Maternal plasma and breastmilk viral loads are associated with HIV-1-specific cellular immune responses among HIV-1-exposed, uninfected infants in Kenya.

Infants exposed to maternal HIV-1 provide an opportunity to assess correlates of HIV-1-specific interferon (IFN)-γ responses and may be informative in the development of HIV-1 vaccines. HIV-1-infected women with CD4 counts 200-500 cells/mm(3) were randomized to short-course zidovudine/nevirapine (ZDV/NVP) or highly active anti-retroviral therapy (HAART) between 2003 and 2005. Maternal plasma and breastmilk HIV-1 RNA and DNA were quantified during the first 6-12 months postpartum. HIV-1 gag peptide-stimulated enzyme-linked immunospot (ELISPOT) assays were conducted in HIV-1-exposed, uninfected infants (EU), and correlates were determined using regression and generalized estimating equations. Among 47 EU infants, 21 (45%) had ≥1 positive ELISPOT result during follow-up. Infants had a median response magnitude of 177 HIV-1-specific spot-forming units (SFU)/106 peripheral blood mononuclear cells (PBMC) [interquartile range (IQR)=117-287] directed against 2 (IQR = 1-3) gag peptide pools. The prevalence and magnitude of responses did not differ by maternal anti-retroviral (ARV) randomization arm. Maternal plasma HIV-1 RNA levels during pregnancy (P=0.009) and breastmilk HIV-1 DNA levels at 1 month (P=0.02) were associated with a higher magnitude of infant HIV-1-specific ELISPOT responses at 1 month postpartum. During follow-up, concurrent breastmilk HIV-1 RNA and DNA (cell-free virus and cell-associated virus, respectively) each were associated positively with magnitude of infant HIV-1-specific responses (P=0.01). Our data demonstrate the importance of antigenic exposure on the induction of infant HIV-1-specific cellular immune responses in the absence of infection.

Promoting reproductive options for HIV-affected couples in sub-Saharan Africa.

HIV-affected couples face unique challenges that require access to information and reproductive services to prevent HIV transmission to the uninfected partner and offspring while allowing couples to fulfil their reproductive goals. In regions of high HIV prevalence in sub-Saharan Africa, HIV-affected couples require multipurpose prevention technologies (MPTs) to enhance their reproductive healthcare options beyond contraception and prevention of HIV/sexually transmitted infections (STIs) to include assistance in childbearing. The unique characteristics of the condom and its accepted use in conjunction with safer conception interventions allow HIV-serodiscordant couples an opportunity to maintain reproductive health, prevent HIV/STI transmission, and achieve their reproductive goals while timing conception. Re-thinking the traditional view of the condom and incorporating a broader reproductive health perspective of HIV-affected couples into MPT methodologies will impact demand, acceptability and uptake of these future technologies.

Acyclovir and transmission of HIV-1 from persons infected with HIV-1 and HSV-2.

BACKGROUND: Most persons who are infected with human immunodeficiency virus type 1 (HIV-1) are also infected with herpes simplex virus type 2 (HSV-2), which is frequently reactivated and is associated with increased plasma and genital levels of HIV-1. Therapy to suppress HSV-2 reduces the frequency of reactivation of HSV-2 as well as HIV-1 levels, suggesting that suppression of HSV-2 may reduce the risk of transmission of HIV-1. METHODS: We conducted a randomized, placebo-controlled trial of suppressive therapy for HSV-2 (acyclovir at a dose of 400 mg orally twice daily) in couples in which only one of the partners was seropositive for HIV-1 (CD4 count, > or = 250 cells per cubic millimeter) and that partner was also infected with HSV-2 and was not taking antiretroviral therapy at the time of enrollment. The primary end point was transmission of HIV-1 to the partner who was not initially infected with HIV-1; linkage of transmissions was assessed by means of genetic sequencing of viruses. RESULTS: A total of 3408 couples were enrolled at 14 sites in Africa. Of the partners who were infected with HIV-1, 68% were women, and the baseline median CD4 count was 462 cells per cubic millimeter. Of 132 HIV-1 seroconversions that occurred after randomization (an incidence of 2.7 per 100 person-years), 84 were linked within couples by viral sequencing: 41 in the acyclovir group and 43 in the placebo group (hazard ratio with acyclovir, 0.92, 95% confidence interval [CI], 0.60 to 1.41; P=0.69). Suppression with acyclovir reduced the mean plasma concentration of HIV-1 by 0.25 log(10) copies per milliliter (95% CI, 0.22 to 0.29; P<0.001) and the occurrence of HSV-2-positive genital ulcers by 73% (risk ratio, 0.27; 95% CI, 0.20 to 0.36; P<0.001). A total of 92% of the partners infected with HIV-1 and 84% of the partners not infected with HIV-1 remained in the study for 24 months. The level of adherence to the dispensed study drug was 96%. No serious adverse events related to acyclovir were observed. CONCLUSIONS: Daily acyclovir therapy did not reduce the risk of transmission of HIV-1, despite a reduction in plasma HIV-1 RNA of 0.25 log(10) copies per milliliter and a 73% reduction in the occurrence of genital ulcers due to HSV-2. (ClinicalTrials.gov number, NCT00194519.)

