"I never thought that it would happen " Experiences of HIV seroconverters among HIV-discordant partnerships in a prospective HIV prevention study in Kenya.

In spite of access to behavioral and biomedical HIV prevention strategies, HIV transmission occurs. For HIV-serodiscordant couples, prevention programs can be tailored to address individual and couples' needs to preserve their relationship while minimizing HIV risk. Programs for serodiscordant couples may benefit from learning from experiences of couples who transmit HIV. We conducted 20 individual in-depth interviews with 10 initially HIV-serodiscordant couples who transmitted HIV during prospective follow-up at a peri-urban research site in Thika, Kenya. Data were analyzed inductively to identify situations that led to prevention failure and coping mechanisms. Inconsistent condom use driven by low HIV risk perception and alcohol use often preceded seroconversion while persistent blame frequently hindered couples' communication soon after seroconversion. In this emerging era of antiretroviral-based HIV prevention, couples' counseling can capitalize on opportunities to foster a supportive environment to discuss initiation and adherence to time-limited pre-exposure prophylaxis and lifelong antiretroviral therapy, in addition to strategies to reduce alcohol use, diffuse blame, and use condoms.

My intention was a child but I was very afraid: fertility intentions and HIV risk perceptions among HIV-serodiscordant couples experiencing pregnancy in Kenya.

We sought to understand fertility intentions and HIV risk considerations among Kenyan HIV-serodiscordant couples who became pregnant during a prospective study. We conducted individual in-depth interviews (n = 36) and focus group discussions (n = 4) and performed qualitative data analysis and interpretation using an inductive approach. Although most of the couples were aware of the risk of horizontal and vertical HIV transmission, almost all couples reported that they had intended to become pregnant and that the desire for children superseded HIV risk considerations. Motivations for pregnancy were numerous and complex: satisfying desired family size, desire for biological children, maintaining stability of the union, and sociocultural pressures. Couples desired strategies to reduce HIV risk during conception, but expressed hesitation toward assisted reproductive technologies as unnatural. HIV prevention programs should therefore address conception desires and counsel about coordinated periconception risk-reduction strategies.

Prevention of mother-to-child transmission of HIV: assessing the accuracy of routinely collected data on maternal antiretroviral prophylaxis coverage in Kenya.

OBJECTIVE: To explore the accuracy of routinely collected prevention of mother-to-child transmission of HIV (PMTCT) coverage data in Kenya. METHODS: In case studies at two government hospitals, the authors reviewed national reporting guidelines, interviewed nurses and undertook a retrospective analysis of routine hospital data from antenatal care, maternity and HIV services from January 2009 to June 2010. Each woman attending these services was given a unique study number to enable analysis of her recorded use of PMTCT services across different hospital visits. These data were compared with the hospitals' monthly PMTCT reports to the district. RESULTS: Where a woman made more than one visit, PMTCT drug provision could be reported multiple times for the same woman, and women known to be HIV positive prior to pregnancy were omitted from the denominator of PMTCT coverage calculations. Practices for reporting data on maternal PMTCT prophylaxis provision varied in the two hospitals. According to the study data, using the hospital registers and accounting for multiple visits by the same woman, 642 women were known to have HIV and 412 (64%) were given maternal PMTCT prophylaxis. According to the monthly reports, 430 women were diagnosed as having HIV in pregnancy-related services and 538 (125%) were given maternal PMTCT prophylaxis. CONCLUSIONS: If replicated elsewhere, these reporting practices could lead to overestimation of national PMTCT coverage. Simple yet accurate routine data collection systems are needed to monitor PMTCT coverage accurately and to highlight where changes need to be made so as to ensure that infants are born HIV free.

Facilitators, context of and barriers to acute coronary syndrome care at Kenyatta National Hospital, Nairobi, Kenya: a qualitative analysis.

BACKGROUND: The prevalence of ischaemic heart disease and its acute manifestation, acute coronary syndrome (ACS), is growing throughout sub-Saharan Africa, including Kenya. To address this increasing problem, we sought to understand the facilitators, context of and barriers to ACS care at Kenyatta National Hospital, with the aim of improving the quality of care of ACS. METHODS: We conducted in-depth interviews with healthcare providers involved in the management of ACS patients from January to February 2017 at Kenyatta National Hospital in Nairobi, Kenya. We selected an initial sample of key participants for interviewing and used a snowballing technique to identify additional participants until we achieved saturation. After transcription of audio recordings of the interviews, two authors conducted data coding and analysis using a framework approach. RESULTS: We conducted 16 interviews with healthcare providers. Major themes included the need to improve the diagnostic and therapeutic capabilities of the hospital, including increasing the number of ECG machines and access to thrombolytics. Participants highlighted an overall wide availability of other guideline-directed medical therapies, including antiplatelets, beta-blockers, statins, anticoagulants and ACE inhibitors. All participants also stated the need for and openness to accepting future interventions for improvement of quality of care, including checklists and audits to improve ACS care at Kenyatta National Hospital. CONCLUSION: Major barriers to ACS care at Kenyatta National Hospital include inadequate diagnostic and therapeutic capabilities, lack of hospital-wide ACS guidelines, undertraining of healthcare providers and delayed presentation of patients seeking care. We also identified potential targets, including checklists and audits for future improvements in quality of care from the perspective of healthcare providers.

