period, 61.4 % of LDTD had at least four sexual partners and 27.1 % paid for sex. Among sexually-active LDTD, 76.5 % did not use a condom at last sex. HIV was associated (p < 0.05) with primary education or lower (AOR 2.1), residence in Mozambique (AOR 2.3) and never having tested for HIV (AOR 2.2). Our findings reveal that broader coverage of HIV prevention and comprehensive care services for LDTD are urgently needed.

High Burden of HIV Infection and Risk Behaviors Among Female Sex Workers in Three Main Urban Areas of Mozambique.

This is the first integrated biological and behavioral survey among female sex workers (FSW) in Mozambique. Using respondent-driven sampling, 400, 411 and 429 FSW were enrolled respectively in Maputo, Beira and Nampula in 2011-2012. Estimates were produced using RDSAT 7.1. HIV prevalence was 31.2, 23.6, and 17.8 % in each location respectively. Among HIV-positive FSW, 48.1, 79.8 and 89.6 % in each city, were unaware of their serostatus. Condom use at last sex with a client was 85.8, 73.4 and 62.8 % among FSW, respectively. HIV was associated with current age, age of first sex for money, low educational level, and having had a genital ulcer in the last 6 months. Results suggest the urgent need to increase behavioral and structural interventions in this key population.

Genome of an arbuscular mycorrhizal fungus provides insight into the oldest plant symbiosis.

The mutualistic symbiosis involving Glomeromycota, a distinctive phylum of early diverging Fungi, is widely hypothesized to have promoted the evolution of land plants during the middle Paleozoic. These arbuscular mycorrhizal fungi (AMF) perform vital functions in the phosphorus cycle that are fundamental to sustainable crop plant productivity. The unusual biological features of AMF have long fascinated evolutionary biologists. The coenocytic hyphae host a community of hundreds of nuclei and reproduce clonally through large multinucleated spores. It has been suggested that the AMF maintain a stable assemblage of several different genomes during the life cycle, but this genomic organization has been questioned. Here we introduce the 153-Mb haploid genome of Rhizophagus irregularis and its repertoire of 28,232 genes. The observed low level of genome polymorphism (0.43 SNP per kb) is not consistent with the occurrence of multiple, highly diverged genomes. The expansion of mating-related genes suggests the existence of cryptic sex-related processes. A comparison of gene categories confirms that R. irregularis is close to the Mucoromycotina. The AMF obligate biotrophy is not explained by genome erosion or any related loss of metabolic complexity in central metabolism, but is marked by a lack of genes encoding plant cell wall-degrading enzymes and of genes involved in toxin and thiamine synthesis. A battery of mycorrhiza-induced secreted proteins is expressed in symbiotic tissues. The present comprehensive repertoire of R. irregularis genes provides a basis for future research on symbiosis-related mechanisms in Glomeromycota.

Correlates of HIV Testing Among Men Who have Sex with Men in Three Urban Areas of Mozambique: Missed Opportunities for Prevention.

This is the first study to identify levels of recent HIV testing and associated factors among men who have sex with men (MSM) in Mozambique. Using data from Maputo (n = 493), Beira (n = 572), and Nampula/Nacala (n = 347), collected via respondent-driven sampling in 2011, and excluding those with prior known infection, we found that 30.4 % [95 % confidence interval (CI) 25.0-36.3 %], 42.1 % (95 % CI 36.8-47.3 %) and 29.8 % (95 % CI 22.9-36.9 %), respectively, had recently tested for HIV (≤12 months), while between three and five out of 10 MSM had never tested. A range of factors was associated with recent HIV testing such as familiarity with the modes of transmission, knowledge of antiretroviral treatment for HIV, contact with peer educators and awareness of partner serostatus; yet, surprisingly recent healthcare utilization was not associated with recent testing. Findings provide evidence that structural and behavioral interventions among MSM may play an important role in increasing HIV testing.

Socio-demographic, Behavioral and Health Characteristics of Underage Female Sex Workers in Mozambique: The Need to Protect a Generation from HIV Risk.