REMINDER SYSTEMS FOR SELF UTERINE MASSAGE IN THE PREVENTION OF POSTPARTUM BLOOD LOSS.

BACKGROUND: Uterine massage may significantly reduce post partum blood loss and could be patient-driven. OBJECTIVE: To assess the effectiveness of an alarm reminder system for self uterine massage in the prevention of post partum blood loss. DESIGN: A random controlled trial. SETTING: Meru District Hospital, Kenya. SUBJECTS: One hundred and twenty seven (127) women were randomly assigned to a 15 minute alarm reminder system (71) and non-alarm (56) control arm during the fourth stage of labour. RESULTS: Uterine massage compliance was better in the alarm group compared to the non-alarm group (Average massage of seven and two in two hours respectively P-value <0.0001), however the difference in blood loss was not significant 45.6 ml (95% CI 43-46) vs 47.1 ml (95% CI 43-52)ml p-value 0.892. CONCLUSION: Uterine massage compliance is remarkably increased by the use of an alarm reminder.

Infertility prevalence and the methods of estimation from 1990 to 2021: a systematic review and meta-analysis.

STUDY QUESTION: What is the contemporary prevalence of infertility in world populations and how do they differ by methodological and study characteristics? SUMMARY ANSWER: Pooled estimates of lifetime and period prevalence of 12-month infertility were 17.5% and 12.6%, respectively, but this varied by study population and methodological approach. WHAT IS KNOWN ALREADY: Infertility affects millions of individuals worldwide. Accurate measures of its magnitude are needed to effectively address and manage the condition. There are distinct challenges and variation in how infertility is defined and measured, limiting comparability of estimates across studies. Further research is needed to understand whether and how differences in methodological approaches and study characteristics account for heterogeneity in estimates. STUDY DESIGN SIZE DURATION: We conducted a systematic review and meta-analysis. Six electronic databases, websites of relevant organizations, and conference proceedings were systematically searched. Searches were limited to those published between 1 January 1990 and 11 March 2021, with no language restrictions. PARTICIPANTS/MATERIALS SETTING METHODS: Descriptive and random-effects meta-analysis models were used to examine range of estimates and generate estimates of pooled lifetime and period prevalence of 12-month infertility, respectively, among representative populations. Meta-regression using restricted maximum likelihood was applied to account for definitional and study characteristics and to obtain adjusted estimates. Risk of bias was assessed with a validated tool. MAIN RESULTS AND THE ROLE OF CHANCE: The search yielded 12 241 unique records of which 133 studies met the criteria for the systematic review. There were 65 and 69 studies that provided data for lifetime and period prevalence of 12-month infertility, respectively. Five methodological approaches were identified: prospective time-to-pregnancy (TTP) design, current duration design, retrospective TTP design, self-reported infertility measure and constructed infertility measure. Ranges for lifetime (3.3-39.7%) and period estimates (1.6-34.0%) were similar and wide even after accounting for methodological and study characteristics. Pooled estimates of lifetime and period prevalence were 17.5% (95% CI: 15.0, 20.3, n = 37 studies, I 2 = 99.5%) and 12.6% (95% CI: 10.7, 14.6, n = 43 studies, I 2 = 99.8%), respectively, with some variation in magnitude by region and methodological approach, but with most CIs overlapping. LIMITATIONS REASONS FOR CAUTION: Pooled estimates generated from meta-analysis were derived from 12-month infertility prevalence estimates that were heterogeneous across different domains, even after adjusting for definitional and study characteristics. The number of studies was small for certain strata from which pooled estimates were derived (e.g. there were only two studies for lifetime prevalence in Africa). WIDER IMPLICATIONS OF THE FINDINGS: While findings show a high prevalence of infertility globally and regionally, it also reveals variation in measures to ascertain and compare infertility prevalence. More systematic and comprehensive collection of data using a consistent definition is needed to improve infertility prevalence estimates at global, regional and country-levels. STUDY FUNDING/COMPETING INTERESTS: This work was supported by the World Health Organization. The authors have no conflicts of interest. REGISTRATION NUMBER: PROSPERO CRD42020211704.

