Exploratory analysis of the potential impact of violence on HIV among female sex workers in Mombasa, Kenya: a mathematical modelling study.

BACKGROUND: Understanding the frequency of violence experienced by female sex workers (FSWs) and how violence contributes to HIV transmission can help improve HIV programs. METHODS: Using recent recommendations for modelling structural factors and associated causal pathways, we developed a HIV transmission dynamic model for FSWs and their clients in Mombasa, Kenya, mechanistically representing three types of violence (sexual violence, SV; physical violence, PV; police assault and arrest, PAA). Each type of violence affects HIV transmission through key mediators (condom non-use, HIV testing). We parameterized the model using data from a cross-sectional study of FSWs aged 15-24 recruited from a systematic geographical mapping sampling frame in Mombasa, Kenya (Cheuk E et al., Frontiers in Reproductive Health 2(7), 2020). Using this model, calibrated (and cross-validated) to HIV epidemiological and violence outcomes, we estimated the incidence of violence episodes, the contribution of violence to the HIV epidemic measured by the transmission population-attributable fraction, and the potential impact of possible violence interventions. RESULTS: The median estimated incidence of PAA in 2023 among FSWs who had not previously experienced that type of violence was 0.20 (95% credible interval: 0.17-0.22) per person-year (ppy), about double the incidence of SV and PV (0.10 (0.09-0.11), 0.11 (0.09-0.12), respectively). The incidence of violence was higher among FSWs who had previously experienced violence: the incidence of recurrent PV was 2.65 (1.82-3.37) ppy, while the incidence of recurrent SV and PAA were 1.26 (0.80-1.67) and 1.37 (0.94-1.74 ppy, respectively. In this setting, we estimated that a median of 35.3% (3.4-55.8%) infections in FSWs and clients combined over the next 10 years may be due to all types of violence (and mediators), mainly through reduced condom use in FSWs who have ever experienced SV (34.6% (2.4-55.5%)). Interventions that prevent future violence without mitigating the effects of past violence may only prevent 8.8% (0.8-14.0%) infections over 10 years. CONCLUSIONS: FSWs in Mombasa experience violence frequently. In this population, we find that addressing sexual violence, including mitigating the effects of past violence, is potentially important in reducing HIV transmission in this population. However, the wide uncertainty range shows longitudinal studies are needed to strengthen the evidence of the influence of violence on HIV risk behavior. We find that the recommendations for modelling structural factors provide a useful framework for describing the model.

Measuring non-events: infertility estimation using cross-sectional, population-based data from four countries in sub-Saharan Africa.

STUDY QUESTION: Does the prevalence of 12-month infertility in Burkina Faso, Côte d'Ivoire, Kenya, and Uganda differ between women trying to conceive and the broader population of women exposed to unprotected sex, and how are prevalence estimates affected by model assumptions and adjustments? SUMMARY ANSWER: Estimates of 12-month infertility among tryers ranged from 8% in Burkina Faso to 30% in Côte d'Ivoire, increasing substantially among a larger population of women exposed to unprotected intercourse. WHAT IS KNOWN ALREADY: While having a child is a fundamental human experience, the extent to which women and couples experience infertility is a neglected area of research, particularly in sub-Saharan Africa. Existing estimates of infertility in this region vary widely from 2% to 32%, however, potential impacts of variability in study populations and model assumptions have not been well-examined. STUDY DESIGN, SIZE, DURATION: We used cross-sectional nationally representative survey data from Burkina Faso, Côte d'Ivoire, Kenya, and Uganda. We employed a multi-stage cluster random sampling design with probability proportional to the size selection of clusters within each country to produce representative samples of women aged 15-49. Samples ranged from 3864 in Côte d'Ivoire to 9489 in Kenya. PARTICIPANTS/MATERIALS, SETTING, METHODS: We created two analytic samples in each country-tryers and a broader sample of women exposed to unprotected sex-exploring differences in population characteristics and estimating the period prevalence of 12-month infertility using the current duration (CD) approach. We also examined the impact of several model assumptions within each of the two analytic samples, including adjustments for recent injectable contraceptive use, unrecognized pregnancy, infertility treatment, underreported contraceptive use, and sexual activity. MAIN RESULTS AND THE ROLE OF CHANCE: Employing the CD approach among tryers produced an overall 12-month infertility prevalence of 7.9% (95% CI 6.6-12.7) in Burkina Faso, 29.6% (95% CI 15.3-100.0) in Côte d'Ivoire, 24.5% (95% CI 16.5-34.6) in Kenya, and 14.7% (95% CI 8.1-22.4) in Uganda. Results among women exposed to unprotected intercourse indicated much higher levels of infertility, ranging from 22.4% (95% CI 18.6-30.8) in Uganda to 63.7% (95% CI 48.8-87.9) in Côte d'Ivoire. Sensitivity analyses suggest infertility estimates are particularly sensitive to adjustments around pregnancy recognition timing and sexual activity, with little impact of adjustments for recent injectable contraceptive use, infertility treatment, and underreporting of traditional and coital dependent contraceptive use. LIMITATIONS, REASONS FOR CAUTION: There was substantial digit preference in responses at 12 months, particularly among the tryers, which could introduce bias. Data quality concerns in the reproductive calendar may impact the accuracy of the CD approach among the broader sample of women exposed to unprotected sex, particularly with regard to underreported contraceptive use, induced and spontaneous abortions, and unrecognized pregnancies. Lastly, we lacked information on postpartum amenorrhea or abstinence. WIDER IMPLICATIONS OF THE FINDINGS: Understanding the inconsistencies in definition and analytic approach and their implications for infertility estimation is important for reliably monitoring population-level infertility trends, identifying factors influencing infertility, improving prevention programs, and ensuring access to quality treatment and services. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by grants from the Bill & Melinda Gates Foundation (INV009639) and the National Institute of Child Health and Human Development (K01HD107172). The funders were not involved in the study design, analyses, manuscript writing, or the decision to publish. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Sexual practices, their influencers, and utilization of HIV services among female sex workers in Mombasa County, Kenya.

