Fertility desires and sexual behaviours among women recovering from genital fistula repair in Eldoret, Kenya.

OBJECTIVES: The reproductive desire of women following genital fistula repair surgery is complex, varied and often not addressed, although it carries significant consequences. The aim of this study was to better understand the fertility desires and sexual behaviours of women who recently underwent surgical repair of a genital fistula. METHODS: This is a secondary analysis of a retrospective cohort study designed to assess the effectiveness of Beyond Fistula, a reintegration programme for women recovering from genital fistula surgery in Eldoret, Kenya. One hundred women who participated in the Beyond Fistula programme between 2013 and 2019 were interviewed in person regarding future fertility desire, current sexual behaviour and contraceptive use. RESULTS: Among the 79 reproductive-aged women included in this study, 63.3% reported no future desire for pregnancy. Those that desired another pregnancy were significantly younger (48.3% were 18-29 years old vs. 66.0% were 35 years old or more, p = 0.004), had fewer living children (70% had 0-2 children vs. 56% had 3 or more children, p < 0.001), and a lower level of food insecurity (27.6% reported no to marginal insecurity vs. 14%, p = 0.014). Current sexual activity was marginally different between women who did and did not desire future pregnancy (82.8% vs. 66.0%, p = 0.053). Of the 50 women in our study who did not desire pregnancy, 62.0% were sexually active and of these, only 38.7% were preventing pregnancy. Lack of knowledge and access to methods were most commonly cited as barriers to use. CONCLUSIONS: Many women recovering from genital fistula surgery do not desire pregnancy and are sexually active but are not using a method to prevent pregnancy. The potential for post-surgical reintegration programmes to address education and access to contraception is a vital and unmet need to promote reproductive empowerment in this population of women as they reestablish their lives.

Mothers of adolescent girls and Human Papilloma Virus (HPV) vaccination in Western Kenya.

INTRODUCTION: human papilloma virus (HPV) which is preventable is the main cause of cervical cancer and it targets mostly young adolescents. The study was to determine the practice desire, attitude and knowledge of mothers of adolescent girls on HPV vaccination in Western Kenya. METHODS: this was a descriptive cross-sectional study design. Data was obtained using semi-structured questionnaires and analyzed using both descriptive and inferential statistics at 95% confidence level using the SPSS software version 22. A p-value ≤ 0.05 was considered statistically significant. RESULTS: ninety five percent of the mothers had intentions to vaccinate their daughters and also had a positive attitude and their response to HPV vaccination was significantly lower than those without intentions p=0.02, 95% CI, OR=0.48 (0.90-0.89). Vaccination against HPV was low at 9.4% with a mean age of 34 years. Our results found a high level of cervical cancer awareness (85.0%), HPV and vaccine awareness respectively (62.0%, and 64.0%). "Vaccination of my daughters will prompt early sexual activity and the cost of HPV vaccination being a barrier to vaccination" had a statistically significant influence on the practice of vaccination. Negative attitude to daughters´ early onset of sexual activity significantly reduced up take while positive attitude to cost of HPV vaccine significantly increased up take of HPV vaccination with p value of 0.007 and 0.04 respectively. CONCLUSION: awareness of HPV and HPV vaccine prevention is low among mothers of adolescent girls in Western Kenya. There was a positive attitude and high desire towards the use of HPV vaccination therefore a need for awareness, policy and unify efforts to reduce cervical cancer burden.

Knowledge of Cervical Cancer and Acceptability of Prevention Strategies Among Human Papillomavirus-Vaccinated and Human Papillomavirus-Unvaccinated Adolescent Women in Eldoret, Kenya.