Characteristics, HIV risk, and program coverage for underage female sex workers (FSW) are rarely systematically described worldwide. We compared characteristics of underage (15-17 years old) and adult (≥18 years old) FSW in three main urban areas of Mozambique (Maputo, Beira and Nampula) using data from three respondent-driven sampling surveys implemented in 2011-2012. Among survey participants, 9.8 % (39/400) in Maputo, 17.0 % (70/411) in Beira and 25.6 % (110/429) in Nampula were underage. Over half reported performing sex work to afford daily living, and 29.7-50.0 % had unprotected sex with their last client. The proportion of underage FSW having accessed care and prevention services was lower compared to adult FSW. While HIV prevalence among underage FSW was lower than in adults, it increased markedly with age. Our results point to the urgency of expanding prevention and care programs geared towards underage FSW.

HIV prevalence and risk behaviors among Mozambicans working in South African mines.

Mineworkers are considered a population at risk for HIV due to risk behaviors associated with migratory work patterns. This was the first study in Mozambique to determine the prevalence of HIV and associated demographic and risk behaviors, and assess use and access to prevention and healthcare services among Mozambicans working in South African mines. Men who had worked in a South African mine in the past 12 months were recruited between February and May 2012 using time location sampling (TLS) at the Ressano Garcia border between Mozambique and South Africa. Demographic and behavioral data were collected through a standardized questionnaire, and HIV prevalence was estimated by testing dried blood spots (DBS) with two enzyme immunoassays. In total, 432 eligible mine workers were recruited. Mean age was 43 years. Most were married or cohabitating; among them, 12.6 % had two or more wives/marital partners in Mozambique. In the 12 months preceding the survey, 24.7 % had an occasional sexual partner, and 6.6 % had at least one partner who was a female sex worker. Only one in five (18.5 %) used a condom during last sex. HIV prevalence among mineworkers was 22.3 %, and 74.6 % of those who tested positive as part of the survey did not know their status. HIV prevalence was significantly higher (p = 0.018) among those that were uncircumcised (31.2 %) than those who were circumcised (18.5 %). Multiple partners (multiple spouses, cross-border relations, and multiple occasional partnerships), inconsistent condom use, and a high proportion of infected mineworkers who do not know their HIV status increases the risk of HIV transmission in this population. Combination strategies involving the promotion of condom use, HIV testing, and male circumcision should be strengthened among mineworkers.

Routine data from prevention of mother-to-child transmission (PMTCT) HIV testing not yet ready for HIV surveillance in Mozambique: a retrospective analysis of matched test results.

BACKGROUND: Opt-out HIV testing is offered at 70% of antenatal care (ANC) clinics in Mozambique through the prevention of mother-to-child transmission (PMTCT) program. If routine data from this program were of sufficient quality, their heightened coverage and continuous availability could complement or even replace biannual sentinel serosurveys that currently serve as the primary HIV surveillance system in Mozambique. METHODS: We assessed the efficacy of routine HIV testing data from prevention of mother-to-child transmission programs for estimating the prevalence of HIV infection among pregnant women. The PMTCT program uses sequential point-of-care rapid tests conducted on site while ANC surveillance surveys use dried blood spots tested sequentially for HIV-1/2 antibodies at a central laboratory. We compared matched routine PMTCT and ANC surveillance test results collected during 2007 and 2009 ANC surveillance surveys from 36 sentinel sites. RESULTS: After excluding 659 women without PMTCT data, including 83 who refused rapid testing, test results from a total of 20,563 women were available. Pooling the data from both years indicated HIV prevalence from routine PMTCT testing was 14.4% versus 15.2% from surveillance testing (relative difference -5.1%; absolute difference -0.78%). Positive percent agreement (PPA) of PMTCT versus surveillance tests was 88.5% (95% Confidence Interval [CI]: 85.7-91.3%), with 19 sites having PPA below 90%; Negative percent agreement (NPA) was 98.9% (CI: 98.5-99.2%). No significant difference was found among three regions (North, Center and South), however both PPA and NPA were significantly higher in 2009 than 2007 (p < 0.05). CONCLUSIONS: We found low PPA of PMTCT test results compared to surveillance data which is indicative either of testing errors or data reporting problems. Nonetheless, PPA improved significantly from 2007 to 2009, a possible positive trend that should be investigated further. Although use of PMTCT test results would not dramatically change HIV prevalence estimates among pregnant women, the impact of site-level differences on surveillance models should be evaluated before these data are used to replace or complement ANC surveillance surveys.