I Knew I Would Be Safer. Experiences of Kenyan HIV Serodiscordant Couples Soon After Pre-Exposure Prophylaxis (PrEP) Initiation.

Pre-exposure prophylaxis (PrEP) for HIV-uninfected persons is highly efficacious for HIV prevention. Understanding how people at risk for HIV will use PrEP is important to inform PrEP scale-up and implementation. We used qualitative methods to gather insights into couples' early experiences with PrEP use within the Partners Demonstration Project, an open-label implementation study evaluating integrated delivery of PrEP and antiretroviral therapy (ART). PrEP is offered to HIV uninfected partners until the HIV-infected partner initiates and sustains ART use (i.e., PrEP as a "bridge" to ART initiation and viral suppression). From August 2013 to March 2014 we conducted 20 in-depth dyadic interviews (n = 40) with heterosexual HIV serodiscordant couples participating at the Thika, Kenya study site, exploring how couples make decisions about using PrEP for HIV prevention. We developed and applied deductive and inductive codes to identify key themes related to experiences of PrEP initiation and use of time-limited PrEP. Couples reported that PrEP offered them an additional strategy to reduce the risk of HIV transmission, meet their fertility desires, and cope with HIV serodiscordance. Remaining HIV negative at follow-up visits reinforced couples' decisions and motivated continued adherence to PrEP. In addition, confidence in their provider's advice and client-friendly services were critical to their decisions to initiate and continue use of PrEP. Strategies for wide-scale PrEP delivery for HIV serodiscordant couples in low resource settings may include building capacity of health providers to counsel on PrEP adoption while addressing couples' concerns and barriers to adoption and continued use.

Access and Attitudes to HPV Vaccination amongst Hard-To-Reach Populations in Kenya.

BACKGROUND: Sub-Saharan Africa bears the greatest burden of cervical cancer. Human papillomavirus (HPV) vaccination programmes to prevent the disease will need to reach vulnerable girls who may not be able access health and screening services in the future. We conducted formative research on facilitators and barriers to HPV vaccination and potential acceptability of a future HPV vaccination programme amongst girls living in hard-to-reach populations in Kenya. METHODS: Stakeholder interviews with Ministry of Health staff explored barriers to and support for the uptake of HPV vaccination. A situation assessment was conducted to assess community services in Maasai nomadic pastoralist communities in Kajiado County and in Korogocho informal settlement in Nairobi city, followed by focus group discussions (n=14) and semi-structured interviews (n=28) with health workers, parents, youth, and community and religious leaders. These covered marriage, knowledge of cervical cancer and HPV, factors that might inhibit or support HPV vaccine uptake and intention to accept HPV vaccine if a programme was in place. RESULTS: Reported challenges to an HPV vaccination programme included school absenteeism and drop-out, early age of sex and marriage, lack of parental support, population mobility and distance from services. Despite little prior knowledge of cervical cancer and HPV, communities were interested in receiving HPV vaccination. Adequate social mobilisation and school-based vaccination, supplemented by out-reach activities, were considered important facilitating factors to achieve high coverage. There was some support for a campaign approach to vaccine delivery. CONCLUSIONS: Given the high level of support for a vaccine against cervical cancer and the experience of reaching pastoralist and slum-dwellers for other immunizations, implementing an HPV vaccine programme should be feasible in such hard-to-reach communities. This may require additional delivery strategies in addition to the standard school-based delivery, with vaccine offered at multiple venues, potentially through a campaign approach.

Fertility Decision-Making Among Kenyan HIV-Serodiscordant Couples Who Recently Conceived: Implications for Safer Conception Planning.

HIV-serodiscordant couples often choose to attempt pregnancy despite their HIV transmission risk. Optimizing delivery of HIV risk reduction strategies during peri-conception periods (i.e., safer conception) requires understanding how HIV-serodiscordant couples approach fertility decisions. We conducted 36 in-depth individual interviews with male and female partners of Kenyan heterosexual HIV-serodiscordant couples who recently conceived. Transcripts were analyzed by gender and HIV serostatus using open coding. Matrices were used to identify patterns and emerging themes. Most participants expressed acceptance of being in an HIV-serodiscordant couple and affirmed their resilience to live with serodiscordance and achieve their fertility goals. Overall, while the goal for childbearing was unchanged, conception became an urgent desire so that both partners could experience childrearing together while the HIV-infected partner was still healthy. Children also add value to the relationship, and multiple children were a commonly expressed desire. Couples' desires dominated those of individual partners in fertility decision-making, but male preferences were more influential when the individual desires differed. Values and preferences of the couple as a unit may mediate fertility decision-making in HIV-discordant couples. Thus, it is important that safer conception programs include both partners when appropriate and consider the relationship context during risk reduction counseling and when recommending risk reduction interventions.

Linking women who test HIV-positive in pregnancy-related services to HIV care and treatment services in Kenya: a mixed methods prospective cohort study.

