Mapping the Current and Future Noncommunicable Disease Burden in Kenya by Human Immunodeficiency Virus Status: A Modeling Study.

BACKGROUND: The noncommunicable disease (NCD) burden in Kenya is not well characterized, despite estimates needed to identify future health priorities. We aimed to quantify current and future NCD burden in Kenya by human immunodeficiency virus (HIV) status. METHODS: Original systematic reviews and meta-analyses of prevalence/incidence of cardiovascular disease (CVD), chronic kidney disease, depression, diabetes, high total cholesterol, hypertension, human papillomavirus infection, and related precancerous stages in Kenya were carried out. An individual-based model was developed, simulating births, deaths, HIV disease and treatment, aforementioned NCDs, and cancers. The model was parameterized using systematic reviews and epidemiological national and regional surveillance data. NCD burden was quantified for 2018-2035 by HIV status among adults. RESULTS: Systematic reviews identified prevalence/incidence data for each NCD except ischemic heart disease. The model estimates that 51% of Kenyan adults currently suffer from ≥1 NCD, with a higher burden in people living with HIV (PLWH) compared to persons not living with HIV (62% vs 51%), driven by their higher age profile and partly by HIV-related risk for NCDs. Hypertension and high total cholesterol are the main NCD drivers (adult prevalence of 20.5% [5.3 million] and 9.0% [2.3 million]), with CVD and cancers the main causes of death. The burden is projected to increase by 2035 (56% in persons not living with HIV; 71% in PLWH), with population growth doubling the number of people needing services (15.4 million to 28.1 million) by 2035. CONCLUSIONS: NCD services will need to be expanded in Kenya. Guidelines in Kenya already support provision of these among both the general and populations living with HIV; however, coverage remains low.

Addressing violence against women: a call to action.

Violence against women and girls is prevalent worldwide but historically has been overlooked and condoned. Growing international recognition of these violations creates opportunities for elimination, although solutions will not be quick or easy. Governments need to address the political, social, and economic structures that subordinate women, and implement national plans and make budget commitments to invest in actions by multiple sectors to prevent and respond to abuse. Emphasis on prevention is crucial. Community and group interventions involving women and men can shift discriminatory social norms to reduce the risk of violence. Education and empowerment of women are fundamental. Health workers should be trained to identify and support survivors and strategies to address violence should be integrated into services for child health, maternal, sexual, and reproductive health, mental health, HIV, and alcohol or substance abuse. Research to learn how to respond to violence must be strengthened. The elimination of violence against women and girls is central to equitable and sustainable social and economic development and must be prioritised in the agenda for development after 2015.

Maximising the effect of combination HIV prevention through prioritisation of the people and places in greatest need: a modelling study.

BACKGROUND: Epidemiological data show substantial variation in the risk of HIV infection between communities within African countries. We hypothesised that focusing appropriate interventions on geographies and key populations at high risk of HIV infection could improve the effect of investments in the HIV response. METHODS: With use of Kenya as a case study, we developed a mathematical model that described the spatiotemporal evolution of the HIV epidemic and that incorporated the demographic, behavioural, and programmatic differences across subnational units. Modelled interventions (male circumcision, behaviour change communication, early antiretoviral therapy, and pre-exposure prophylaxis) could be provided to different population groups according to their risk behaviours or their location. For a given national budget, we compared the effect of a uniform intervention strategy, in which the same complement of interventions is provided across the country, with a focused strategy that tailors the set of interventions and amount of resources allocated to the local epidemiological conditions. FINDINGS: A uniformly distributed combination of HIV prevention interventions could reduce the total number of new HIV infections by 40% during a 15-year period. With no additional spending, this effect could be increased by 14% during the 15 years-almost 100,000 extra infections, and result in 33% fewer new HIV infections occurring every year by the end of the period if the focused approach is used to tailor resource allocation to reflect patterns in local epidemiology. The cumulative difference in new infections during the 15-year projection period depends on total budget and costs of interventions, and could be as great as 150,000 (a cumulative difference as great as 22%) under different assumptions about the unit costs of intervention. INTERPRETATION: The focused approach achieves greater effect than the uniform approach despite exactly the same investment. Through prioritisation of the people and locations at greatest risk of infection, and adaption of the interventions to reflect the local epidemiological context, the focused approach could substantially increase the efficiency and effectiveness of investments in HIV prevention. FUNDING: The Bill & Melinda Gates Foundation and UNAIDS.

Transformation of HIV from pandemic to low-endemic levels: a public health approach to combination prevention.

