Availability and stock-outs of paediatric antiretroviral treatment formulations at health facilities in Kenya and Uganda.

INTRODUCTION: The large number of deaths among children with HIV is driven by poor antiretroviral treatment (ART) coverage among this cohort. The aim of the study was to assess the availability and stock-outs of paediatric and adult ART formulations in Kenya and Uganda across various regions and types of health facilities. METHODS: A survey on availability and stock-outs of paediatric ART at health facilities was adapted from the standardized Health Action International-WHO Medicine Availability Monitoring Tool. All preferred and limited-use formulations, and three phased-out formulations according to the 2021 WHO optimal formulary list were included in the survey, as well as a selection of adult ART formulations suitable for older children, adolescents, and adults. Availability data were collected in June-July 2022 and stock-out data were obtained over the previous year from randomly selected public and private-not-for-profit (PNFP) facilities registered to dispense paediatric ART across six districts per country. All data were analysed descriptively. RESULTS: In total, 144 health facilities were included (72 per country); 110 were public and 34 PNFP facilities. Overall availabilities of preferred paediatric ART formulations were 52.2% and 63.5% in Kenya and Uganda, respectively, with dolutegravir (DTG) 10 mg dispersible tablets being available in 70.2% and 77.4% of facilities, respectively, and abacavir/lamivudine dispersible tablets in 89.8% and 98.2% of facilities. Of note, availability of both formulations was low (37.5% and 62.5%, respectively) in Kenyan PNFP facilities. Overall availabilities of paediatric limited-use products were 1.1% in Kenya and 1.9% in Uganda. At least one stock-out of a preferred paediatric ART formulation was reported in 40.0% of Kenyan and 74.7% of Ugandan facilities. Nevirapine solution stock-outs were reported in 43.1% of Ugandan facilities, while alternative formulations for postnatal HIV prophylaxis were not available. CONCLUSIONS: Recommended DTG-based first-line ART for children across all ages was reasonably available at health facilities in Kenya and Uganda, with the exception of Kenyan PNFP facilities. Availability of paediatric ART formulations on the limited-use list was extremely low across both countries. Stock-outs were reported regularly, with the high number of reported stock-outs of neonatal ART formulations in Uganda being most concerning.

Healthcare workers' perspectives on access to sexual and reproductive health services in the public, private and private not-for-profit sectors: insights from Kenya, Tanzania, Uganda and Zambia.

BACKGROUND: Access to sexual and reproductive health services remains a challenge for many in Kenya, Tanzania, Uganda and Zambia. Health service delivery in the four countries is decentralised and provided by the public, private and private not-for-profit sectors. When accessing sexual and reproductive health services, clients encounter numerous challenges, which might differ per sector. Healthcare workers have first-hand insight into what impediments to access exist at their health facility. The aim of this study was to identify differences and commonalities in barriers to access to sexual and reproductive health services across the public, private and private not-for-profit sectors. METHODS: A cross-sectional survey was conducted among healthcare workers working in health facilities offering sexual and reproductive health services in Kenya (n = 212), Tanzania (n = 371), Uganda (n = 145) and Zambia (n = 243). Data were collected in July 2019. Descriptive statistics were used to describe the data, while binary logistic regression analyses were used to test for significant differences in access barriers and recommendations between sectors. RESULTS: According to healthcare workers, the most common barrier to accessing sexual and reproductive health services was poor patient knowledge (37.1%). Following, issues with supply of commodities (42.5%) and frequent stockouts (36.0%) were most often raised in the public sector; in the other sectors these were also raised as an issue. Patient costs were a more significant barrier in the private (33.3%) and private not-for-profit sectors (21.1%) compared to the public sector (4.6%), and religious beliefs were a significant barrier in the private not-for-profit sector compared to the public sector (odds ratio = 2.46, 95% confidence interval = 1.69-3.56). In all sectors delays in the delivery of supplies (37.4-63.9%) was given as main stockout cause. Healthcare workers further believed that it was common that clients were reluctant to access sexual and reproductive health services, due to fear of stigmatisation, their lack of knowledge, myths/superstitions, religious beliefs, and fear of side effects. Healthcare workers recommended client education to tackle this. CONCLUSIONS: Demand and supply side barriers were manifold across the public, private and private not-for-profit sectors, with some sector-specific, but mostly cross-cutting barriers. To improve access to sexual and reproductive health services, a multi-pronged approach is needed, targeting client knowledge, the weak supply chain system, high costs in the private and private not-for-profit sectors, and religious beliefs.