INTRODUCTION: There has been insufficient attention to long-term care and treatment for pregnant women diagnosed with HIV. OBJECTIVE AND METHODS: This prospective cohort study of 100 HIV-positive women recruited within pregnancy-related services in a district hospital in Kenya employed quantitative methods to assess attrition between women testing HIV-positive in pregnancy-related services and accessing long-term HIV care and treatment services. Qualitative methods were used to explore barriers and facilitators to navigating these services. Structured questionnaires were administered to cohort participants at enrolment and 90+ days later. Participants' medical records were monitored prospectively. Semi-structured qualitative interviews were carried out with a sub-set of 19 participants. FINDINGS: Only 53/100 (53%) women registered at an HIV clinic within 90 days of HIV diagnosis, of whom 27/53 (51%) had a CD4 count result in their file. 11/27 (41%) women were eligible for immediate antiretroviral therapy (ART); only 6/11 (55%) started ART during study follow-up. In multivariable logistic regression analysis, factors associated with registration at the HIV clinic within 90 days of HIV diagnosis were: having cared for someone with HIV (aOR:3.67(95%CI:1.22, 11.09)), not having to pay for transport to the hospital (aOR:2.73(95%CI:1.09, 6.84)), and having received enough information to decide to have an HIV test (aOR:3.61(95%CI:0.83, 15.71)). Qualitative data revealed multiple factors underlying high patient drop-out related to women's social support networks (e.g. partner's attitude to HIV status), interactions with health workers (e.g. being given unclear/incorrect HIV-related information) and health services characteristics (e.g. restricted opening hours, long waiting times). CONCLUSION: HIV testing within pregnancy-related services is an important entry point to HIV care and treatment services, but few women successfully completed the steps needed for assessment of their treatment needs within three months of diagnosis. Programmatic recommendations include simplified pathways to care, better-tailored counselling, integration of ART into antenatal services, and facilitation of social support.

'If I am given antiretrovirals I will think I am nearing the grave': Kenyan HIV serodiscordant couples' attitudes regarding early initiation of antiretroviral therapy.

OBJECTIVES: Early initiation of antiretroviral therapy (ART) - that is, at higher CD4 cell counts (>350 cells/µl) - is a potent HIV prevention strategy. The WHO recommends ART initiation by all HIV-infected individuals in HIV serodiscordant relationships to prevent HIV transmission, yet the acceptability of early ART among couples has not been well studied. DESIGN: Qualitative study exploring HIV serodiscordant couples' attitudes toward early initiation of ART. METHODS: We conducted eight focus group discussions and 20 in-depth interviews with members of heterosexual HIV serodiscordant couples in Kenya. Investigators iteratively applied inductive and deductive codes, developed matrices to identify patterns in codes, and reached consensus on key attitudes (motivations and barriers) related to early ART and one central, emerging theme. RESULTS: Most participants expressed interest in early initiation of ART, with maintaining health and preventing HIV transmission as key benefits. However, many identified personal concerns and potential barriers to wider community acceptance, including side-effects, adherence to life-long treatment, and stigma. The meaning of ART emerged as a fundamental consideration, with initiating therapy perceived as emblematic of the final stage of AIDS, when one was 'nearing the grave.' One particular challenge was what early ART might signify for someone who looks and feels healthy. CONCLUSION: HIV serodiscordant couples recognized the potential benefits of early ART, but ART was frequently viewed as signifying AIDS and approaching mortality. Potential implementation of early ART presents challenges and an opportunity to re-orientate individuals toward a new image of ART as health-preserving for patients and partners.

Patient attrition between diagnosis with HIV in pregnancy-related services and long-term HIV care and treatment services in Kenya: a retrospective study.

BACKGROUND: There has been little attention, until recently, to linking women who test HIV positive in pregnancy-related services to long-term HIV care and treatment services. METHODS: A retrospective review of routine hospital data was carried out in 2 hospitals in Kenya. Associations between available demographic information and uptake of HIV-related services within 6 months of HIV diagnosis in pregnancy-related services were assessed using logistic regression. Kaplan-Meier survival analysis was used to assess time between HIV diagnosis and registration at the HIV clinic. Referrals between pregnancy-related and HIV-related services were observed. RESULTS: At Naivasha hospital, the proportion of women registering at the HIV clinic within 6 months was 17.2% (153 of 892); at Gilgil hospital, it was 35.4% (84 of 237). Highly active antiretroviral therapy (HAART) was initiated by 40% and 27% of known eligible women in Naivasha and Gilgil, respectively. Non-systematic registration of clients on first contact at the HIV clinic, and restricted availability of services due to costs and opening hours were observed. In Naivasha, year, attendance at multiple pregnancy-related visits, and attendance at antenatal care in Naivasha hospital were associated with registration at the HIV clinic. In Gilgil, year, attendance at multiple pregnancy-related visits, and women being in their first pregnancy were associated with the outcome. CONCLUSIONS: Only 4% of women estimated to need HAART for their own care initiated HAART within 6 months of HIV diagnosis. Challenges associated with providing longitudinal care are especially evident in the context of high population mobility. Innovation in service delivery is required to improve uptake of services.