Estimation of HIV-1 Incidence Using a Testing History-Based Method; Analysis From the Population-Based HIV Impact Assessment Survey Data in 12 African Countries.

BACKGROUND: Estimating HIV incidence is essential to monitoring progress in sub-Saharan African nations toward global epidemic control. One method for incidence estimation is to test nationally representative samples using laboratory-based incidence assays. An alternative method based on reported HIV testing history and the proportion of undiagnosed infections has recently been described. METHODS: We applied an HIV incidence estimation method which uses history of testing to nationally representative cross-sectional survey data from 12 sub-Saharan African nations with varying country-specific HIV prevalence. We compared these estimates with those derived from laboratory-based incidence assays. Participants were tested for HIV using the national rapid test algorithm and asked about prior HIV testing, date and result of their most recent test, and date of antiretroviral therapy initiation. RESULTS: The testing history-based method consistently produced results that are comparable and strongly correlated with estimates produced using a laboratory-based HIV incidence assay (ρ = 0.85). The testing history-based method produced incidence estimates that were more precise compared with the biomarker-based method. The testing history-based method identified sex-, age-, and geographic location-specific differences in incidence that were not detected using the biomarker-based method. CONCLUSIONS: The testing history-based method estimates are more precise and can produce age-specific and sex-specific incidence estimates that are informative for programmatic decisions. The method also allows for comparisons of the HIV transmission rate and other components of HIV incidence among and within countries. The testing history-based method is a useful tool for estimating and validating HIV incidence from cross-sectional survey data.

Measuring the burden of SARS-CoV-2 infection among persons living with HIV and healthcare workers and its impact on service delivery in Mozambique: protocol of a prospective cohort study.

INTRODUCTION: As COVID-19 continues to spread globally and within Mozambique, its impact among immunosuppressed persons, specifically persons living with HIV (PLHIV), and on the health system is unknown in the country. The 'COVid and hIV' (COVIV) study aims to investigate: (1) the seroprevalence and seroincidence of SARS-CoV-2 among PLHIV and healthcare workers providing HIV services; (2) knowledge, attitudes, practices and perceptions regarding SARS-CoV-2 infection; (3) the pandemic's impact on HIV care continuum outcomes and (4) facility level compliance with national COVID-19 guidelines. METHODS AND ANALYSIS: A multimethod study will be conducted in a maximum of 11 health facilities across Mozambique, comprising four components: (1) a cohort study among PLHIV and healthcare workers providing HIV services to determine the seroprevalence and seroincidence of SARS-CoV-2, (2) a structured survey to assess knowledge, attitudes, perceptions and practices regarding COVID-19 disease, (3) analysis of aggregated patient data to evaluate retention in HIV services among PLHIV, (4) an assessment of facility implementation of infection prevention and control measures. ETHICS AND DISSEMINATION: Ethical approval was obtained from the National Health Bioethics Committee, and institutional review boards of implementing partners. Study findings will be discussed with local and national health authorities and key stakeholders and will be disseminated in clinical and scientific forums. TRIAL REGISTRATION NUMBER: NCT05022407.

Leading causes of death and high mortality rates in an HIV endemic setting (Kisumu county, Kenya, 2019).