Cervical cancer is a critical public health concern in sub-Saharan Africa. Adolescents are key targets in primary prevention strategies. Following a human papillomavirus (HPV) vaccination initiative (Gardasil) in Eldoret, Kenya, the knowledge and source of information of cervical cancer and acceptance of prevention strategies among vaccinated and unvaccinated adolescents were evaluated. A cross-sectional comparative study enrolled 60 vaccinated and 120 unvaccinated adolescent women. Institutional ethical approval was obtained and signed consent was obtained from the parents. Data collection was performed using interviewer-administered questionnaires derived from factual statements based on information from print material used for community sensitization on cervical cancer. The median age of the participants was 14.0 years (interquartile range [IQR] = 13.0-15.0). Of 60 vaccinated adolescents, 56 (93.3%) had heard of the HPV vaccine compared with 6 (5%) of unvaccinated participants (p < 0.001). Of 60 vaccinated participants, 58 (96.7%) had heard of cervical cancer compared with 61 (50.8%) unvaccinated participants (p < 0.001). Both cohorts identified the school as the main source of information for cervical cancer. The two groups also showed similarity in their selection of cervical cancer prevention strategies acceptable to them such as delaying sexual debut, limiting number of sexual partners, and use of condoms for protection against sexually transmitted infections. Of 120 unvaccinated participants, 63.7% expressed willingness to be vaccinated. Exposure to the HPV vaccine was associated with a higher knowledge of cervical cancer. The adolescents predominantly rely on the school for health information. Both cohorts of adolescents showed remarkable acceptability for cervical cancer prevention strategies.

Effects of malaria/helminthic coinfections on cervical cancer progression among sub Saharan African women on highly active antiretroviral therapy: A scoping review.

In Africa, the HIV prevalence in rural areas has begun to reach levels estimated within urban settings, where women are also more at risk for both malaria and intestinal parasitic infections. The objective of this review is to assess whether concomitant infections with malaria and/or helminthic diseases have an impact on cervical disease progression in women on HAART. This scoping review was conducted in August 2018. To conduct this scoping review, we searched the relevant studies in electronic databases such as PUBMED, Global Health, EMBASE, CINAHL and SCOPUS published in the year between 1960 and 2018 using the following search terms HAART AND malaria OR Helminth and Female OR women. Eight studies qualified for this review. The literature underscores the need for women on HAART with multiple co-infections to use adjuncts to retain immune recovery and undetectable HIV viral load, to reduce risk of cervical disease progression. A trend for higher risk of CIN3+ in HIV+ women reporting recent malarial infection was observed in one study. Given the public health impact of synergistic interactions between malaria and helminthic infections in HIV/HPV co-infected women on HAART, it is urgent that these interactions are elucidated.

Correction to: Multiple HPV infections in female sex workers in Western Kenya: implications for prophylactic vaccines within this sub population.

[This corrects the article DOI: 10.1186/s13027-016-0114-5.].

Pattern of Ureteric Pathology Presenting to a Fistula Centre in Western Kenya.

BACKGROUND: Ureteric pathology arises from surgical misadventures, trauma, and congenital anomalies. Early detection and treatment is of the essence. OBJECTIVES: To determine the types/etiology and outcome of ureteric pathology presenting to Gynocare Fistula Centre, Eldoret, Kenya. METHODS: Descriptive retrospective study that evaluated patients presenting with ureteric pathology at Gynocare between 1st January 2012 and 31st December 2016. We pulled out patient charts and extracted and analyzed relevant data using STATA 13E statistical software. RESULTS: We analyzed 33 charts, and their age ranged from 10 to 58 years. Annual proportion for 2012, 2013, 2014, 2015, and 2016 was 2.5%, 2.8%, 1.2%, 1.4%, and 3.0% respectively among all the fistula patients treated in the hospital. All the patients presented with urinary incontinence, and 7 (21.2%) had flank pain. Iatrogenic injuries contributed 84.8% (28), and 3 (9.1%) were congenital while trauma and infection had 1 each. Of those resulting from surgical misadventures, 17 (60.7%) were from obstetric while 11 (39.2%) were from gynecological surgery. All the injuries were in the distal third of the ureter; 5 were bilateral; and 11 were left sided while 17 were right-sided. Repair and/or reimplantation was successful in 31 (93.93%) of the patients. CONCLUSION: Highest proportion of ureteric pathologies was accounted for by iatrogenic causes and surgical repair and/or reimplantation has a high success rate.