Introduction: female sex workers (FSWs) are vulnerable to acquiring HIV and other sexually transmitted infections due to unprotected sex. Understanding and addressing the gaps in safer sex among FSWs can help to reduce HIV acquisition and transmission. This study described sexual practices, their correlates and use of HIV services among FSWs in Mombasa County, Kenya. Methods: participants were recruited for a baseline survey by a time-location cluster randomized design at predetermined intervals from five bars and five clubs in Mombasa County until a sample size of 160 was reached. Descriptive statistics and inferential analysis using R were conducted, and p<0.05 was regarded as statistically significant. Results: nearly all (99%) of the participants were unmarried, and 11% had tertiary education. Ninety-eight percent (98%) reported vaginal intercourse, 51% reported using alcohol/drugs before sex, and 28% practiced unprotected intercourse. About 64% had tested for HIV within three months, 14% believed that it is safe to reuse condoms, and 10% that it is safe to engage in unprotected sex. In bi-variate analysis, FSWs were more likely to engage in unprotected intercourse if they reported more frequent sex, more frequent sex with regular clients, poor HIV knowledge, alcohol/drug use, and violence. In multivariate analysis, risky sexual practices were associated with frequency of sexual intercourse, alcohol/drug use, and poor HIV knowledge. Conclusion: female sex workers engage in unprotected sex while under the influence of substances, belief in re-using condoms and have high frequency of sexual intercourse. Inadequate knowledge of HIV and substance use significantly correlated with unprotected sex. Interventions to address these modifiable factors are needed to mitigate the risk of HIV among FSWs.

Are Contraceptive Method Preferences Stable? Measuring Change in the Preferred Method among Kenyan Women.

Contraceptive preferences are important for reproductive outcomes, such as contraceptive continuation and pregnancy. Current approaches to measuring reproductive preferences in population surveys are limited to exploring only fertility preferences and implicitly assume that contracepting people are using a method they want. We know that people change their fertility preferences over the life course as a response to life events, but there is no information about changes in contraceptive preferences, given the limited evidence about the measurement and distribution of contraceptive preferences. In this study, we examined the extent of change in women's contraceptive preferences over one year and identified characteristics associated with this change in Kenya using three rounds of nationally representative longitudinal data. Over one year, 18 percent of contraceptive users and 46 percent of contraceptive nonusers reported changes in their preferred contraceptive. Experiencing a pregnancy or birth and changes in marital status were associated with changes in contraceptive preferences for users and nonusers. We found that contraceptive preferences are dynamic, suggesting that family planning programs should ensure people's access to various methods to respond to women's changing circumstances and preferences.

Care-seeking for difficulties conceiving in sub-Saharan Africa: findings from population-based surveys in eight geographies.