BACKGROUND: In resource-limited settings, underlying causes of death (UCOD) often are not ascertained systematically, leading to unreliable mortality statistics. We reviewed medical charts to establish UCOD for decedents at two high volume mortuaries in Kisumu County, Kenya, and compared ascertained UCOD to those notified to the civil registry. METHODS: Medical experts trained in COD certification examined medical charts and ascertained causes of death for 456 decedents admitted to the mortuaries from April 16 through July 12, 2019. Decedents with unknown HIV status or who had tested HIV-negative >90 days before the date of death were tested for HIV. We calculated annualized all-cause and cause-specific mortality rates grouped according to global burden of disease (GBD) categories and separately for deaths due to HIV/AIDS and expressed estimated deaths per 100,000 population. We compared notified to ascertained UCOD using Cohen's Kappa (κ) and assessed for the independence of proportions using Pearson's chi-squared test. FINDINGS: The four leading UCOD were HIV/AIDS (102/442 [23.1%]), hypertensive disease (41/442 [9.3%]), other cardiovascular diseases (23/442 [5.2%]), and cancer (20/442 [4.5%]). The all-cause mortality rate was 1,086/100,000 population. The highest cause-specific mortality was in GBD category II (noncommunicable diseases; 516/100,000), followed by GBD I (communicable, perinatal, maternal, and nutritional; 513/100,000), and III (injuries; 56/100,000). The HIV/AIDS mortality rate was 251/100,000 population. The proportion of deaths due to GBD II causes was higher among females (51.9%) than male decedents (42.1%; p = 0.039). Conversely, more men/boys (8.6%) than women/girls (2.1%) died of GBD III causes (p = 0.002). Most of the records with available recorded and ascertained UCOD (n = 236), 167 (70.8%) had incorrectly recorded UCOD, and agreement between notified and ascertained UCOD was poor (29.2%; κ = 0.26). CONCLUSIONS: Mortality from infectious diseases, especially HIV/AIDS, is high in Kisumu County, but there is a shift toward higher mortality from noncommunicable diseases, possibly reflecting an epidemiologic transition and improving HIV outcomes. The epidemiologic transition suggests the need for increased focus on controlling noncommunicable conditions despite the high communicable disease burden. The weak agreement between notified and ascertained UCOD could lead to substantial inaccuracies in mortality statistics, which wholly depend on death notifications.

Causes of death in HIV-infected and HIV-uninfected children aged under-five years in western Kenya.

OBJECTIVES: Describe the causes of death among infants and children less than 5 years stratified by HIV status. DESIGN: Cross-sectional analysis of causes of death ascertained through minimally invasive tissue sampling (MITS) in the Kenya Child Health and Mortality Prevention Surveillance site. METHODS: We included decedents aged 28 days to less than 5 years, whose death was reported within 36 h, underwent MITS, and had HIV test results and causes of death determined. MITS specimens were tested using Taqman Array Cards, culture, cytology, histopathology and immunohistochemistry and HIV PCR. A panel evaluated epidemiologic, clinical, verbal autopsy and laboratory data to assign causes of death using ICD-10 guidelines. Causes of death and etiological agents were stratified by HIV status. RESULTS: Of 176 included decedents, 14% (n = 25) were HIV-infected, median viral load was 112 205 copies/ml [interquartile range (IQR) = 9349-2 670 143). HIV-disease (96%; n = 24) and malnutrition (23%; n = 34) were the leading underlying causes of death in HIV-infected and HIV-uninfected decedents, respectively. Malnutrition was more frequent in the causal chain of HIV-infected (56%; n = 14) than HIV-uninfected decedents (31%; n = 49) (P value = 0.03). Viral pneumonia was twice as common in HIV-infected (50%; n = 9) than HIV-uninfected decedents (22%; n = 7) (P value = 0.04). CONCLUSION: Nearly all HIV-infected decedents' underlying cause of death was HIV disease, which was associated with malnutrition. Our findings underscore the need for strengthening early identification and management of HIV-infected children. Prevention, early diagnosis and treatment of malnutrition could be instrumental in improving the survival of HIV-infected and HIV-uninfected children.

Evaluation of the Performance of OraQuick Rapid HIV-1/2 Test Among Decedents in Kisumu, Kenya.

