Pre-Exposure Prophylaxis (PrEP) Initiation and Retention Among Young Kenyan Women.

The DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, Safe) Initiative works to reduce HIV infection among adolescent girls and young women (AGYW) through prevention interventions including Pre-Exposure Prophylaxis (PrEP). Pamoja CBO in Kisumu, Kenya implemented DREAMS. We describe PrEP initiation and persistence in 549 AGYW who started PrEP through Pamoja and factors associated with discontinuation. Median persistence time was 308 days (95% CI 245, 382) with 59% of AGYW discontinuing by the end of the study. The most common reasons for stopping PrEP were lack of perceived risk (27.9%) and relocation (18.7%). In the multivariable model, only age < 18 was associated with stopping PrEP. Younger age was associated with shorter time to discontinuation. Implementing PrEP through DREAMS was successful in supporting initiation of PrEP for AGYW. However, low rates of persistence at 1 year emphasizes the need for strategies to support PrEP persistence if HIV elimination is to be achieved.

The impact of Moringa oleifera leaf supplementation on human and animal nutrition, growth, and milk production: A systematic review.

Childhood undernutrition contributes to up to 45% of deaths in children under age 5. Moringa oleifera (moringa) leaves are nutrient dense and promote breastmilk production. We performed a systematic review assessing the impact of moringa leaf supplementation in humans and animals on the outcomes of iron, vitamin A status, the measures of growth, and/or breastmilk production. Our inclusion/exclusion criteria were as follows; inclusion: quantitative primary data assessing the effect of moringa leaf supplementation on humans or animals including any of the outcomes defined earlier with no exclusion for geography, age, or language. Exclusion: full text not available. Our search yielded 148 unique studies; among them, 33 were included (seven human studies and 26 animal studies). Quality assessment by Effective Public Health Practice Project guidelines was strong for one study and moderate for all other studies. In humans, moringa at higher (14-30 g/day) not lower (<10 g/day) doses improved hemoglobin (Hgb) in children with iron deficiency anemia, improved Hgb and vitamin A status in postmenopausal women, and increased BMI in HIV+ underweight adults. Moringa (0.5 g/day) also increased breastmilk volumes. In animals, moringa increased milk production in two of three studies, inconsistently affected growth, and had no effect on iron status. Evidence on moringa supplementation's utility is limited but promising. Larger, more rigorous trials are needed to characterize its impact.

The influence of an agricultural intervention on social capital and water insecurity coping strategies: Qualitative evidence from female smallholder farmers living with HIV in western Kenya.

Background: Greater social capital is associated with positive health outcomes and better HIV management. The ways by which social capital may influence household water insecurity (HHWI), a critical determinant of health among persons living with HIV, remain underexplored. Further, despite the importance of reliable water access and use for health and agricultural productivity, few studies have described the strategies smallholder farmers living with HIV use to manage water insecurity. Objective: We qualitatively explored how an agricultural intervention (provision of a treadle pump for irrigation) influenced HHWI coping strategies through its impacts on social capital among smallholder farmers living with HIV in western Kenya. Method: In 2018, we purposively recruited participants from the Shamba Maisha study, a randomized agricultural intervention (NCT02815579) that provided irrigation pumps to improve treatment outcomes and food security among smallholder farmers living with HIV in western Kenya (n = 42). Participants shared their experiences with water insecurity through go-along and photo-elicitation interviews. Data were thematically analyzed using inductively developed codes. Results: Participants described diverse strategies for coping with agricultural water insecurity. Dimensions of social capital such as feelings of belonging, connectedness, and trust influenced the use of the treadle water pump and other water access behaviors. For instance, participants reported borrowing or sharing water pumps with friends and neighbors if they felt they had a good rapport. In addition, participants indicated a willingness to engage in collective activities, such as supporting the operation of the irrigation pump during planting, when they felt sufficiently connected to a larger group. Overall, individuals in the intervention arm described greater social cohesion, reciprocity, and community connectedness than those in the control arm. Conclusion: The impact of an agricultural intervention on water access and use was described as being modified by social capital among female smallholder farmers living with HIV. Findings suggest that social capital may create an enabling environment for implementing strategies that improve the management and reduce the burden of HIV. Measuring these strategies and their associations with HIV outcomes may strengthen our understanding of resilience among female smallholder farmers living with HIV. The development of a coping strategies index and its use in a longitudinal study could help to identify pathways through which social capital influences health and the effectiveness of livelihood interventions.

Early uptake of HIV clinical care after testing HIV-positive during home-based testing and counseling in western Kenya.