STUDY QUESTION: What is the nature of women's care-seeking for difficulties conceiving in sub-Saharan Africa (SSA), including the correlates of seeking biomedical infertility care at a health facility? SUMMARY ANSWER: Care-seeking for difficulties getting pregnant was low, much of which involved traditional or religious sources of care, with evidence of sociodemographic disparities in receipt of biomedical care. WHAT IS KNOWN ALREADY: Nearly all research on infertility care-seeking patterns in SSA is limited to clinic-based studies among the minority of people in these settings who obtain facility-based services. In the absence of population-based data on infertility care-seeking, we are unable to determine the demand for services and disparities in the use of more effective biomedical sources of care. STUDY DESIGN, SIZE, DURATION: We used cross-sectional, population-based data from the Performance Monitoring for Action (PMA) female survey in eight geographies in SSA, including nationally representative data from Burkina Faso, Côte d'Ivoire, Kenya, and Uganda and regionally representative data from two provinces in the Democratic Republic of the Congo (DRC) (Kinshasa and Kongo Central) and two states in Nigeria (Kano and Lagos). We employed a multi-stage cluster random sampling design with probability proportional to size selection of clusters within each geography to produce representative samples of women aged 15-49. Samples ranged from 1144 in Kano, Nigeria, to 9489 in Kenya. PMA collected these data between November 2021 and December 2022. PARTICIPANTS/MATERIALS, SETTING, METHODS: We restricted the sample to women who had ever had sex, with analytic samples ranging from 854 in Kano to 8,059 in Kenya, then conducted descriptive and bivariable analyses to examine characteristics of those who sought care for difficulties getting pregnant. Among those who reported seeking care, we conducted bivariable and multivariable logistic regression analyses to determine factors associated with receipt of biomedical services from a health facility. All analyses were conducted separately by geography. MAIN RESULTS AND THE ROLE OF CHANCE: Our study found low levels of care-seeking for difficulties getting pregnant among sexually active women in eight geographies in SSA, ranging from 3.7% (Kenya) to 15.3% (Côte d'Ivoire). Of this, 51.8% (Burkina Faso) to 86.7% (Kinshasa) involved receipt of biomedical services in health facilities. While many factors were consistently associated with infertility care-seeking from any source across geographies, factors associated with receipt of biomedical care specifically were less pronounced. This may be a result of the highly limited sources of infertility services in SSA; thus, even privileged groups may struggle to obtain effective treatment for difficulties getting pregnant. However, we did observe disparities in biomedical care-seeking in our bivariable results in several geographies, with the wealthiest women, those with more education, and those residing in urban areas generally more likely to have sought biomedical care for difficulties getting pregnant. LIMITATIONS, REASONS FOR CAUTION: Our data lacked details on the nature of the services received and outcomes, and we do not have information on reasons why women chose the sources they did. Small samples of women who sought care limited our power to detect significant differences in care-seeking by women's characteristics in several geographies. WIDER IMPLICATIONS OF THE FINDINGS: Infertility and access to appropriate treatment are issues of reproductive health and human rights. While our results do not indicate to what extent use of non-biomedical sources of care is driven by preferences, cost, or lack of accessible services, it is clear from our results and existing literature that more needs to be done to ensure access to affordable, quality, cost-effective infertility services in SSA. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by grants from the Bill & Melinda Gates Foundation (INV009639) and the National Institute of Child Health and Human Development (K01HD107172). The funders were not involved in the study design, analyses, manuscript writing, or the decision to publish. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Trends in Adolescent Sexual and Reproductive Health Outcomes Before and Into the COVID-19 Pandemic in Burkina Faso and Kenya: Evidence From Panel Data.

PURPOSE: Many predicted that COVID-19 would have a substantial impact on the sexual and reproductive health (SRH) trajectories of adolescents in sub-Saharan Africa. The lack of longitudinal data with information collected before and into the pandemic has limited investigation into this topic. METHODS: We performed a secondary analysis using nationally representative longitudinal data from Kenya and Burkina Faso, collected at three time points (pre-COVID-19 in late 2019, and during COVID-19 in 2020 and 2021), to determine the extent to which SRH outcomes and behaviors, including pregnancy, contraceptive use, partnership status, and sexual activity, changed during the pandemic among adolescent women. RESULTS: Among adolescents aged 15-19 years (Kenya n = 1,893, Burkina Faso n = 1,422), there was a reduction in both partnership and pregnancy in 2021 as compared to pre-COVID 2019. Contraception use significantly increased between 2019 and 2021 in Kenya only (adjusted odds ratio [aOR]: 1.42, 95% confidence interval [CI] 1.03-1.97). COVID-19-related household income loss was associated with a decline in sexual activity among unmarried Kenyan girls (aOR: 0.47, 95% CI 0.25-0.87) and lower odds of pregnancy in Burkina Faso (aOR: 0.13, 95% CI 0.02-0.91). We did not find a relationship between COVID-19 measures and initiation of partnership or marriage in either setting. DISCUSSION: Contrary to expectations, our results suggest that COVID-19 did not have a consistent or sustaining impact on adolescent SRH and behaviors in Burkina Faso and Kenya. Further research is needed to assess the longer-term implications of the pandemic on adolescent social and health outcomes.

Trends in and Correlates of Short-Acting Contraceptive Stock-Outs: Multicountry Analysis of Performance Monitoring for Action Agile Platform Data.