Large declines in HIV incidence have been reported since 2001, and scientific advances in HIV prevention provide strong hope to reduce incidence further. Now is the time to replace the quest for so-called silver bullets with a public health approach to combination prevention that understands that risk is not evenly distributed and that effective interventions can vary by risk profile. Different countries have different microepidemics, with very different levels of transmission and risk groups, changing over time. Therefore, focus should be on high-transmission geographies, people at highest risk for HIV, and the package of interventions that are most likely to have the largest effect in each different microepidemic. Building on the backbone of behaviour change, condom use, and medical male circumcision, as well as expanded use of antiretroviral drugs for infected people and pre-exposure prophylaxis for uninfected people at high risk of infection, it is now possible to consider the prospect of what would be one of the most remarkable achievements in the history of public health: reduction of HIV transmission from a pandemic to low-level endemicity.

Strengthening measurement and performance of HIV prevention programmes.

Indicators for the measurement of programmes for the primary prevention of HIV are less aligned than indicators for HIV treatment, which results in a high burden of data collection, often without a clear vision for its use. As new evidence becomes available, the opportunity arises to critically evaluate the way countries and global bodies monitor HIV prevention programmes by incorporating emerging data on the strength of the evidence linking various factors with HIV acquisition, and by working to streamline indicators across stakeholders to reduce burdens on health-care systems. Programmes are also using new approaches, such as targeting specific sexual networks that might require non-traditional approaches to measurement. Technological advances can support these new directions and provide opportunities to use real-time analytics and new data sources to more effectively understand and adapt HIV prevention programmes to reflect population movement, risks, and an evolving epidemic.

The impact of scaling up cervical cancer screening and treatment services among women living with HIV in Kenya: a modelling study.

Introduction: We aimed to quantify health outcomes and programmatic implications of scaling up cervical cancer (CC) screening and treatment options for women living with HIV in care aged 18-65 in Kenya. Methods: Mathematical model comparing from 2020 to 2040: (1) visual inspection with acetic acid (VIA) and cryotherapy (Cryo); (2) VIA and Cryo or loop excision electrical procedure (LEEP), as indicated; (3) human papillomavirus (HPV)-DNA testing and Cryo or LEEP; and (4) enhanced screening technologies (either same-day HPV-DNA testing or digitally enhanced VIA) and Cryo or LEEP. Outcomes measured were annual number of CC cases, deaths, screening and treatment interventions, and engaged in care (numbers screened, treated and cured) and five yearly age-standardised incidence. Results: All options will reduce CC cases and deaths compared with no scale-up. Options 1-3 will perform similarly, averting approximately 28 000 (33%) CC cases and 7700 (27%) deaths. That is, VIA screening would yield minimal losses to follow-up (LTFU). Conversely, LTFU associated with HPV-DNA testing will yield a lower care engagement, despite better diagnostic performance. In contrast, option 4 would maximise health outcomes, averting 43 200 (50%) CC cases and 11 800 (40%) deaths, given greater care engagement. Yearly rescreening with either option will impose a substantial burden on the health system, which could be reduced by spacing out frequency to three yearly without undermining health gains. Conclusions: Beyond the specific choice of technologies to scale up, efficiently using available options will drive programmatic success. Addressing practical constraints around diagnostics' performance and LTFU will be key to effectively avert CC cases and deaths.

Recommendations for the use of mathematical modelling to support decision-making on integration of non-communicable diseases into HIV care.

INTRODUCTION: Integrating services for non-communicable diseases (NCDs) into existing primary care platforms such as HIV programmes has been recommended as a way of strengthening health systems, reducing redundancies and leveraging existing systems to rapidly scale-up underdeveloped programmes. Mathematical modelling provides a powerful tool to address questions around priorities, optimization and implementation of such programmes. In this study, we examine the case for NCD-HIV integration, use Kenya as a case-study to highlight how modelling has supported wider policy formulation and decision-making in healthcare and to collate stakeholders' recommendations on use of models for NCD-HIV integration decision-making. DISCUSSION: Across Africa, NCDs are increasingly posing challenges for health systems, which historically focused on the care of acute and infectious conditions. Pilot programmes using integrated care services have generated advantages for both provider and user, been cost-effective, practical and achieve rapid coverage scale-up. The shared chronic nature of NCDs and HIV means that many operational approaches and infrastructure developed for HIV programmes apply to NCDs, suggesting this to be a cost-effective and sustainable policy option for countries with large HIV programmes and small, un-resourced NCD programmes. However, the vertical nature of current disease programmes, policy financing and operations operate as barriers to NCD-HIV integration. Modelling has successfully been used to inform health decision-making across a number of disease areas and in a number of ways. Examples from Kenya include (i) estimating current and future disease burden to set priorities for public health interventions, (ii) forecasting the requisite investments by government, (iii) comparing the impact of different integration approaches, (iv) performing cost-benefit analysis for integration and (v) evaluating health system capacity needs. CONCLUSIONS: Modelling can and should play an integral part in the decision-making processes for health in general and NCD-HIV integration specifically. It is especially useful where little data is available. The successful use of modelling to inform decision-making will depend on several factors including policy makers' comfort with and understanding of models and their uncertainties, modellers understanding of national priorities, funding opportunities and building local modelling capacity to ensure sustainability.