Women's reproductive span: a systematic scoping review.

STUDY QUESTION: What is the scope of literature regarding women's reproductive span in terms of definitions, trends and determinants? SUMMARY ANSWER: The scoping review found a wide variation in definitions, trends and determinants of biological, social and effective women's reproductive span. WHAT IS KNOWN ALREADY: A woman's reproductive span refers to her childbearing years. Its span influences a woman's reproductive decisions. STUDY DESIGN SIZE DURATION: A systematic scoping review was conducted. We searched MEDLINE, PubMed, JSTOR, CINAHL, Web of Science and Scopus electronic databases from inception to January 2021 without imposing language or date restrictions. We searched unpublished sources including the Global Burden of Disease, Demographic and Health Surveys, and National Health and Nutrition Examination Surveys. The list of relevant references was searched by hand. Sixty-seven reports on women's reproductive span were included in this review. PARTICIPANTS/MATERIALS SETTING METHODS: This scoping systematic review followed an established framework. The reporting of this scoping review followed the reporting requirements provided in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Extension for Scoping Reviews. Identified records were independently screened and data were extracted. We performed conceptual synthesis by grouping the studies by available concepts of reproductive span and then summarized definitions, measures used, temporal trends, determinants, and broad findings of implications on population demographics and assisted reproduction. Structured tabulation and graphical synthesis were used to show patterns in the data and convey detailed information efficiently, along with a narrative commentary. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 67 relevant reports on women's reproductive span were published between 1980 and 2020 from 74 countries. Most reports (42/67) were cross-sectional in design. Literature on reproductive span was conceptually grouped as biological (the interval between age at menarche and age at menopause), effective (when a woman is both fertile and engaging in sexual activity) and social (period of exposure to sexual activity). We summarized the working definitions, trends and determinants of each concept. Few articles addressed implications on demographics and assisted reproduction. LIMITATIONS REASONS FOR CAUTION: A formal assessment of methodological quality of the included studies was not performed because the aim of this review was to provide an overview of the existing evidence base regardless of quality. WIDER IMPLICATIONS OF THE FINDINGS: The review produced a comprehensive set of possible definitions of women's reproductive span, trends, and potential determinants. Further advancement of these findings will involve collaboration with relevant stakeholders to rate the importance of each definition in relation to demography and fertility care, outline a set of core definitions, identify implications for policy, practice or research and define future research opportunities to explore linkages between reproductive spans, their determinants, and the need for assisted reproduction. STUDY FUNDING/COMPETING INTERESTS: This work received funding from the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO). The authors had no competing interests. STUDY REGISTRATION NUMBER: N/A.

Nevirapine-associated hepatotoxicity was not predicted by CD4 count ≥250 cells/µL among women in Zambia, Thailand and Kenya.

OBJECTIVE: The aim of the study was to determine risk factors for developing severe hepatotoxicity (grade 3 or 4 hepatotoxicity) and rash-associated hepatotoxicity (rash with ≥ grade 2 hepatotoxicity) among women initiating nevirapine-based antiretroviral therapy (ART). METHODS: The Non-Nucleoside Reverse Transcriptase Inhibitor Response Study was a prospective cohort study carried out in Zambia, Thailand and Kenya. Between May 2005 and January 2007, we enrolled antiretroviral-naïve HIV-infected women initiating nevirapine-based ART. At enrollment and at weeks 2, 4, 8, 16 and 24, participants had serum alanine transferase (ALT) and aspartate transaminase (AST) measured and were evaluated clinically for hepatitis and rash. RESULTS: Nevirapine-based ART was initiated in 820 women and baseline ALT or AST results were abnormal (≥ grade 1) in 113 (14%) women. After initiating nevirapine-based ART, severe hepatotoxicity occurred in 41 (5%) women and rash-associated hepatotoxicity occurred in 27 (3%) women. In a multivariate logistic regression model, severe hepatotoxicity and rash-associated hepatotoxicity were both associated with baseline abnormal (≥ grade 1) ALT or AST results, but not with a baseline CD4 cell count ≥250 cells/µL. Three participants (0.4%) died with symptoms suggestive of fatal hepatotoxicity; all three women had baseline CD4 count <100 cells/µL and were receiving anti-tuberculosis therapy. CONCLUSION: Among women taking nevirapine-based ART, severe hepatotoxicity and rash-associated hepatotoxicity were predicted by abnormal baseline ALT or AST results, but not by a CD4 count ≥250 cells/µL. In resource-limited settings where transaminase testing is available, testing should focus on early time-points and on women with abnormal baseline ALT or AST results.