Understanding trends in contraceptive stock-outs, as well as their structural and demand-side correlates, is critical for policymakers and program managers to identify strategies to further anticipate, reduce, and prevent stock-outs. We analyzed trends as well as supply- and demand-side correlates of short-acting contraceptive method stock-outs by using data from multiple rounds of Performance Monitoring for Action Agile surveys. These data longitudinally measured contraceptive availability over 2 years (between November 2017 and January 2020) across 2,134 public and private service delivery points (SDPs) from urban areas of 5 countries (Burkina Faso, Democratic Republic of the Congo [DRC], India, Kenya, and Nigeria). For each country, we analyzed the trends and used multilevel mixed-effect logistic regression to model the odds of short-acting contraceptive stock-outs, adjusting for key structural and demand-side factors of the SDPs. Stock-outs in short-acting contraceptive methods were common in health facilities and varied markedly, ranging from as low as 2.9% (95% confidence interval [CI]=1.7%, 5.1%) in India to 51.0% (95% CIs=46.8%, 56.0%) in Kenya. During the observation period, stock-out rates decreased by 28% in the SDP samples in India (aOR=0.72, P<.001) and 8% in Nigeria (aOR=0.92, P<.001) but increased by 15% in DRC (aOR=1.15; P=036) and 5% in Kenya (aOR=1.05, P=003) with each round of data collection. Correlates of stock-out rates included the facility managerial authority (private versus public), whether the facility was rated high quality, whether the facility was at an advanced tier, and whether there was high demand for short-acting contraceptives. In conclusion, stock-outs of short-acting contraceptives are still common in many settings. Measuring and monitoring contraceptive stock-outs is crucial for identifying and addressing issues related to the availability and supply of short-acting contraceptives.

Differential Burden of HIV Among Adolescent Girls and Young Women by Places Associated With Sex Work: An Observational Study in Mombasa, Kenya.

BACKGROUND: The design of HIV prevention programs for adolescent girls and young women (AGYW) are informed by data on who is at highest risk and where they can be reached. Places (hotspots) associated with selling sex are an established outreach strategy for sex work (SW) programs but could be used to reach other AGYW at high risk. SETTING: This study took place in Mombasa, Kenya. METHODS: We conducted a cross-sectional, bio-behavioural survey among (N = 1193) sexually active AGYW aged 14-24 years recruited at hotspots. We compared HIV prevalence by subgroup (SW; transactional sex, TS; and non-transactional sex), stratified by hotspot type (venues and nonvenues). We examined whether associations between HIV prevalence and hotspot/subgroup remained after adjustment for individual-level risk factors, and estimated HIV prevalence ratio with and without adjustment for these individual-level factors. RESULTS: Overall HIV prevalence was 5.6%, 5.3% in venues and 7.3% in nonvenues. Overall SW HIV prevalence was 2-fold higher than among participants engaged in nontransactional sex. After adjusting for age and individual-level risk factors, HIV prevalence was 2.72 times higher among venue-based SWs (95% confidence interval: 1.56 to 4.85) and 2.11 times higher among nonvenue AGYW not engaged in SW (95% confidence interval: 0.97 to 4.30) compared with venue-based AGYW not engaged in SW. CONCLUSION: AGYW who sell sex remain at high risk of HIV across types of hotspots. The residual pattern of elevated HIV burden by AGWY subgroup and hotspot type suggests that unmeasured, network-level factors underscore differential risks. As such, hotspots constitute a "place" to reach AGYW at high risk of HIV.

Impact of varying maternal dietary folate intake on cerebellar cortex histomorphology and cell density in offspring rats.

The cerebellum has a long, protracted developmental period that spans from the embryonic to postnatal periods; as a result, it is more sensitive to intrauterine and postnatal insults like nutritional deficiencies. Folate is crucial for foetal and early postnatal brain development; however, its effects on cerebellar growth and development are unknown. The aim of this study was to examine the effects of maternal folate intake on the histomorphology and cell density of the developing cerebellum. Twelve adult female rats (rattus norvegicus) were randomly assigned to one of four premixed diet groups: standard (2 mg/kg), folate-deficient (0 mg/kg), folate-supplemented (8 mg/kg) or folate supra-supplemented (40 mg/kg). The rats started their diets 14 days before mating and consumed them throughout pregnancy and lactation. On postnatal days 1, 7, 21 and 35, five pups from each group were sacrificed, and their brains were processed for light microscopic analysis. Histomorphology and cell density of the external granule, molecular, Purkinje and internal granule layers were obtained. The folate-deficient diet group had smaller, dysmorphic cells and significantly lower densities of external granule, molecular, Purkinje and internal granule cells. Although the folate-enriched groups had greater cell densities than the controls, the folate-supplemented group had considerably higher cell densities than the supra-supplemented group. The folate supra-supplemented group had ectopic Purkinje cells in the internal granule cell layer. These findings imply that a folate-deficient diet impairs cellular growth and reduces cell density in the cerebellar cortex. On the other hand, folate supplementation increases cell densities, but there appears to be an optimal dose of supplementation since excessive folate levels may be detrimental.