An exploratory focus group study on experiences with snakebites: health-seeking behaviour and challenges in rural communities of Kenya.

BACKGROUND: Snakebite envenoming is a long-hidden public health threat in the rural communities of Kenya. This study aimed to shed light on the health-seeking behaviour of people bitten by snakes, views on prevention measures and community needs and the consequences for snakebite patients in these areas. METHODS: Six focus group interviews were conducted in communities in the Kajiado (n=3) and Kilifi (n=3) counties. RESULTS: Traditional first-aid practices such as the use of a tourniquet and/or cutting the wound, use of a black stone and a variety of other traditional remedies were common. Challenges with transportation to health facilities and inadequately resourced facilities complicated accessing medical care. Community members voiced a need to improve access to trained healthcare workers and snakebite treatments at health facilities. CONCLUSION: While communities had high trust in evidence-based medical care, traditional treatment was often sought, causing delays in timely medical attention. Traditional practices were often used in the home environment and these were not usually administered by a traditional healer. The findings illustrate the need to combine improving the availability of effective snakebite treatment and healthcare worker training on snakebite with community education to reduce the impact of snakebite.

The Burden of Snakebite in Rural Communities in Kenya: A Household Survey.

Annually, about 2.7 million snakebite envenomings occur worldwide, primarily affecting those living in rural regions. Effective treatment exists but is scarce, and traditional treatments are commonly used. To inform context-specific policies in Kenya, this study aimed to determine the health-seeking behavior and the health, social, and economic burden of snakebites in rural communities. Nonprobability sampling was used to survey 382 respondents from four snakebite-endemic counties, from February to August 2020, using a structured questionnaire. Descriptive statistics, Fisher's exact tests, binary logistic regressions, and Mantel-Haenszel tests were used for analysis. Life-time experience with snakebites included 13.1% of respondents who reported being personally bitten and 37.4% who reported knowing of a community member being bitten. Respondents reported death after a snakebite in 9.1% of bitten community members and in 14.6% of bitten family members. Risk of snakebite was not significantly associated with sex, educational level, or occupation. Snakebite victims were most often walking (38%) or farming (24%) when bitten. Of those bitten, 58% went to a health facility, 30% sought traditional treatment, and 12% first went to a traditional healer before visiting a facility. Significant differences existed in perceptions on the financial consequences of snakebites among those who had been personally bitten and those who had observed a snakebite. Most commonly mentioned preventive measures were wearing shoes and carrying a light in the dark. Community engagement, including engagement with traditional healers, is needed to reduce snakebites. This should be done through education and sensitization to improve used preventive measures and effective health-seeking behavior.

Availability, affordability and stock-outs of commodities for the treatment of snakebite in Kenya.

BACKGROUND: Annually, about 2.7 million snakebite envenomings occur globally. Alongside antivenom, patients usually require additional care to treat envenoming symptoms and antivenom side effects. Efforts are underway to improve snakebite care, but evidence from the ground to inform this is scarce. This study, therefore, investigated the availability, affordability, and stock-outs of antivenom and commodities for supportive snakebite care in health facilities across Kenya. METHODOLOGY/PRINCIPAL FINDINGS: This study used an adaptation of the standardised World Health Organization (WHO)/Health Action International methodology. Data on commodity availability, prices and stock-outs were collected in July-August 2020 from public (n = 85), private (n = 36), and private not-for-profit (n = 12) facilities in Kenya. Stock-outs were measured retrospectively for a twelve-month period, enabling a comparison of a pre-COVID-19 period to stock-outs during COVID-19. Affordability was calculated using the wage of a lowest-paid government worker (LPGW) and the impoverishment approach. Accessibility was assessed combining the WHO availability target (≥80%) and LPGW affordability (<1 day's wage) measures. Overall availability of snakebite commodities was low (43.0%). Antivenom was available at 44.7% of public- and 19.4% of private facilities. Stock-outs of any snakebite commodity were common in the public- (18.6%) and private (11.7%) sectors, and had worsened during COVID-19 (10.6% versus 17.0% public sector, 8.4% versus 11.7% private sector). Affordability was not an issue in the public sector, while in the private sector the median cost of one vial of antivenom was 14.4 days' wage for an LPGW. Five commodities in the public sector and two in the private sector were deemed accessible. CONCLUSIONS: Access to snakebite care is problematic in Kenya and seemed to have worsened during COVID-19. To improve access, efforts should focus on ensuring availability at both lower- and higher-level facilities, and improving the supply chain to reduce stock-outs. Including antivenom into Universal Health Coverage benefits packages would further facilitate accessibility.