Sexual violence legislation in sub-Saharan Africa: the need for strengthened medico-legal linkages.

Six sub-Saharan African countries currently have laws on sexual violence, including Kenya, and eight others have provisions on sexual violence in other legislation. Effective legislation requires functioning medico-legal linkages to enable both justice to be done in cases of sexual violence and the provision of health services for survivors of sexual violence. The health sector also needs to provide post-rape care services and collect and deliver evidence to the criminal justice system. This paper reviews existing data on sexual violence in sub-Saharan Africa, and summarises the content of sexual violence legislation in the region and the strengths and weaknesses of existing medico-legal linkages, using Kenya as a case study. Many sub-Saharan African countries do not yet have comprehensive post-rape care services, nor substantial co-ordination between HIV and sexual and reproductive health services, the legal and judicial systems, and sexual violence legislation. These need to be integrated by cross-referrals, using standardised referral guidelines and pathways, treatment protocols, and medico-legal procedures. Common training approaches and harmonised information across sectors, and common indicators, would facilitate government accountability. Joint and collaborative planning and working at country level, through sharing of information and data between the different systems remain key to achieving this.

Promoting female condoms in HIV voluntary counselling and testing centres in Kenya.

Promotion of male condoms and voluntary counselling and testing for HIV (VCT) have been cornerstones of Kenya's fight against the HIV epidemic. This paper argues that there is an urgent need to promote the female condom in Kenya through VCT centres, which are rapidly being scaled-up across the country and are reaching increasingly large numbers of people. Training of counsellors using a vaginal demonstration model is needed, as well an adequate supply of free female condoms. In a study in five VCT centres, however, counsellors reported that most people they counselled believed female condoms were "not as good" as male condoms. In fact, many clients had little or no knowledge or experience of female condoms. Counsellors' knowledge too was largely based on hearsay; most felt constrained by lack of experience and had many doubts about female condoms, which need addressing. Additional areas that require attention in training include how to re-use female condoms and the value of female condoms for contraception. VCT counsellors in Kenya already promote male condoms as a routine part of risk reduction counselling alongside HIV testing. This cadre, trained in client-centred approaches, has the potential to champion female condoms as well, to better support the right to a healthy and safe sex life.

The preexposure prophylaxis revolution; from clinical trials to programmatic implementation.

PURPOSE OF REVIEW: An investment in preexposure prophylaxis (PrEP) delivery must have public health impact in reducing HIV infections. Sustainable delivery of PrEP requires policy, integration of services, and synergy with other existing HIV prevention programs. This review discusses key policy and programmatic considerations for implementation and scale up of PrEP in Africa. RECENT FINDINGS: PrEP delivery has been delayed by concerns about adherence and delivery in 'real world' settings. Demonstration projects and clinical service delivery models are providing evidence of PrEP effectiveness with an impact much higher than that found in randomized clinical trials. Data confirm that PrEP uptake, adherence, and retention has been high, more so by persons who perceive themselves at high risk for HIV infection, and PrEP is well tolerated. PrEP delivery is more than dispensation of a pill and programs should address other risk drivers, which differ by population. In Africa, barriers to PrEP uptake and adherence include stigma among MSM and low HIV risk perception among young women. Additional data have provided insight into optimal points of service delivery, provider training requirements and quality assurance needs. Of the 2 million new HIV infections in 2014, 70% were in Africa. PrEP use is not lifelong, and use limited to periods of risk may be both effective and cost-effective for the continent. SUMMARY: HIV prevention programs should determine strategies to identify those at substantial risk for HIV infection, formulate and deliver PrEP in combination with interventions that target social drivers of HIV vulnerability specific to each population. Policy guidance for optimal combination of interventions and service delivery avenues, clinical protocols, health infrastructure requirements are required. Cost-effectiveness and efficiency data are essential for policy guidance to navigate ethical questions over use of antiretroviral therapy for HIV-negative individuals when treatment coverage has not been attained in many parts of Africa. Countries need to invest in purposeful advocacy at both local and global forums. Failure to implement PrEP will be a failure to protect future generations.

"How I Wish This Thing Was Initiated 100 Years Ago!" Willingness to Take Daily Oral Pre-Exposure Prophylaxis among Men Who Have Sex with Men in Kenya.