Maternal usage of varying levels of dietary folate affects the postnatal development of cerebellar folia and cortical layer volumes.

OBJECTIVE: The cerebellum has a long, protracted developmental period; therefore, it is more sensitive to intrauterine and postnatal insults like nutritional deficiencies. Folate is an essential nutrient in fetal and postnatal brain development, and its supplementation during pregnancy is widely recommended. This study aimed to describe the effects of maternal folate intake on postnatal cerebellum development. METHODS: Twelve adult female Rattus norwegicus (6-8 weeks old) rats were randomly assigned to one of four groups and given one of four premixed diets: a standard diet (2 mg/kg), a folate-deficient (folate 0 mg/kg), folate-supplemented (8 mg/kg), or folate supra-supplemented (40 mg/kg). The rats began consuming their specific diets 14 days before mating and were maintained on them throughout pregnancy and lactation. Five pups from each group were sacrificed, and their brains processed for light microscopic examination on postnatal days 1, 7, 21, and 35. The data gathered included the morphology of the cerebellar folia and an estimate of the volume of the cerebellar cortical layer using the Cavalieri method. RESULTS: Folia of the folate-supplemented and supra-supplemented groups were thicker and showed extensive branching with sub-lobule formation. The folate-deficient diet group's folia were smaller, had more inter-folial spaces, or fused. When compared to the folate-deficient group, the volumes of the cerebellum and individual cerebellar cortical layers were significantly larger in the folate-supplemented and supra-supplemented groups (p<0.05). CONCLUSION: Folate supplementation during pregnancy and lactation improves the degree and complexity of the cerebellar folia and the volumes of individual cerebellar cortical layers.

Pattern and determinants of contraceptive use among the muslim women in Wajir and Lamu counties in Kenya: a cross-sectional study.

BACKGROUND: Improving access to family planning (FP) is associated with positive health benefits that includes averting nearly a third of all maternal deaths and 10% of childhood deaths. Kenya has made great strides in improving access to family planning services. However, amid this considerable progress, regional variation has been noted which begs the need for a clearer understanding of the the patterns and determinants that drive these inconsistencies. METHODS: We conducted a cross-sectional study that involved 663 Muslim women of reproductive age (15-49 years) from Wajir and Lamu counties in Kenya between March and October 2018.The objective of this study was to understand patterns and determinants of contraceptive use in two predominantly Muslim settings of Lamu and Wajir counties that have varying contraceptive uptake. Eligible women were interviewed using a semi-structured questionnaire containing socio-demographic information and history of family planning use. Simple and multiple logistic regression were used to identify determinants of family planning use. The results were presented as Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR) ratios at 95% confidence interval. A p-value of 0.05 was considered statistically significant. RESULTS: Of the 663 Muslim women of reproductive age consenting to participate in the study, 51.5%, n = 342 and 48.5%, n = 321 were from Lamu and Wajir County, respectively. The prevalence of women currently using contraceptive was 18.6% (n = 123). In Lamu, the prevalence was 32.8%, while in Wajir, it was 3.4%. The determinants of current contraceptive use in Lamu include; marital status, age at marriage, employment status, discussion with a partner on FP, acceptability of FP in culture, and willingness to obtain information on FP. While in Wajir, determinants of current contraceptive use were education, and the belief that family planning is allowed in Islam. CONCLUSIONS: Our study found moderately high use of contraceptives among Muslim women of reproductive age in Lamu county and very low contraceptive use among women in Wajir. Given the role of men in decision making, it is critical to design male involvement strategy particularly in Wajir where the male influence is very prominent. It is critical for the government to invest in women and girls' education to enhance their ability to make informed decisions; particularly in Wajir where FP uptake is low with low education attainment. Further, our findings highlight the need for culturally appropriate messages and involvement of religious leaders to demystify the myths and misconception around family planning and Islam particularly in Wajir.

Family planning service disruptions in the first two years of the COVID-19 pandemic: Evidence from health facilities in seven low- and middle-income countries.