Determinants of breast cancer early detection for cues to expanded control and care: the lived experiences among women from Western Kenya.

BACKGROUND: Estimately, 70-80% of cancer cases are diagnosed in late stages in Kenya with breast cancer being a common cause of mortality among women where late diagnosis is the major ubiquitous concern. Numerous studies have focused on epidemiological and health policy dynamics essentially underestimating the determining factors that shape people's choices and cues to health care service uptake. The study sought to evaluate the knowledge, attitude and health seeking behavior towards breast cancer and its screening in a quest to explain why women present for prognosis and treatment when symptomatic pointers are in advanced stages, impeding primary prevention strategies. METHODS: Eight focus groups (6-10 members per group) and four key informant interviews were conducted among adult participants from rural and urban settings. Sessions were audio-recorded and transcribed. A thematic analysis of the data was based on the concepts of the health belief model. Data analysis was conducted using NVIVO10. RESULTS: Most women perceived breast cancer as a fatal disease and conveyed fear of having early screening. Rural women preferred self-prescribed medications and the use of alternative medicine for long periods before presenting for professional care on suspicion that the lump is cancerous. Accessibility to equipped health facilities, lack of information to establish effective follow-up treatment and low-income status were underscored as their major health seeking behavior barriers whereas, urban women identified marital status as their main barrier. Key informant interviews revealed that health communication programs emphasized more on communicable diseases. This could in part explain why there is a high rate of misconception and suspicion about breast cancer among rural and urban women in the study setting. CONCLUSIONS: Creating breast cancer awareness alongside clear guidelines on accessing screening and treatment infrastructure is critical. It was evident, a diagnosis of breast cancer or lump brings unexpected confrontation with mortality; fear, pain, cultural barriers, emotional and financial distress. Without clear referral channels to enable those with suspicious lumps or early stage disease to get prompt diagnosis and treatment, then well-meaning awareness will not necessarily contribute to reducing morbidity and mortality.

Uptake of three doses of HPV vaccine by primary school girls in Eldoret, Kenya; a prospective cohort study in a malaria endemic setting.

BACKGROUND: All women are potentially at risk of developing cervical cancer at some point in their life, yet it is avoidable cause of death among women in Sub- Saharan Africa with a world incidence of 530,000 every year. It is the 4th commonest cancer affecting women worldwide with over 260,000 deaths reported in 2012. Low resource settings account for over 75% of the global cervical cancer burden. Uptake of HPV vaccination is limited in the developing world. WHO recommended that 2 doses of HPV vaccine could be given to young girls, based on studies in developed countries. However in Africa high rates of infections like malaria and worms can affect immune responses to vaccines, therefore three doses may still be necessary. The aim of this study was to identify barriers and facilitators associated with uptake of HPV vaccine. METHODS: A cross-sectional survey was conducted at Eldoret, Kenya involving 3000 girls aged 9 to 14 years from 40 schools. Parents/guardians gave consent through a questionnaire. RESULTS: Of all 3083 the school girls 93.8% had received childhood vaccines and 63.8% had a second HPV dose, and 39.1% had a third dose. Administration of second dose and HPV knowledge were both strong predictors of completion of the third dose. Distance to the hospital was a statistically significant risk factor for non-completion (P: 0.01). CONCLUSIONS: Distance to vaccination centers requires a more innovative vaccine-delivery strategy and education of parents/guardians on cervical screening to increase attainment of the HPV vaccination.

Public health approach to prevent cervical cancer in HIV-infected women in Kenya: Issues to consider in the design of prevention programs.