Adherence to national guidelines in prevention of mother to child transmission of HIV.

BACKGROUND: Mother-to-child transmission (MTCT) of Human Immunodeficiency Virus (HIV) contributes to over 90% of the paediatric HIV infections. The national PMTCT guidelines make recommendations for specific interventions to reduce perinatal transmission. Data on adherence to the guidelines by caregivers and quality of PMTCT care is however limited. OBJECTIVE: To evaluate the extent to which PMTCT care offered to HIV positive women admitted for delivery at Kenyatta National Hospital (KNH) and Pumwani Maternity Hospital (PMH) adheres to National Guidelines in order to reduce vertical transmission of HIV during labour and delivery. DESIGN: A cross-sectional study. SETTING: Kenyatta National Hospital and Pumwani Maternity Hospital from January to April 2009. SUBJECTS: All consenting HIV positive women admitted to the labour wards at the two facilities and planned for delivery. RESULTS: A total of 370 women were enrolled, 266 at Pumwani Maternity Hospital and 104 at Kenyatta National Hospital. Among the enrolled women 357 (96.4%) had been counselled on vertical transmission and 205 (55.4%) had HIV disease staging by CD4 cell count. There were no significant differences between the two study sites in the proportion of women counselled on MTCT (p = 0.398) and receiving HIV disease staging by CD4 testing (p = 0.28). Three hundred and forty nine (94.3%) women were offered varied ARV regimens for PMTCT. 101(27.3%) received HAART, 94 (26.9%) were given single dose nevirapine and 130 (37%) received AZT+NVP combination prophylaxis. Twenty one women received no ARV prophylaxis. Overall, 268 women (72.5%) had spontaneous vertex delivery. An episiotomy rate of 7% was observed and no vacuum delivery was recorded. A Caesarean section rate of 27.5% was recorded with PMTCT as an indication in almost half of the cases. Women delivered at KNH were more likely to receive HAART (p < 0.001) and to be delivered by elective caesarean (p < 0.001). CONCLUSION: A great majority of HIV positive women admitted for delivery received counseling on vertical transmission and were offered ARVs for PMTCT. Many women did not get CD4 measurement and clinical staging as recommended in the National guidelines.

Mode of delivery decisions among HIV-infected mothers at an urban maternity hospital in Kenya.

OBJECTIVES: To quantify the use of elective Caesarean section (ECS) for prevention of mother-to-child transmission of HIV (PMTCT) at an urban Kenyan maternity hospital, to describe mode of delivery decision making among HIV positive women, and to understand patient knowledge and attitudes regarding ECS for PMTCT. DESIGN: Descriptive cross-sectional study. SETTING: Pumwani Maternity Hospital, Nairobi, Kenya. SUBJECTS: Two hundred and fifty postpartum HIV-infected women. MAIN OUTCOME MEASURES: ECS delivery rate, correlates of mode of delivery decisions and ECS for PMTCT knowledge and attitudes RESULTS: The rate of delivery by ECS for PMTCT was 4.0% (10/250), though 13.6% (34/250) planned this mode of delivery. Patient education regarding ECS for PMTCT was limited, and 64% (160/250) of participants had never heard of ECS. Planning ECS for PMTCT was positively correlated with attending clinic at PMH (OR=9.12, 95% CI: 2.94-28.28, p<0.001), knowledge of ECS (OR=27.22, 95% CI: 5.04-148.20, p<0.001) and having a history of abdominal surgery (OR=30.96, 95% CI: 6.32-205.02, p<0.001). Delivering by ECS was associated with planning this mode of delivery (OR=19.52, 95% CI: 3.69-103.23, p<0.001). Planning but not delivering by ECS was mostly due to labour before scheduled ECS (55.6%, 15/27) or poor patient understanding of the intervention (29.6%,8/27). After education on ECS for PMTCT, 48.0% (120/250) of participants would consider elective Caesarean section if offered, though cost represented a significant barrier to acceptability. CONCLUSIONS: Knowledge and utilisation of ECS for PMTCT are limited and varied in this patient population. ECS may be an acceptable mode of delivery for some Kenyan women, especially if the burden of cost is removed. A clear policy on ECS counselling and utilisation is urgently needed to ensure consistent and appropriate use of this PMTCT intervention in Kenya.