BACKGROUND: Estimating cause-related mortality among the dead is not common, yet for clinical and public health purposes, a lot can be learnt from the dead. HIV/AIDS accounted for the third most frequent cause of deaths in Kenya; 39.7 deaths per 100,000 population in 2019. OraQuick Rapid HIV-1/2 has previously been validated on oral fluid and implemented as a screening assay for HIV self-testing in Kenya among living subjects. We assessed the feasibility and diagnostic accuracy of OraQuick Rapid HIV-1/2 for HIV screening among decedents. METHODS: Trained morticians collected oral fluid from 132 preembalmed and postembalmed decedents aged >18 months at Jaramogi Oginga Odinga Teaching and Referral Hospital mortuary in western Kenya and tested for HIV using OraQuick Rapid HIV-1/2. Test results were compared with those obtained using the national HIV Testing Services algorithm on matched preembalming whole blood specimens as a gold standard (Determine HIV and First Response HIV 1-2-O). We calculated positive predictive values, negative predictive values, area under the curve, and sensitivity and specificity of OraQuick Rapid HIV-1/2 compared with the national HTS algorithm. RESULTS: OraQuick Rapid HIV-1/2 had similar sensitivity of 92.6% [95% confidence interval (CI): 75.7 to 99.1] on preembalmed and postembalmed samples compared with the gold standard. Specificity was 97.1% (95% CI: 91.9 to 99.4) and 95.2% (95% CI: 89.2 to 98.4) preembalming and postembalming, respectively. Preembalming and postembalming positive predictive value was 89.3% (95% CI: 71.8 to 97.7) and 83.3% (95% CI: 65.3 to 94.4), respectively. The area under the curve preembalming and postembalming was 94.9% (95% CI: 89.6 to 100) and 93.9% (95% CI: 88.5 to 99.4), respectively. CONCLUSIONS: The study showed a relatively high-performance sensitivity and specificity of OraQuick Rapid HIV-1/2 test among decedents, similar to those observed among living subjects. OraQuick Rapid HIV-1/2 presents a convenient and less invasive screening test for surveillance of HIV among decedents within a mortuary setting.

%svy_freqs: A Generic SAS Macro for Creating Publication-Quality Three-Way Cross-Tabulations.

Cross-tabulations are a simple but important tool for understanding the distribution of socio-demographic characteristics among participants in epidemiological studies. We developed a generic SAS macro, %svy_freqs, to create publication-quality tables from cross-tabulations between a factor and a by-group variable given a third variable using survey or non-survey data. The macro also performs two-way cross-tabulations and provides extra features not available in existing procedures such as ability to incorporate parameters for survey design and replication-based variance estimation methods, performing validation checks for input parameters, transparently formatting variable values from character into numeric and allowing for generalizability. We demonstrate the macro using the 2013-2014 National Health and Nutrition Examination Survey (NHANES), a complex survey designed to assess the health and nutritional status of adults and children in the United States.

Prevalence of male circumcision in four culturally non-circumcising counties in western Kenya after 10 years of program implementation from 2008 to 2019.

INTRODUCTION: Kenya started implementing voluntary medical male circumcision (VMMC) for HIV prevention in 2008 and adopted the use of decision makers program planning tool version 2 (DMPPT2) in 2016, to model the impact of circumcisions performed annually on the population prevalence of male circumcision (MC) in the subsequent years. Results of initial DMPPT2 modeling included implausible MC prevalence estimates, of up to 100%, for age bands whose sustained high uptake of VMMC pointed to unmet needs. Therefore, we conducted a cross-sectional survey among adolescents and men aged 10-29 years to determine the population level MC prevalence, guide target setting for achieving the goal of 80% MC prevalence and for validating DMPPT2 modelled estimates. METHODS: Beginning July to September 2019, a total of 3,569 adolescents and men aged 10-29 years from households in Siaya, Kisumu, Homa Bay and Migori Counties were interviewed and examined to establish the proportion already circumcised medically or non-medically. We measured agreement between self-reported and physically verified circumcision status and computed circumcision prevalence by age band and County. All statistical were test done at 5% level of significance. RESULTS: The observed MC prevalence for 15-29-year-old men was above 75% in all four counties; Homa Bay 75.6% (95% CI [69.0-81.2]), Kisumu 77.9% (95% CI [73.1-82.1]), Siaya 80.3% (95% CI [73.7-85.5]), and Migori 85.3% (95% CI [75.3-91.7]) but were 0.9-12.4% lower than DMPPT2-modelled estimates. For young adolescents 10-14 years, the observed prevalence ranged from 55.3% (95% CI [40.2-69.5]) in Migori to 74.9% (95% CI [68.8-80.2]) in Siaya and were 25.1-32.9% lower than DMMPT 2 estimates. Nearly all respondents (95.5%) consented to physical verification of their circumcision status with an agreement rate of 99.2% between self-reported and physically verified MC status (kappa agreement p-value<0.0001). CONCLUSION: This survey revealed overestimation of MC prevalence from DMPPT2-model compared to the observed population MC prevalence and provided new reference data for setting realistic program targets and re-calibrating inputs into DMPPT2. Periodic population-based MC prevalence surveys, especially for established programs, can help reconcile inconsistencies between VMMC program uptake data and modeled MC prevalence estimates which are based on the number of procedures reported in the program annually.