Home-based HIV testing and counseling (HBTC) has the potential to increase access to HIV testing. However, the extent to which HBTC programs successfully link HIV-positive individuals into clinical care remains unclear. To determine factors associated with early enrollment in HIV clinical care, adult residents (aged ≥13 years) in the Health and Demographic Surveillance System in Kisumu, Kenya were offered HBTC. All HIV-positive residents were referred to nearby HIV clinical care centers. Two to four months after HBTC, peer educators conducted home visits to consenting HIV-positive residents. Overall, 9,895 (82 %) of 12,035 residents accepted HBTC; 1,087 (11 %) were HIV-positive; and 737 (68 %) received home visits. Of those receiving home visits, 42 % reported HIV care attendance. Factors associated with care attendance included: having disclosed, living with someone attending HIV care, and wanting to seek care after diagnosis. Residents who reported their current health as excellent or who doubted their HBTC result were less likely to report care attendance. While findings indicate that HBTC was well-received in this setting, less than half of HIV-positive individuals reported current care attendance. Identification of effective strategies to increase early enrollment and retention in HIV clinical care is critical and will require coordination between testing and treatment program staff and systems.

"The people here knew how I used to live, but now I have to start again:" Lived experiences and expectations of the displaced and non-displaced women affected by the Thwake Multipurpose Dam construction in Makueni County, Kenya.

BACKGROUND: Dam construction and associated disruptive activities such as population displacement can have significant societal consequences, especially for those socially and economically disadvantaged. Though community-level health and social consequences of displacements have been documented, there is little understanding of the individual-level consequences and intra-household gendered dynamics. OBJECTIVE/METHODS: We sought to explore the experiences and expectations of displaced (n = 30) and non-displaced (n = 20) women in Makueni County, Kenya, where Kenya's second largest dam, Thwake Multipurpose Dam, is being constructed. We used qualitative techniques, including photo-elicitation interviews, go-along interviews, key informant interviews, and participant observation, to understand the lived experiences of women affected by the dam construction processes and their associated disruptions. RESULTS: We found that both displaced and non-displaced women experienced the impacts of dam construction in four areas, i.e., economic (income loss), health (hearing damage), social (disrupted social networks), and environmental (flooding) domains. Though both groups described adverse effects, the displaced women perceived worse economic and social outcomes than non-displaced ones. Further, older and married women in both groups had the worst lived experiences and negative perceptions about the consequences for social well-being, e.g., loss of cultural identity, land ownership, and access to important religious sites. Changes in livelihood also transformed gender roles as women assumed economic responsibilities to cushion their families from hunger. CONCLUSION: Development projects such as dams negatively impact the host community-displaced and the non-displaced experience adverse health, social, and environmental effects. However, poor women who are smallholder farmers bear the greatest burden. Assessment of individual-level experiences and intrahousehold dynamics might enhance our understanding of the biosocial outcomes of these consequences. Therefore, integrative biosocial approaches should be considered when examining the impacts of dam construction.

The accuracy and usability of point-of-use fluoride biosensors in rural Kenya.

Geogenic fluoride contaminates the water of tens of millions of people. However, many are unaware of the fluoride content due in part to shortcomings of detection methods. Biosensor tests are a relatively new approach to water quality testing that address many of these shortcomings but have never been tested by non-experts in a "real-world" setting. We therefore sought to assess the accuracy and usability of a point-of-use fluoride biosensor using surveys and field tests in Nakuru County, Kenya. Biosensor tests accurately classified elevated fluoride (≥1.5 ppm) in 89.5% of the 57 samples tested. Usability was also high; all participants were able to use the test and correctly interpreted all but one sample. These data suggest that biosensor tests can provide accurate, meaningful water quality data that help non-experts make decisions about the water they consume. Further scaling of these technologies could provide new approaches to track global progress towards Sustainable Development Goal 6.

Investigating the Impact of Moringa oleifera Supplemented to Kenyan Breastfeeding Mothers on Maternal and Infant Health: A Cluster Randomized Single-Blinded Controlled Pilot Trial Protocol.

Undernutrition contributes to up to 45% of deaths globally in children <5 years, with an optimal time for intervention before 24 months of age. Breastmilk microbiome helps establish the infant intestinal microbiome and impacts infant intestinal and nutritional health. Inadequacies in breastmilk composition such as low vitamin A contribute to infant nutrient deficiencies. Changes in milk fatty acid composition (reduced saturated and increased unsaturated fatty acids) may reduce susceptibility to enteric infection and increase protective intestinal bacteria. Moringa oleifera leaves (moringa) provide high nutrient concentrations (including protein, iron, vitamin A) and increase milk production; this may enhance breastmilk quantity and quality and improve infant health. Objective: To investigate the role of moringa supplementation to improve maternal and infant nutritional and intestinal health via changes in maternal milk quantity and quality. Methods: Fifty mother-infant pairs exclusively breastfeeding will be enrolled in a single-blinded randomized controlled trial in Kombewa County Hospital and Chulaimbo SubCounty Hospital, Kisumu, Kenya. Intervention: Dietary Supplementation of 20 g of Moringa oleifera leaf powder divided twice daily in corn porridge consumed daily for 3 months while control comparator will receive porridge daily for 3 months. Outcomes: Change in infant growth and maternal milk output (primary); maternal and infant vitamin A and iron status, changes in infant and maternal intestinal health (secondary). Participating Centers: Pamoja Community Based Organization, Kombewa Sub-County Hospital, and Chulaimbo Sub-County Hospital.