Many speculated that COVID-19 would severely restrict the delivery of essential health services, including family planning (FP), but evidence of this impact is limited, partly due to data limitations. We use cross-sectional data collected from regional and national samples of health facilities (n = 2,610) offering FP across seven low- and middle-income countries (LMICs) between 2019 and 2021, with longitudinal data from four geographies, to examine reported disruptions to the FP service environment during COVID-19, assess how these disruptions varied according to health system characteristics, and evaluate how disruptions evolved throughout the first two years of the pandemic, relative to a pre-pandemic period. Findings show significant variation in the impact of COVID-19 on facility-based FP services across LMICs, with the largest disruptions to services occurring in Rajasthan, India, where COVID-19 cases were highest among geographies sampled, while in most sub-Saharan African settings there were limited disruptions impacting FP service availability, method provision, and contraceptive supplies. Facility-reported disruptions to care were not reflected in observed changes to the number of FP clients or types of stockouts experienced in the first two years of the pandemic. Public and higher-level facilities were generally less likely to experience COVID-19-related disruptions to FP services, suggesting policy mitigation measures-particularly those implemented among government-operated health facilities-may have been critical to ensuring sustained delivery of reproductive healthcare during the pandemic.

Reversible effect of castration induced hypogonadism on the morphology of the left coronary arteries in adult male rabbits.

Hypogonadism is associated with an increased risk of coronary artery disease. This study sought to describe the histomorphology of the left coronary arteries of the adult male rabbit following orchiectomy and subsequent testosterone administration. We included 20 adult male rabbits, divided into a baseline group (n=2), an interventional group subjected to castration only (n=6), an intervention group subjected to castration followed by testosterone injection (n=6), and a control group (n=6). Key variables under investigation were serum testosterone levels, the intima-media thickness of coronary arteries, smooth muscle cell density, and adventitial collagen fiber density. The mean coronary arteries' intimal medial thickness was significantly higher in the castrated group than in controls (0.488 mm and 0.388 mm, respectively), while the testosterone-injected group had a mean of 0.440 mm. Mean smooth muscle cell density was significantly lower in the castrated rabbits vs. controls (26.96% and 47.80%, respectively), this observation being reversed with testosterone injection (47.53%). Mean adventitial collagen fiber density was significantly higher in the castrated group than in controls (66.6% and 36.1%, respectively), with a marginal difference after testosterone injection (65.2%). This study demonstrates that castration-induced hypogonadism causes morphological changes in the coronary arteries that are partly reversible using testosterone injections. These findings provide a morphological basis for understanding the role of testosterone in coronary arteries.

Differential discontinuation by covert use status in Kenya.

Objectives: Qualitative research suggests that covert users may be more likely to discontinue contraception due to the logistics of discretion and fear of disclosure. This study sought to quantify whether covert users are more likely to discontinue contraception than overt users. Study design: We used a national longitudinal survey from Kenya conducted from November 2019/February 2020 to November 2020/April 2021 to test whether the time to discontinuation between covert and overt users still in need of contraception differed using survival analyses over a period of 5 years since method initiation. Results: Multivariate Cox regression results showed there was an interaction with time and covert use on the risk of discontinuation; for every additional month of use, there was an increased risk of discontinuation of covert users compared to overt users (3% increased hazard, p = 0.02). At 1 and 2 years, there were no differences in the hazard of discontinuation (adjusted hazard ratio [aHR]1 year 0.95, 95% CI 0.54-1.65 and aHR2 years 1.37, 95% CI 0.85-2.21), yet at 3, 4, and 5 years, the hazard of discontinuation was higher for covert compared to overt users (aHR3 years 1.99, 95% 1.11-3.56; aHR4 years 2.89, 95% CI 2.0-6.40; aHR5 years 4.18, 95% CI 1.45-12.0). Conclusions: These results suggest efforts are needed to support covert users in managing their contraceptive use and for improving contraceptive counseling surrounding covert use. Our findings shed light on the increasing challenge covert users face after approximately the first 2 years of use; covert users require additional follow-up in both research and care provision. Implications: Covert users are at a higher risk of discontinuation of contraception while still trying to avoid pregnancy, particularly after the first 2 years of use. Family planning providers and programs must protect access to and maintain the privacy of reproductive services to this population, focusing on follow-up care provision and counseling.

The effectiveness of combined approaches towards improving utilisation of adolescent sexual and reproductive health services in Kenya: a quasi-experimental evaluation.

Adolescent sexual and reproductive health (ASRH) services are key to improving the health of adolescents. This study aimed to establish the effectiveness of an intervention that combined activities in health facilities and communities in Kenya to increase utilisation of ASRH services. A quasi-experimental evaluation design was used to assess the effectiveness of the intervention. Using a stratified cluster sampling approach, two cross-sectional household surveys targeting girls aged 15-19 were conducted at baseline (September 2019) and endline (December 2020) in intervention and comparison. We combined the difference-in-difference approach to analyse the net change in outcomes between intervention and comparison arms of the study at baseline and endline and coarsened exact matching for variables that were significantly different to address the imbalance. There were a total of 1011 participants in the intervention arm and 880 in the comparison arm. Descriptive results showed a net increase of 12.7% in intervention sites in the knowledge of misconceptions about sex, pregnancy, and contraception, compared to 10.4% in the control site. In the multivariate regression analysis, two outcomes remained significant: decreases in adolescents' discomfort when seeking ASRH services because of either fear of parents (aPR = 0.58, 95% CI = 0.42-0.79, P = 0.001) or a lack of support from their partner (aPR = 0.25, 95% CI = 0.08-0.82, P = 0.023). The intervention combining a facility and community approach was not effective in increasing the use of ASRH information and services. Possible reasons for this are explored.