Women living with HIV in Africa are at increased risk to be co-infected with Human Papilloma Virus (HPV), persistent high risk (HR) HPV infection and bacterial vaginosis (BV), which compounds HPV persistence, thereby increasing the risk for cervical dysplasia. New guidance from WHO in 2014 advocating for a "screen and treat" approach in resource poor settings is becoming a more widely recommended screening tool for cervical cancer prevention programs in such contexts. This review article summarizes the risk factors to be considered when designing a primary and secondary cervical prevention program in a post-vaccination era for HIV-infected women in Kenya. This review article is based on our prior research on the epidemiology of pHR/HR-HPV genotypes in HIV-infected women and CIN 2 + in Kenya and other sub-Saharan contexts. In order to contextualize the findings, a literature search was carried out in March 2017 by means of four electronic databases: PUBMED, EMBASE, SCOPUS, and PROQUEST. Risk factors for potential (pHR)/HR HPV acquisition, including CD4 count, HAART initiation, Female Sex Worker status (FSW) and BV need to be considered. Furthermore, there may be risk factors for abnormal cytology, including FSW status, multiple potential (p)HR/HR HPV genotypes, which may require that HIV-infected women be subjected to screening at more frequent intervals than the three year recommended by the WHO. The quadruple synergistic interaction between HIV, HPV and BV and its related cervicitis may need to be reflected within a larger prevention framework at the community level. The opportunities brought forth by the roll out of HAART could lead to task shifting of HIV-HPV-BV care to nurses, which may increase access in poorly-served areas.

Multiple HPV infections in female sex workers in Western Kenya: implications for prophylactic vaccines within this sub population.

BACKGROUND: Whilst the imputed role of High Risk (HR) HPV infection in the development of cervical lesions and cancer has been established, the high number of HPV genotypes that Female Sex workers (FSW) harbour warrants that the synergistic effects of potential HR (pHR) and HR HPV genotypes be elucidated to assess the potential impact of prophylactic vaccines. This population in Kenya also harbours a number of other vaginal infections and STIs, including bacterial vaginosis (BV), trichomonas vaginalis (TV) and candida spp. The aims of this cross-sectional analysis in Kenya are to explore the epidemiology of abnormal cytology and the pairing of pHR/HPV genotypes in HIV-negative and HIV-infected FSW. METHODS: A cross-sectional study design of 616 FSW from Western Kenya aged between 18 and 61 years during 2009-2015 using a peer recruitment sampling strategy. RESULTS: Of the 599 FSW who underwent cytological examination, 87 had abnormal cytology (14.5%; 95% CI: 12.0-17.6%). A combined prevalence of HPV16 and 18 (29.6%; 95% CI: 22.2-37.8%) was observed in abnormal cytology. HPV 53 and 51 were the most observed pairing in FSW with abnormal cytology. Significant adjusted associations were found between abnormal cytology and TV (aOR: 30; 95% CI: 14.1-62.9), multiple HR HPV (aOR: 3.7; 95% CI: 1.9-7.3), HPV 51 (aOR 3.7; 95% CI 1.6-8.6) and HPV 52 (aOR 6.1; 95% CI: 2.8-13.3). CONCLUSION: HPV 51 and 52 were independently associated with abnormal cervical cytology in both HIV negative/positive FSW. The strong association between TV and cervical dysplasia and the high percentage of FSW harbouring more than one STI underscore the need for enhanced STI management within the framework of cervical cancer prevention.

Associations Between Vaginal Infections and Potential High-risk and High-risk Human Papillomavirus Genotypes in Female Sex Workers in Western Kenya.