HIV testing men in the antenatal setting: understanding male non-disclosure.

Prevention of infant HIV is a powerful incentive for maternal HIV diagnosis and an opportunity to increase male HIV testing and disclosure of HIV status within couples. We examined male HIV disclosure in couples who attended a Nairobi antenatal clinic (ANC), had individual HIV testing, and were counselled to disclose to their partner. At two-week follow-up, men and women independently reported HIV disclosure. Of 2104 women, 1993 requested partner attendance; 313 male partners came, of whom 183 chose individual HIV testing. Of 106 couples who followed up, 93% of both partners reported disclosure by women versus 71% by men (P < 0.0001); 27% of men reported disclosure while their female partner reported not knowing partner HIV status. In these couples, male ANC HIV testing did not result in shared knowledge of HIV status. Couple counselling models that incorporate disclosure may yield greater HIV prevention benefits than offering individual partner HIV testing services at ANC.

Indeterminate rapid HIV-1 test results among antenatal and postnatal mothers.

The sensitivity and specificity of rapid HIV-1 tests may be altered during pregnancy and postpartum. We conducted a study to determine the prevalence and correlates of false-positive Abbott Determine and false-negative Uni-Gold rapid HIV-1 test results among antenatal and postnatal mothers attending a primary care clinic in Nairobi, Kenya. Mothers were tested for HIV-1 using Abbott Determine and non-reactive results were considered HIV-1 antibody negative. Reactive samples by Determine were re-tested by Uni-Gold. Vironostika HIV-1 and Uni-FORM II Enzyme-linked immunosorbent assays were used to confirm samples that had positive Abbott Determine and negative Uni-Gold. Among 2311 women who accepted HIV-1 testing, 1238 (54%) were tested antenatally and 1073 (46%) were tested postnatally. Of tested women, 274 (12%) women were reactive by Abbott Determine and on retesting with Uni-Gold 30 (11%) had indeterminate results. The prevalence of indeterminate results was significantly higher in antenatal women than in postnatal women (2% versus 1%, P = 0.03). In conclusion, indeterminate rapid HIV-1 test results are more common in the antenatal period and appropriate safeguards to confirm HIV-1 infection status should be implemented in antenatal programmes.

Pregnancy outcomes in mothers with advanced human immunodeficiency virus disease.

OBJECTIVE: To determine the impact of HIV disease on immediate maternal and foetal outcomes at the Kenyatta National Hospital, Nairobi, Kenya. DESIGN: Prospective cohort study. SETTING: Kenyatta National Hospital, Nairobi, Kenya, between September 2004 and April 2005. SUBJECTS: Sixty eight mothers with advanced HIV disease (WHO clinical stage 3 and 4) and 68 HIV negative pregnant mothers. RESULTS: Mothers with advanced HIV disease were more likely to be anaemic (55% vs. 16% p < 0.001), to have sexually transmitted diseases (56% vs. 15%, p = 0.004), to have chorioamnionitis (14.8% vs. 2%, p = 0.004), to develop preterm premature rupture of membranes (31% vs. 9%, p < 0.001), to have puerperal pyrexia (16% vs. 2%, p = 0.032) an to die (5% vs. 0.5%, p = 0.028) compared to HIV negative mothers. The mean gestational age at deliver was lower in mothers with advanced HIV disease compared to the seronegative counterparts (73% vs. 32%, delivery <37 weeks, p < 0.001). Infants of mothers with advanced HIV disease compared to infants of seronegative mothers were more likely to be low birth weight infants (58% vs. 21%, p < 0.001), stillborn (4% vs. 2%, p = 0.308) and to have low Apgar scores (28% vs. 12%, Apgar score < 4 at 5 minutes p = 0.02). Perinatal sepsis and perinatal deaths were more common in infants born to mothers with advanced HIV disease compared to infants born to HIV negative mothers (8 vs. 3, p = 0.003 and 14 vs. 5, p = 0.025 respectively). External congenital anomalies were similar in the two groups (5.9% vs. 5.9%). CONCLUSION: Pregnancies complicated by advanced HIV disease are more likely to have adverse outcomes, both maternal and foetal. Advanced HIV disease is associated with increased risk of both maternal and fetal mortality. HIV infected mothers should be counselled on the increased pregnancy risks associated with advanced disease.