Prevalence and Covariates of Food Insecurity Across the First 1000 Days Among Women of Mixed HIV Status in Western Kenya: A Longitudinal Perspective.

BACKGROUND: Food insecurity (FI) is common globally and can have lifelong consequences. However, few studies have longitudinally examined how FI varies across gestation and the postpartum period ("the first 1000 days"); none have explored this in sub-Saharan Africa or in the context of HIV. OBJECTIVE: To assess the prevalence and covariates of FI in the first 1000 days among Kenyan women. METHODS: All pregnant women attending 7 clinics in western Kenya (n = 1247) were screened for HIV and FI (Individual Food Insecurity Access Scale) between September 2014 and June 2015. A subset of women (n = 371) was recruited into an observational cohort study and surveyed 11 times through 2 years postpartum (NCT02974972, NCT02979418). Data on FI, sociodemographics, and health were repeatedly collected. Severe FI was modeled using multilevel, mixed-effects logistic regressions (n = 346). RESULTS: Of the 1247 pregnant women screened, 76.5% were severely food insecure in the prior month. Further, the prevalence of severe FI was higher among women living with HIV than those without (82.6% vs 74.6%, P < .05). In the cohort, the odds of being severely food insecure decreased monotonically after delivery. Each point higher on the Center for Epidemiologic Studies-Depression scale was associated with 1.08 times greater odds of being severely food insecure (95% CI: 1.05-1.10); each point higher on the Duke/UNC Functional Social Support Scale was associated with 0.97 lower odds of severe FI (95% CI: 0.94-0.99). CONCLUSIONS: Severe FI is prevalent during the first 1000 days in western Kenya. Services to mitigate the far-reaching consequences of this modifiable risk should be considered.

'I know how stressful it is to lack water!' Exploring the lived experiences of household water insecurity among pregnant and postpartum women in western Kenya.

There is rapidly evolving literature on water insecurity in the general adult population, but the role of water insecurity during the vulnerable periods of pregnancy and postpartum, or in the context of HIV, has been largely overlooked. Therefore, we conducted an exploratory study, using Go Along interviews, photo-elicitation interviews, and pile sorts with 40 pregnant and postpartum Kenyan women living in an area of high HIV prevalence. We sought to (1) describe their lived experiences of water acquisition, prioritisation, and use and (2) explore the consequences of water insecurity. The results suggest that water insecurity is particularly acute in this period, and impacts women in far-reaching and unexpected ways. We propose a broader conceptualisation of water insecurity to include consideration of the consequences of water insecurity for maternal and infant psychosocial and physical health, nutrition, and economic well-being.

HIV incidence in western Kenya during scale-up of antiretroviral therapy and voluntary medical male circumcision: a population-based cohort analysis.

BACKGROUND: In Kenya, coverage of antiretroviral therapy (ART) among people with HIV infection has increased from 7% in 2006, to 57% in 2016; and, in western Kenya, coverage of voluntary medical male circumcision (VMMC) increased from 45% in 2008, to 72% in 2014. We investigated trends in HIV prevalence and incidence in a high burden area in western Kenya in 2011-16. METHODS: In 2011, 2012, and 2016, population-based surveys were done via a health and demographic surveillance system and home-based counselling and testing in Gem, Siaya County, Kenya, including 28 688, 17 021, and 16 772 individuals aged 15-64 years. Data on demographic variables, self-reported HIV status, and risk factors were collected. Rapid HIV testing was offered to survey participants. Participants were tracked between surveys by use of health and demographic surveillance system identification numbers. HIV prevalence was calculated as a proportion, and HIV incidence was expressed as number of new infections per 1000 person-years of follow-up. FINDINGS: HIV prevalence was stable in participants aged 15-64 years: 15% (4300/28 532) in 2011, 12% (2051/16 875) in 2012, and 15% (2312/15 626) in 2016. Crude prevalences in participants aged 15-34 years were 11% (1893/17 197) in 2011, 10% (1015/10 118) in 2012, and 9% (848/9125) in 2016; adjusted for age and sex these prevalences were 11%, 9%, and 8%. 12 606 (41%) of the 30 520 non-HIV-infected individuals enrolled were seen again in at least one more survey round, and were included in the analysis of HIV incidence. HIV incidence was 11·1 (95% CI 9·1-13·1) per 1000 person-years from 2011 to 2012, and 5·7 (4·6-6·9) per 1000 person-years from 2012 to 2016. INTERPRETATION: With increasing coverage of ART and VMMC, HIV incidence declined substantially in Siaya County between 2011 and 2016. VMMC, but not ART, was suggested to have a direct protective effect, presumably because ART tended to be given to individuals with advanced HIV infection. HIV incidence is still high and not close to the elimination target of one per 1000 person-years. The effect of further scale-up of ART and VMMC needs to be monitored. FUNDING: Data were collected under Cooperative Agreements with the US Centers for Disease Control and Prevention, with funding from the President's Emergency Fund for AIDS Relief.