PURPOSE: Infection with and persistence of high-risk human papillomavirus (HR HPV) are the strongest risk factors for cervical cancer. Little is known about the prevalence and role of concurrent sexually transmitted infections (STIs) found in HPV-infected female sex workers (FSW) in Africa. This study purports to test our a priori hypotheses that STIs are associated with genotypes pertaining to the α-group species 9. The objectives were to determine the prevalence of bacterial vaginosis (BV), Trichomonas vaginalis, and Candida spp in FSW, the association between these STIs and the prevalence of any potential HR and HR HPV genotypes in FSWs. METHODS: A cross-sectional study design of 616 FSW from Western Kenya aged between 18 and 61 years during 2009-2015 using a peer recruitment sampling strategy. Inclusion criteria for the study entailed female sex and >18 years of age and having engaged in transactional sex in exchange for money, goods, services, or drugs in the last 3 months. Women were excluded if they were pregnant, <18 years of age, had a history of cervical dysplasia or cancer, had current abnormal bleeding, or had a hysterectomy. FINDINGS: Of the FSW, 33.3% had HIV and 57.7% harbored a potential HR and HR HPV genotype. The 2 most prevalent potential HR and HR genotypes were HPV 16 (16.10%) and HPV 59 (12.20%). BV was the most common infection (48.3%), followed by Trichomonas vaginalis (31.4%) and Candida spp (19.9%). A multivariate regression revealed significant associations with both α-group 9 and 6; BV and HPV 58 (adjusted odds ratio [aOR] = 2.3; 95% CI, 1.0-5.2; P = 0.05), Trichomonas vaginalis and HPV 31 and HPV 35 (aOR = 2.0; 95% CI, 1.0-3.8; P = 0.04 and aOR = 1.8; 95% CI, 1.0-3.3, P = 0.05 respectively); and between Candida spp and HPV 53 (aOR = 2.0; 95% CI, 1.1-4.0; P = 0.03) and 16 (aOR = 1.9; 95% CI, 1.1-3.3; P = 0.03). IMPLICATIONS: Snowball sampling may have inadvertently excluded FSW less likely to benefit from a social network. Significant associations between BV and HPV 58 and between Candida spp and HPV 16 and 53 suggest the need for sexually transmitted disease management within a cervical cancer prevention program. The probable synergistic effects of the vaginal microbiota should be elucidated, especially within this vulnerable population. Given the potential for FSW to transmit STIs, robust epidemiologic sampling methods are urgently required that account for the heterogeneity of the FSW population.

Epidemiology of HPV Genotypes among HIV Positive Women in Kenya: A Systematic Review and Meta-Analysis.

BACKGROUND: There is a scarcity of data on the distribution of human papillomavirus (HPV) genotypes in the HIV positive population and in invasive cervical cancer (ICC) in Kenya. This may be different from genotypes found in abnormal cytology. Yet, with the advent of preventive HPV vaccines that target HPV 16 and 18, and the nonavalent vaccine targeting 90% of all ICC cases, such HPV genotype distribution data are indispensable for predicting the impact of vaccination and HPV screening on prevention. Even with a successful vaccination program, vaccinated women will still require screening to detect those who will develop ICC from other High risk (HR) HPV genotypes not prevented by current vaccines. The aim of this review is to report on the prevalence of pHR/HR HPV types and multiple pHR/HR HPV genotypes in Kenya among HIV positive women with normal, abnormal cytology and ICC. METHODS: PUBMED, EMBASE, SCOPUS, and PROQUEST were searched for articles on HPV infection up to August 2nd 2016. Search terms were HIV, HPV, Cervical Cancer, Incidence or Prevalence, and Kenya. RESULTS: The 13 studies included yielded a total of 2116 HIV-infected women, of which 89 had ICC. The overall prevalence of pHR/HR HPV genotypes among HIV-infected women was 64% (95%CI: 50%-77%). There was a borderline significant difference in the prevalence of pHR/HR HPV genotypes between Female Sex workers (FSW) compared to non-FSW in women with both normal and abnormal cytology. Multiple pHR/HR HPV genotypes were highly prominent in both normal cytology/HSIL and ICC. The most prevalent HR HPV genotypes in women with abnormal cytology were HPV 16 with 26%, (95%CI: 23.0%-30.0%) followed by HPV 35 and 52, with 21% (95%CI: 18%-25%) and 18% (95%CI: 15%-21%), respectively. In women with ICC, the most prevalent HPV genotypes were HPV 16 (37%; 95%CI: 28%-47%) and HPV 18 (24%; 95%CI: 16%-33%). CONCLUSION: HPV 16/18 gains prominence as the severity of cervical disease increases, with HPV 16/18 accounting for 61% (95%CI: 50.0%-70.0%) of all ICC cases. A secondary prevention program will be necessary as this population harbors multiple pHR/HR HPV co-infections, which may not be covered by current vaccines. A triage based on FSW as an indicator may be warranted.