Body dysmorphic disorder: case report.

The desire for self-mutilation in the absence of any discernible psychopathology is relatively rare. Self-mutilation is most commonly a manifestation of an underlying psychopathology such as depression, schizophrenia, personality disorder, transexuality, body dysmorphic disorder and factitious disorder. In this article, a case in which a 29-year-old single Kenyan lady of African origin demanded a surgical operation to modify and reduce the size of her external genitalia is presented. Although female genital mutilation is still widespread in the country, this case is of interest in that the woman did not seek the usual circumcision but sought to specifically reduce the size of her labia minora so that she could feel like a normal woman. The unique challenges in her management are discussed. Possible aetiological factors in patients who demand surgical removal or modification of parts of their bodies without an obvious cause is discussed.

Treatment outcomes of drug-resistant tuberculosis patients in Kenya.

SETTING: Successful treatment of drug-resistant tuberculosis (DR-TB) is crucial in preventing disease transmission and reducing related morbidity and mortality. A standardised DR-TB treatment regimen is used in Kenya. Although patients on treatment are monitored, no evaluation of factors affecting treatment outcomes has yet been performed. OBJECTIVE: To analyse treatment outcomes of DR-TB patients in Kenya and factors associated with successful outcome. DESIGN: Retrospective analysis of secondary data from Kenya's National Tuberculosis, Leprosy and Lung disease programme. DR-TB data from the national database for January to December 2012 were reviewed. RESULTS: Of 205 DR-TB patients included in the analysis, 169 (82.4%) had a successful treatment outcome, 18 (9%) died and 18 (9%) were lost to follow-up. Only sex (P = 0.006) and human immunodeficiency virus (HIV) status (P = 0.008) were predictors of successful treatment. Females were more likely to attain treatment success (OR 3.86, 95%CI 1.47-10.12), and HIV-negative status increased the likelihood of successful treatment (OR 3.53, 95%CI 1.4-8.9). CONCLUSION: Treatment success rates were higher than World Health Organization targets. Targeted policies for HIV-positive patients and males will improve treatment outcomes in these groups.

Perceptions and practices of vaginal birth after Caesarean section among privately practicing obstetricians in Kenya.

OBJECTIVE: To determine perceptions, preferences and practices of vaginal birth after Caesarean. DESIGN: Cross-sectional descriptive study. SETTING: Private clinics of obstetricians in five major towns of Kenya. SUBJECTS: Obstetricians in private practice. MAIN OUTCOME MEASURES: Practice and experiences in trial of labour (TOL); need for, and application of, selection criteria in TOL; perceptions on outcomes of TOL and patient preference; perception on trends of vaginal birth after Caesarean (VBAC) and need for policy on TOL. RESULTS: Nearly all respondents (98.4%) believed in the need for, and application of, selection criteria for allowing TOL. However, only 23% believed in routine screening with radiological pelvimetry, while 63.2% believed in routine foetal weight estimation. All obstetricians (100%) have ever managed TOL in private practice, and 74% had managed at least one case in the last six months. Despite lack of tangible selection criteria, 83.1% think that most women prefer TOL while 95.1% discourage it if perceived as inappropriate. Failure rate of TOL was perceived to be more than 50% by 35.2% of the respondents. A majority of the respondents (about 75%) would prefer TOL on themselves or their spouses. Those who perceived that there was a falling trend of VBAC were 58%, citing increased demand by mothers (45.7%), obstetricians' convenience (40.0%) and fear of litigation (26.8%) as the reasons for this observation. A fluid policy of "TOL whenever it is deemed as appropriate" was preferred by 88.7%. CONCLUSION: The perception of obstetricians is that desire for VBAC predominates over elective repeat Caesarean. However, consensus on appropriate selection criteria is lacking, which leaves the obstetrician in a management dilemma. Hence, there is need to study outcomes of both ERC and TOL in order to come out with objective policy guidelines on management of one previous Caesarean in pregnancy.