High HIV prevalence among decedents received by two high-volume mortuaries in Kisumu, western Kenya, 2019.

BACKGROUND: Accurate data on HIV-related mortality are necessary to evaluate the impact of HIV interventions. In low- and middle-income countries (LMIC), mortality data obtained through civil registration are often of poor quality. Though not commonly conducted, mortuary surveillance is a potential complementary source of data on HIV-associated mortality. METHODS: During April-July 2019, we assessed HIV prevalence, the attributable fraction among the exposed, and the population attributable fraction among decedents received by two high-volume mortuaries in Kisumu County, Kenya, where HIV prevalence in the adult population was estimated at 18% in 2019 with high ART coverage (76%). Stillbirths were excluded. The two mortuaries receive 70% of deaths notified to the Kisumu East civil death registry; this registry captures 45% of deaths notified in Kisumu County. We conducted hospital chart reviews to determine the HIV status of decedents. Decedents without documented HIV status, including those dead on arrival, were tested using HIV antibody tests or polymerase chain reaction (PCR) consistent with national HIV testing guidelines. Decedents aged less than 15 years were defined as children. We estimated annual county deaths by applying weights that incorporated the study period, coverage of deaths, and mortality rates observed in the study. RESULTS: The two mortuaries received a total of 1,004 decedents during the study period, of which 95.1% (955/1004) were available for study; 89.1% (851/955) of available decedents were enrolled of whom 99.4% (846/851) had their HIV status available from medical records and post-mortem testing. The overall population-based, age- and sex-adjusted mortality rate was 12.4 per 1,000 population. The unadjusted HIV prevalence among decedents was 28.5% (95% confidence interval (CI): 25.5-31.6). The age- and sex-adjusted mortality rate in the HIV-infected population (40.7/1000 population) was four times higher than in the HIV-uninfected population (10.2/1000 population). Overall, the attributable fraction among the HIV-exposed was 0.71 (95% CI: 0.66-0.76) while the HIV population attributable fraction was 0.17 (95% CI: 0.14-0.20). In children the attributable fraction among the exposed and population attributable fraction were 0.92 (95% CI: 0.89-0.94) and 0.11 (95% CI: 0.08-0.15), respectively. CONCLUSIONS: Over one quarter (28.5%) of decedents received by high-volume mortuaries in western Kenya were HIV-positive; overall, HIV was considered the cause of death in 17% of the population (19% of adults and 11% of children). Despite substantial scale-up of HIV services, HIV disease remains a leading cause of death in western Kenya. Despite progress, increased efforts remain necessary to prevent and treat HIV infection and disease.

Where Are the Newly Diagnosed HIV Positives in Kenya? Time to Consider Geo-Spatially Guided Targeting at a Finer Scale to Reach the "First 90".