The Bakri tamponade balloon as an adjunct treatment for refractory postpartum hemorrhage.

OBJECTIVE: To evaluate the Bakri tamponade balloon as an adjunct treatment for refractory postpartum hemorrhage (PPH). METHODS: A prospective observational intervention study was conducted between January 1, 2013, and May 31, 2015, at Great Lakes Hospital and Moi Teaching and Referral Hospital in Kenya. Eligible participants were diagnosed with PPH (blood loss >500mL after vaginal or >1000mL after cesarean delivery, and/or hemodynamic changes suggestive of excessive blood loss) unresponsive to standard intervention and were treated using the Bakri balloon. Case report forms were completed for all participants. The primary endpoint was the frequency of surgery after use of the Bakri balloon. RESULTS: Among 58 patients, postpartum bleeding was controlled without further surgical intervention in 55 (95%). Among the 55 women with uterine atony, the Bakri balloon successful controlled PPH in 52 (95%). Two of the three hysterectomies performed were for continued bleeding after placement of the Bakri tamponade balloon. Four maternal deaths occurred. CONCLUSION: The Bakri tamponade balloon proved an effective adjunct in the management of refractory PPH.

Distribution of human papillomaviruses and bacterial vaginosis in HIV positive women with abnormal cytology in Mombasa, Kenya.

BACKGROUND: HPV is the major etiological factor in the causal pathway for cervical cancer, which is the leading cancer among women in sub-Saharan Africa. HIV is associated with a higher prevalence and a broader range of high-risk HPV genotypes. Studies have shown a positive association between Bacterial vaginosis (BV) and HPV and HIV. Also, in African women, BV was found to be significantly associated with vaginal inflammation. The high prevalence of BV, HIV and HPV infections in the African continent makes elucidation of the interactions with one another of utmost public health interest. The aims of the current study are to examine the frequency of HPV genotypes and BV as well as their respective risk factors within an HIV infected population with abnormal cytology in the resource-constrained setting of Mombasa, Kenya and, secondly, highlight issues to consider for triple co-infection clinical management. METHOD: Cross-sectional analysis with a sample drawn from an ongoing cohort study. All consenting, non-pregnant HIV infected women, between 18 and 50 years of age, without a history of cervical cancer or hysterectomy, between November 2005 and April 2006 were screened for HR HPV DNA in Mombasa, Kenya. 1 out of 4 HIV positive women fulfilled the criteria by having SIL (24.9 %). 600 HIV infected women were tested to reach a cohort of 74 HIV women with abnormal cytology. To assess which factors were associated with HR HPV, crude statistical analysis was performed through logistic regression. RESULTS: Bacterial vaginosis (BV) was found in 46 women out of 74 (62.2 %). Cervicitis was diagnosed in 15 % of women (n = 11), of which 8 had BV. The most prevalent HPV genotypes were HPV 16 (33.8), HPV 53 (24.3) and HPV 18 (17.6 %), while 65 % of the participants had multiple genotype infection. Statistically significant associations between CD4 counts <200 cells/µl and multiple HPV prevalence, adjusted for age were also noted (OR = 3.7; 95 CI: 1.2-12.1; p = 0.03) and HPV53 (OR = 4.4, 95 % CI: 1.4-13.6; p = 0.01). A statistically significant association was found between CD4 count ≥ 350 µl and HPV 16 adjusted for age (OR = 2.9; 95 % CI: 1.0- 8.3; p = 0.05). A borderline statistically significant association was observed between BV and HPV58 (crude OR = 4.1, 95 % CI: 0.8-21.0; p = 0.07). CONCLUSION: The most prevalent HPV genotypes observed were HPV 16, HPV 53, and HPV 18, which have a combined prevalence of 76 %. Our results show that a triage based on CD4 count should start at CD4 count ≥ 350 µl as our study suggests that HPV 16 are more prevalent when women are moderately immunosuppressed. Given the high prevalence of HPV 53 in a HIV infected population with abnormal cytology, its cervical carcinoma genesis potential as a stand-alone genotype and as well as its synergism with multiple infections should be investigated. The new WHO guideline in resource-poor settings to rescreen women for HPV within ten years may be more effective if BV and cervicitis management become a major component for HIV-HPV management.