BACKGROUND: The MSM population in Kenya contributes to 15% of HIV incidence. This calls for innovative HIV prevention interventions. Pre-exposure prophylaxis (PrEP) has been efficacious in preventing HIV among MSM in trials. There is limited data on the willingness to take daily oral PrEP in sub-Sahara Africa. PrEP has not been approved for routine use in most countries globally. This study aimed to document the willingness to take PrEP and barriers to uptake and adherence to PrEP in Kenya. The findings will inform the design of a PrEP delivery program as part of the routine HIV combination prevention. METHODS: Eighty MSM were recruited in 2 Counties in December 2013. Quantitative data on sexual behaviour and willingness to take PrEP were collected using semi-structured interviews and analysed using SPSS. Qualitative data on knowledge of PrEP, motivators and barriers to uptake and adherence to PrEP were collected using in-depth interviews and FGDs and analysed using Nvivo. Analysis of data in willingness to take PrEP was conducted on the HIV negative participants (n = 55). RESULTS: 83% of MSM were willing to take daily oral HIV PrEP. Willingness to take PrEP was higher among the bi-sexual and younger men. Motivators for taking PrEP were the need to stay HIV negative and to protect their partners. History of poor medication adherence, fear of side effects and HIV stigma were identified as potential barriers to adherence. Participants were willing to buy PrEP at a subsidized price. CONCLUSIONS: There is willingness to take PrEP among MSM in Kenya and there is need to invest in targeted education and messaging on PrEP to enhance adherence, proper use and reduce stigma in the general population and among policy makers.

Intersectionality and gender mainstreaming in international health: using a feminist participatory action research process to analyse voices and debates from the global south and north.

Critiques of gender mainstreaming (GM) as the officially agreed strategy to promote gender equity in health internationally have reached a critical mass. There has been a notable lack of dialogue between gender advocates in the global north and south, from policy and practice, governments and non-governmental organisations (NGOs). This paper contributes to the debate on the shape of future action for gender equity in health, by uniquely bringing together the voices of disparate actors, first heard in a series of four seminars held during 2008 and 2009, involving almost 200 participants from 15 different country contexts. The series used (Feminist) Participatory Action Research (FPAR) methodology to create a productive dialogue on the developing theory around GM and the at times disconnected empirical experience of policy and practice. We analyse the debates and experiences shared at the seminar series using concrete, context specific examples from research, advocacy, policy and programme development perspectives, as presented by participants from southern and northern settings, including Kenya, Mozambique, India, the Democratic Republic of Congo, Canada and Australia. Focussing on key discussions around sexualities and (dis)ability and their interactions with gender, we explore issues around intersectionality across the five key themes for research and action identified by participants: (1) Addressing the disconnect between gender mainstreaming praxis and contemporary feminist theory; (2) Developing appropriate analysis methodologies; (3) Developing a coherent theory of change; (4) Seeking resolution to the dilemmas and uncertainties around the 'place' of men and boys in GM as a feminist project; and (5) Developing a politics of intersectionality. We conclude that there needs to be a coherent and inclusive strategic direction to improve policy and practice for promoting gender equity in health which requires the full and equal participation of practitioners and policy makers working alongside their academic partners.

Sharing experiences and dilemmas of conducting focus group discussions on HIV and tuberculosis in resource-poor settings.

Focus group discussions (FGD) are gaining in popularity in research on HIV and tuberculosis (TB) internationally as researchers seek to understand the experiences, needs and perspectives of people living with TB and/or HIV as well as their carers within the community and health sector. Conducting FGDs in resource-poor settings with vulnerable participants who are living with diseases that are frequently stigmatised poses multiple challenges. Our approach in this discussion paper is to follow the research cycle to present the practical experience of research teams using FGDs in TB and HIV in resource-poor contexts in Africa and Asia in order to contribute to effective practice. The approach highlights dilemmas and shares effective practice for negotiating initial discussions with different communities, constructing sampling frames and samples, choosing a facilitator, encouraging discussion, ethics, translation, pitfalls and dissemination. We demonstrate the techniques and adaptations needed to ensure that FGDs provide rich, high-quality and policy-relevant data on the voices and perspectives of people living with HIV and TB, community groups and health workers within the challenges of resource-poor settings. In applying theory to develop good practice in FGDs across the research cycle, a critical and reflexive approach is needed.

Bypassing districts? Implications of sector-wide approaches and decentralization for integrating gender equity in Uganda and Kenya.

While the concept of gender mainstreaming has gained acceptance among many national and international development organizations, many obstacles are faced in translating the concept into tangible improvements in the health and well-being of women and men. This paper presents two qualitative case studies, one from Kenya and one from Uganda, of experiences of mainstreaming gender at district level; experiences which are set against the context of decentralization and sector-wide approaches (SWAPs). The conceptual framework of social movement theory, as used by Hafner-Burton and Pollack, is drawn upon to analyze the findings of both case studies. This paper has been written in conjunction with a paper by Theobald et al. which explores gender mainstreaming at national level.