Background: The UNAIDS 90-90-90 Fast-Track targets provide a framework for assessing coverage of HIV testing services (HTS) and awareness of HIV status - the "first 90." In Kenya, the bulk of HIV testing targets are aligned to the five highest HIV-burden counties. However, we do not know if most of the new HIV diagnoses are in these five highest-burden counties or elsewhere. Methods: We analyzed facility-level HTS data in Kenya from 1 October 2015 to 30 September 2016 to assess the spatial distribution of newly diagnosed HIV-positives. We used the Moran's Index (Moran's I) to assess global and local spatial auto-correlation of newly diagnosed HIV-positive tests and Kulldorff spatial scan statistics to detect hotspots of newly diagnosed HIV-positive tests. For aggregated data, we used Kruskal-Wallis equality-of-populations non-parametric rank test to compare absolute numbers across classes. Results: Out of 4,021 HTS sites, 3,969 (98.7%) had geocodes available. Most facilities (3,034, 76.4%), were not spatially autocorrelated for the number of newly diagnosed HIV-positives. For the rest, clustering occurred as follows; 438 (11.0%) were HH, 66 (1.7%) HL, 275 (6.9%) LH, and 156 (3.9%) LL. Of the HH sites, 301 (68.7%) were in high HIV-burden counties. Over half of 123 clusters with a significantly high number of newly diagnosed HIV-infected persons, 73(59.3%) were not in the five highest HIV-burden counties. Clusters with a high number of newly diagnosed persons had twice the number of positives per 1,000,000 tests than clusters with lower numbers (29,856 vs. 14,172). Conclusions: Although high HIV-burden counties contain clusters of sites with a high number of newly diagnosed HIV-infected persons, we detected many such clusters in low-burden counties as well. To expand HTS where most needed and reach the "first 90" targets, geospatial analyses and mapping make it easier to identify and describe localized epidemic patterns in a spatially dispersed epidemic like Kenya's, and consequently, reorient and prioritize HTS strategies.

A new method for estimating HIV incidence from a single cross-sectional survey.

Estimating incidence from cross-sectional data sources is both important to the understanding of the HIV epidemic and challenging from a methodological standpoint. We develop a new incidence estimator that measures the size of the undiagnosed population and the amount of time spent undiagnosed in order to infer incidence and transmission rates. The estimator is calculated using commonly collected information on testing history and HIV status and, thus, can be deployed in many HIV surveys without additional cost. If ART biomarker status and/or viral load information is available, the estimator can be adjusted for biases in self-reported testing history. The performance of the estimator is explored in two large surveys in Kenya, where we find our point estimates to be consistent with assay-derived estimates, with much smaller standard errors.

A review of completeness, correctness, and order of cause of death statements among decedents with documented causes of death and HIV status at two major mortuaries in Kenya, 2015.

BACKGROUND: The cause of death (COD) statement is a vital statistic that refers to the disease(s) and process(es) that lead to death. Obtaining accurate COD is valuable for mortality prevention priorities. The statements are formulated using International Classification of Diseases and related health problems, version 10 (ICD-10) system. However, physicians may be unfamiliar with these standards or fail to use them and instead refer to mechanisms or manner of death when stating COD. We present results of an of assessment of quality of COD statements in decedent cases reviewed during a one-month mortuary-based surveillance at Kenyatta National Hospital (KNH) and the City mortuaries in Nairobi, Kenya in 2015. METHODS: Quality elements reviewed were completeness, correctness and order of stating the immediate (ICOD), antecedent, underlying (UCOD), and other significant causes (OSCs) as per the ICD 10 standards, in all deaths reported among adolescents and adults aged 15 years or older at the two mortuaries. COD were assessed for correct sequencing from immediate, antecedent, to underlying compared with autopsy pathology and clinical findings where available. Errors in COD statements were classified as missing or containing incomplete information such as: lack of underlying cause of an injury; incorrect words or statements; presence of more than one competing COD; use of the mechanism of death or anatomic and physiologic processes or signs and symptoms, and or laboratory results as CODs. Pearson's χ-squared test was used to compare proportions. RESULTS: Out of 810, 610 (75.3%) deaths having HIV statuses were abstracted and 356 had at least one COD documented; 114 (32%) females and 242 (68%) males; 239 (67.1%) from KNH and 117 (32.9%) City mortuary. The cases from City mortuary had higher rates of correct statements on 116 (99.1%) ICOD, 90 (89.1%) UCOD, and 40 (81.6%) OSCs, compared to KNH Mortuary; 50 (20.9%), 200 (90.1%) and 62 (76.5%) respectively, p < 0.001. The most common type of errors was incomplete information and citing mechanisms of death as the COD. CONCLUSIONS: In addition to revising national forms to conform to ICD-10, there is a need for periodic training of individuals responsible for completing death certificates. This will improve correctness and completeness of COD in order to provide reliable mortality data in Kenya.