Determinants of acceptance and subsequent uptake of the HPV vaccine in a cohort in Eldoret, Kenya.

The development of Human Papillomavirus (HPV) vaccines provides new opportunities in the fight against cervical cancer. Many acceptability studies have revealed high interest in these vaccines, but acceptance is only a precursor of behavior, and many factors, at personal, community and provider level, may inhibit the translation of willingness to vaccinate into actual uptake. Through a longitudinal study in Eldoret, Kenya, HPV vaccine acceptability was measured before a vaccination program (n = 287) and vaccine uptake, as reported by mothers, once the program was finished (n = 256). In between baseline and follow-up, a pilot HPV vaccination program was implemented via the GARDASIL Access Program, in which parents could have their daughter vaccinated for free at the referral hospital. The program was promoted at schools: Health staff informed teachers who were then asked to inform students and parents. Even though baseline acceptance was very high (88.1%), only 31.1% of the women reported at follow-up that their daughter had been vaccinated. The vaccine was declined by 17.7%, while another 51.2% had wanted the vaccination but were obstructed by practical barriers. Being well-informed about the program and baseline awareness of cervical cancer were independently associated with vaccine uptake, while baseline acceptance was correlated in bivariate analysis. Side effects were of great concern, even among those whose daughter was vaccinated. Possible partner disapproval lowered acceptance at baseline, and women indeed reported at follow-up that they had encountered his opposition. In Kenya, women prove to be very willing to have their daughter vaccinated against cervical cancer. However, in this study, uptake was more determined by program awareness than by HPV vaccine acceptance. School-based vaccination might improve coverage since it reduces operational problems for parents. In addition, future HPV vaccination campaigns should address concerns about side effects, targeting men and women, given both their involvement in HPV vaccination decision-making.

Characteristics and surgical success of patients presenting for repair of obstetric fistula in western Kenya.

OBJECTIVE: To carry out a large-scale retrospective review of patients who had undergone surgical repair of obstetric fistula in Kenya to determine patient characteristics and determinants of successful surgical repair. METHODS: The patient records of 483 surgical repairs of obstetric fistula treated by a single surgeon (H.M.) between January 2005 and July 2010 at 3 medical centers in western Kenya were retrospectively reviewed. Descriptive and bivariate statistical analyses were performed. RESULTS: Young women with some primary or no education and prolonged labor at the time of first delivery were most highly correlated with obstetric fistula formation. Success of fistula closure was 86% for first-time vesicovaginal fistula (VVF) repairs and 67% for first-time VVF combined with rectovaginal fistula (RVF) repairs. Among women who had previously attempted VVF or combined VVF/RVF repairs, 73% and 50% of fistulas, respectively, were repaired successfully. First-time repair was significantly associated with surgical success compared with patients with a history of previous repair attempts (P=0.027). CONCLUSION: Among Kenyan women presenting for fistula repair, fistula most was most highly correlated with a low level of education and prolonged labor. The findings are consistent with results reported from other countries in Sub-Saharan Africa.

Comparison of conventional cervical cytology versus visual inspection with acetic acid among human immunodeficiency virus-infected women in Western Kenya.