Assessing trends and reasons for unsuccessful implant discontinuation in Burkina Faso and Kenya between 2016 and 2020: a cross-sectional study.

OBJECTIVES: Contraceptive implant use has grown considerably in the last decade, particularly among women in Burkina Faso and Kenya, where implant use is among the highest globally. We aim to quantify the proportion of current implant users who have unsuccessfully attempted implant removal in Burkina Faso and Kenya and document reasons for and location of unsuccessful removal. METHODS: We use nationally representative data collected between 2016 and 2020 from a cross-section of women of reproductive age in Burkina Faso and Kenya to estimate the prevalence of implant use, proportion of current implant users who unsuccessfully attempted removal and proportion of all removal attempts that have been unsuccessful. We describe reasons for and barriers to removal, including the type of facility where successful and unsuccessful attempts occurred. FINDINGS: The total number of participants ranged from 3221 (2017) to 6590 (2020) in Burkina Faso and from 5864 (2017) to 9469 (2019) in Kenya. Over a 4 year period, the percentage of current implant users reporting an unsuccessful implant discontinuation declined from 9% (95% CI: 7% to 12%) to 2% (95% CI: 1% to 3%) in Kenya and from 7% (95% CI: 4% to 14%) to 3% (95% CI: 2% to 6%) in Burkina Faso. Common barriers to removal included being counselled against removal by the provider or told to return a different day. CONCLUSION: Unsuccessful implant discontinuation has decreased in recent years. Despite progress, substantial numbers of women desire having their contraceptive implant removed but are unable to do so. Greater attention to health systems barriers preventing implant removal is imperative to protect reproductive autonomy and ensure women can achieve their reproductive goals.

Changes in context, typology and programme outcomes between early and recent periods of sex work among young female sex workers in Mombasa, Kenya: A cross-sectional study.

INTRODUCTION: The sex work context and typology change continuously and influence HIV related risk and vulnerability for young female sex workers (YFSW). We sought to describe changes in the context and typology of sex work between the first (early) and past month (recent) of sex work among YFSW to inform HIV prevention programming for sex workers. METHODS: We used data from a cross-sectional survey (April-November 2015), administered using physical location-based sampling to 408 cis-women, aged 14-24 years, who self-identified as sex workers, in Mombasa, Kenya. We collected self-reported data on the early and recent month of sex work. The analysis focused on changes in a) sex work context and typology (defined by setting where sex workers practice sex work) where YFSW operated, b) primary typology of sex work, and c) HIV programme outcomes among YFSW who changed primary typology, within the early and recent month of sex work. We analysed the data using a) SPSS27.0 and excel; b) bivariate analysis and χ2 test; and c) bivariate logistic regression models. RESULTS: Overall, the median age of respondents was 20 years and median duration in sex work was 2 years. Higher proportion of respondents in the recent period managed their clients on their own (98.0% vs. 91.2%), had sex with >5 clients per week (39.3% vs.16.5%); were able to meet > 50% of living expenses through sex work income (46.8% vs. 18.8%); and experienced police violence in the past month (16.4% vs. 6.5%). YFSW reported multiple sex work typology in early and recent periods. Overall, 37.2% reported changing their primary typology. A higher proportion among those who used street/ bus stop typology, experienced police violence, or initiated sex work after 19 years of age in the early period reported a change. There was no difference in HIV programme outcomes among YFSW who changed typology vs. those who did not. CONCLUSIONS: The sex work context changes even in a short duration of two years. Hence, understanding these changes in the early period of sex work can allow for development of tailored strategies that are responsive to the specific needs and vulnerabilities of YFSW.

Clinical outcomes of intrauterine device insertions by newly trained providers: The ECHO trial experience.