Antenatal care and pregnancy outcomes in a safe motherhood health voucher system in rural Kenya, 2007-2013.

SETTING: A rural private health facility, Ruby Medical Centre (RMC), participating in a safe motherhood health voucher system for poor women in Kiambu County, Kenya. OBJECTIVES: Between 2007 and 2013, to determine 1) the number of women who delivered at the RMC, their characteristics and pregnancy-related outcomes, and 2) the number of women who received an incomplete antenatal care (ANC) package and associated factors. DESIGN: Retrospective cross-sectional study using routine programme data. RESULTS: During the study period, 2635 women delivered at the RMC: 50% were aged 16-24 years, 60% transferred in from other facilities and 59% started ANC in the third trimester of pregnancy. Of the 2635 women, 1793 (68%) received an incomplete ANC package: 347 (13%) missed essential blood tests, 312 (12%) missed the tetanus toxoid immunisation and 1672 (65%) had fewer than four visits. Presenting late and starting ANC elsewhere were associated with an incomplete package. One pregnancy-related mortality occurred; the stillbirth rate was 10 per 1000 births. CONCLUSION: This first assessment of the health voucher system in rural Kenya showed problems in ANC quality. Despite favourable pregnancy-related outcomes, increased efforts should be made to ensure earlier presentation of pregnant women, comprehensive ANC, and more consistent and accurate monitoring of reproductive indicators and interventions.

Contexte : Une structure de santé privée rurale, le Ruby Medical Centre (RMC), participant à un système de bons de traitement de Maternité sans risques destiné à des femmes pauvres du conté de Kiambu au Kenya.Objectifs : Entre 2007 et 2013, déterminer 1) le nombre de femmes qui ont accouché au RMC, leurs caractéristiques et le devenir de leur grossesse, et 2) le nombre ne bénéficiant que d'un paquet de soins anténataux (ANC) incomplets et les facteurs associés.Schéma : Etude rétrospective transversale basée sur les données recueillies en routine dans les programmes.Résultats : Au cours de la période d'étude, 2635 femmes ont accouché au RMC : 50% étaient âgées de 16 à 24 ans, 60% avaient été transférées d'autres structures et 59% avaient débuté les ANC au cours du 3e trimestre. De ces 2635 femmes, 1793 (68%) avaient un paquet d'ANC incomplet : 347 (13%) ont manqué les principaux tests sanguins, 312 (12%) n'ont pas eu de vaccination anti-tétanique et 1672 (65%) ont eu moins de quatre consultations. Un démarrage tardif et des ANC débutés ailleurs étaient associés à un paquet d'ANC incomplet. Un décès lié à la grossesse est survenu et le taux de mortinatalité a été de 10/1000 naissances.Conclusion : Cette première évaluation du système de bons de traitement dans les zones rurales du Kenya a mis en évidence des problèmes de qualité des ANC. En dépit de l'évolution favorable des grossesses, il est nécessaire d'accroitre les efforts pour faire venir les femmes enceintes plus tôt, offrir des ANC complets et un suivi plus cohérent et précis des indicateurs et des interventions de santé reproductive.

Marco de referencia: El Ruby Medical Centre (RMC) es un centro de atención de salud privado en zona rural, que participa en el sistema de cupones por una maternidad sin riesgo en el condado de Kiambu, en Kenia.Objetivos: Determinar entre el 2007 y el 2013: 1) la cantidad de mujeres cuyo parto se atendió en el RMC, las características de las mujeres y los desenlaces relacionados con el embarazo; y 2) el número de mujeres que recibieron una atención prenatal (ANC) incompleta y los factores asociados con esta situación.Métodos: Fue este un estudio transversal retrospectivo a partir de los datos del programa corriente.Resultados: Durante el período del estudio, se atendió el parto de 2635 mujeres en el RMC, el 50% de las cuales tenía entre 16 y 24 años de edad, el 60% acudió como remisión de otros centros de atención y el 59% había comenzado la ANC durante el tercer trimestre del embarazo. De las 2635 mujeres, 1793 recibieron una ANC incompleta (68%) a saber: en 347 no se practicaron los principales exámenes sanguíneos (13%); 312 no recibieron la vacuna con el toxoide antitetánico (12%); y 1672 acudieron a menos de cuatro citas de control (65%). Los factores asociados con una ANC incompleta fueron una presentación tardía al programa y el inicio de la ANC en un centro diferente. Se presentó un caso de mortalidad relacionada con el embarazo y la tasa de mortinatalidad fue de 10 por 1000 nacimientos.Conclusión: El presente estudio es la primera evaluación del sistema de cupones por una maternidad sin riesgo en la zona rural de Kenia y puso en evidencia problemas en materia de calidad de la ANC. Pese a los desenlaces favorables del embarazo, se precisan iniciativas que fomenten una presentación más temprana de las embarazadas al programa, la ANC integral, y una vigilancia más regular y exacta de los indicadores y las intervenciones en materia de salud reproductiva.