OBJECTIVE: This study aimed to determine the accuracy of visual inspection with acetic acid (VIA) versus conventional Pap smear as a screening tool for cervical intraepithelial neoplasia/cancer among human immunodeficiency virus (HIV)-infected women. MATERIALS AND METHODS: A total of 150 HIV-infected women attending the Moi Teaching and Referral Hospital HIV clinic in Eldoret underwent conventional Pap smear, VIA, colposcopy, and biopsy. Both VIA and Pap smears were done by nurses, whereas colposcopy and biopsy were done by a physician. Receiver operating characteristic analysis was conducted to compare the accuracies between VIA and Pap smear in sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: Among the study participants: VIA was abnormal in 55.3% (83/150, 95% confidence interval [CI] = 47.0%-63.5%); Pap smear showed atypical squamous cells of undetermined significance or worse in 43.7% (59/135, 95% CI = 35.2%-52.5%) and 10% (15/150) of the Pap smears were unsatisfactory. Of the abnormal Pap smears, 3% (2/59) had atypical squamous cells of undetermined significance, 7% (4/59) had high-grade atypical squamous cells, 60% (35/59) had low-grade squamous intraepithelial lesions, 29% (17/59) had high-grade squamous intraepithelial lesions, and 2% (1/59) was suspicious for cervical cancer. Using cervical intraepithelial neoplasia 2 or higher disease on biopsy as an end point, VIA has a sensitivity of 69.6% (95% CI = 55.1%-81.0%), specificity of 51.0% (95% CI = 41.5%-60.4%), PPV of 38.6% (95% CI = 28.8%-49.3%), and NPV of 79.1% (95% CI = 67.8%-87.2%). For conventional Pap smear, sensitivity was 52.5% (95% CI = 42.1%-71.5%), specificity was 66.3% (95% CI = 52.0%-71.2%), PPV was 39.7% (95% CI = 27.6%-51.8%), and NPV was 76.8% (95% CI = 67.0%-85.6%). CONCLUSIONS: Visual inspection with acetic acid is comparable to Pap smear and acceptable for screening HIV-infected women in resource-limited settings such as Western Kenya.

Retrospective review of predisposing factors and surgical outcomes in obstetric fistula patients at a single teaching hospital in Western Kenya.

OBJECTIVE: We examined success rates and complications of obstetric fistula (OF) surgical repairs in association with patient and fistula characteristics, including sociocultural and socioeconomic determinants of health. A better understanding of these associations will help guide surgical management and prevent predisposing factors. METHODS: We reviewed the medical records of 86 patients who underwent OF repair at Moi Teaching and Referral Hospital in Kenya between 1999 and 2007. RESULTS: Women with OF presented for repair with a variety of concurrent conditions. Seventy-eight percent had laboured for at least 24 hours; 29% had undergone previous unsuccessful surgery. Of the women who presented at postoperative follow-up, 54% still complained of incontinence. Persistent incontinence was associated with larger, more complicated fistulas and having had previous failed attempts at surgical repair. CONCLUSION: The association of factors such as duration of labour with OF reflects the limited availability of obstetrical care in Western Kenya. There is a significant difference in postoperative success of fistula repair between women with large fistulas or those who had previous failed surgery and other patients. This reflects the importance of primary and secondary prevention.

A code of ethics for the fistula surgeon.

Vesicovaginal fistulas from obstructed labor no longer exist in wealthy industrialized countries. In the impoverished countries of sub-Saharan Africa and south Asia obstetric fistulas continue to be a prevalent clinical problem. As many as 3.5 million women may suffer from this condition and few centers exist that can provide them with competent and compassionate surgical repair of their injuries. As this situation has become more widely known in the industrialized world, increasing numbers of surgeons have begun traveling to poor countries to perform fistula operations. To date, these efforts have been carried out largely by well-intentioned individuals, acting alone. An international community of fistula surgeons who share common goals and values is still in the process of being created. To help facilitate the development of a common ethos and to improve the quality of care afforded to women suffering from obstetric fistulas, we propose a Code of Ethics for fistula surgeons that embraces the fundamental principles of beneficence, non-maleficence, respect for personal autonomy, and a dedication to the pursuit of justice.