Objectives: To assess the rates of failed insertion, expulsion, and perforation when intrauterine device (IUD) insertions were done by newly trained clinicians, and to examine factors that may affect these outcomes. Study design: We evaluated skill-based outcomes following IUD insertion at 12 African sites in a secondary analysis of the Evidence for Contraceptive Options and HIV Outcomes (ECHO) randomized trial. Before trial initiation, we provided competency-based IUD training to clinicians and offered ongoing clinical support. We used Cox proportional hazards regression to examine factors associated with expulsion. Results: Among 2582 IUD acceptors who underwent first attempted IUD insertion, 141 experienced insertion failure (5.46%) and seven had uterine perforation (0.27%). Perforation was more common among breastfeeding women within three months postpartum (0.65%) compared with non-breastfeeding women (0.22%). We recorded 493 expulsions (15.5 per 100 person-years, 95% confidence interval [CI] 14.1─16.9): 383 partial and 110 complete. The risk of IUD expulsion was lower among women older than 24 years (aHR 0.63, 95% CI 0.50─0.78) and may be higher among nulliparous women. (aHR 1.65, 95% CI 0.97─2.82). Breastfeeding (aHR 0.94, 95% CI 0.72─1.22) had no significant effect on expulsion. IUD expulsion rate was highest during the first three months of the trial. Conclusions: IUD insertion failure and uterine perforation rates in our study were comparable to those reported in the literature. These results suggest that training, ongoing support, and opportunities to apply new skills were effective in ensuring good clinical outcomes for women receiving IUD insertion by newly trained providers. Implications: Data from this study support recommendations to program managers, policymakers, and clinicians that IUDs can be inserted safely in resource-constrained settings when providers receive appropriate training and support.

Intersection of reproductive coercion and intimate partner violence: cross-sectional influences on women's contraceptive use in Burkina Faso, Côte d'Ivoire and Kenya.

OBJECTIVES: Among nationally representative cross-sections of women in need of contraception from Burkina Faso, Côte d'Ivoire and Kenya, we aimed to: (1) examine the intersection of past-year physical/sexual intimate partner violence (IPV), emotional IPV and reproductive coercion (RC) and (2) assess the impact of physical/sexual IPV, emotional IPV and RC on women's contraceptive use outcomes, including current contraceptive use, method type and covert use. DESIGN: The present analysis uses cross-sectional female data collected in Burkina Faso (December 2020-March 2021), Côte d'Ivoire (October-November 2021) and Kenya (November-December 2020). SETTINGS: Burkina Faso, Côte d'Ivoire and Kenya PARTICIPANTS: Analytical samples were restricted to partnered women with contraceptive need who completed a violence module (Burkina Faso n=1863; Côte d'Ivoire n=1105; Kenya n=3390). PRIMARY AND SECONDARY OUTCOME MEASURES: The exposures of interest-past-year emotional IPV, physical/sexual IPV and RC-were assessed using abridged versions of the Revised Conflict and Tactics Scale-2 and Reproductive Coercion Scale, respectively. Outcomes of interest included current contraceptive use, contraceptive method type (female controlled vs male compliant), and covert contraceptive use, and used standard assessments. RESULTS: Across sites, 6.4% (Côte d'Ivoire) to 7.8% (Kenya) of women in need of contraception experienced RC; approximately one-third to one-half of women experiencing RC reported no other violence forms (31.7% in Burkina Faso to 45.8% in Côte d'Ivoire), whereas physical/sexual IPV largely occurred with emotional IPV. In multivariable models, RC was consistently associated with covert use (Burkina Faso: aOR 2.84 (95% CI 1.21 to 6.64); Côte d'Ivoire: aOR 4.45 (95% CI 1.76 to 11.25); Kenya: aOR 5.77 (95% CI 3.51 to 9.46)). Some IPV in some settings was also associated with covert use (emotional IPV, Burkina Faso: aOR 2.99 (95% CI 1.56 to 5.74); physical/sexual, Kenya: aOR 2.35 (95% CI 1.33 to 4.17)). CONCLUSIONS: Across settings, covert use is a critical strategy for women experiencing RC. Country policies must recognise RC as a unique form of violence with profound implications for women's reproductive health.

Condom Use Among Male Sex Workers With Their Male Clients in Mombasa, Kenya: Results of a Sub-analysis of a Pilot, Multilevel, Structural, HIV Risk-Reduction Intervention.

ABSTRACT: Despite the advent of preexposure prophylaxis, consistent condom use continues to be recommended because preexposure prophylaxis does not prevent sexually transmitted infections. This is important for high-risk populations (e.g., male sex workers; MSW) in low-resource, high-HIV/sexually transmitted infection prevalence settings, such as the Mombasa region in Kenya. This study aimed to examine the relationship between MSW's condom use, and their knowledge, beliefs, and attitudes about condoms. MSW (N = 158) completed surveys on their sexual behaviors/practices/attitudes. We used multiple regressions to identify associations between condom use, HIV knowledge/attitudes, and self-efficacy. Three quarters of participants reported always using condoms in the past week, and 64.3% reported always using condoms in the past month with male clients. Mean scores for knowledge and attitudes/self-efficacy toward condoms/safer sex were positively associated with condom use. Interventions to build self-efficacy, such as condom negotiation, and/or bringing up condom use with clients may be useful for Kenyan MSW.