Effect of chronic trypanosomiasis on immunization against East Coast fever.

Two experiments were carried out in which uninfected cattle, or cattle chronically infected with Trypanosoma congolense, were immunized by the infection and treatment method against East Coast fever (ECF; Theileria parva infection). Chronic trypanosomiasis did not prevent cattle mounting an effective immunological response to ECF immunization and resisting subsequent lethal challenge. There appeared to be no difference in the level or quality of immunity between uninfected cattle and trypanosome-infected cattle. Thus, T. congolense infection on its own does not appear to provide a constraint to ECF immunization in the field.

Demonstration of colonies of Cowdria ruminantium in midgut epithelial cells of Amblyomma variegatum.

The development of colonies of Cowdria ruminantium was studied in midgut epithelial cells of adult Amblyomma variegatum that had become infected by feeding as nymphs on cattle with experimentally induced heart-water disease. Colonies were not observed in gut tissues obtained from nymphs during the feeding period, but were present in midgut epithelial cells of ticks obtained at 15 days after they were replete through molting to the adult stage. Colonies were small (1 to 10 micron) initially, but as tick development progressed, their diameter increased to as much as 60 micron. With electron microscopy, colonies were observed to be membrane bound and contained pleomorphic organisms that were reticulated. The organisms seemed to be dividing by binary fission. Many colonies contained a large, electron-dense inclusion that was morphologically similar to hemoglobin deposits found in the cytoplasm of midgut epithelial cells of recently fed ticks. Cowdria ruminantium was often observed adhered to these inclusions.

Biomarker evaluation of self-reported condom use among women in HIV-discordant couples.

Self-reported condom use is a commonly collected statistic, yet its use in research studies may be inaccurate. We evaluated this statistic among women in HIV-discordant couples enrolled in a clinical trial in Nairobi, Kenya. Vaginal swabs were acquired from 125 women and tested for prostate-specific antigen (PSA), a biomarker for semen exposure, using an enzyme-linked immunosorbent assay. Ten (10%) of 98 women who reported 100% use of condoms in the previous month tested PSA positive. In a bivariate logistic regression analysis, among women who reported 100% condom use in the previous month, those with ≤8 years of school had significantly higher odds of testing PSA-positive (odds ratio [OR] = 8.39, 95% confidence interval [CI] 1.02-69.13) than women with more schooling. Our estimate may be conservative, as the ability to detect PSA may be limited to 24-48 hours after exposure. Less educated women may be a target group for counselling regarding reporting sexual behaviour in clinical trials.

HIV infection and sexual partnerships and behaviour among adolescent girls in Nairobi, Kenya.

Early sexual partnerships place young women in sub-Saharan Africa at high risk for HIV. Few studies have examined both individual- and partnership-level characteristics of sexual relationships among adolescent girls. A cross-sectional survey of sexual history and partnerships was conducted among 761 adolescent girls aged 15-19 years in Nairobi, Kenya. Rapid HIV testing was conducted and correlates of HIV infection were determined using multivariate logistic regression. The HIV prevalence was 7% and seropositive adolescents had a younger age at sexual debut (P < 0.01), more sexual partners in 12 months (P = 0.03), and were more likely to report transactional or non-consensual sex (P < 0.01). Girls who reported not knowing their partner's HIV status were 14 times as likely to be HIV-seropositive than girls who knew their partner's status (adjusted odds ratio: 14.2 [1.8, 109.3]). Public health messages to promote HIV testing and disclosure within partnerships could reduce sexual risk behaviours and HIV transmission among adolescents.