Effect of enforcement of the national referral guidelines on patterns of orthopedic admissions to Kenyatta National Hospital, Kenya: Pre-post intervention study.

BACKGROUND: Inappropriate utilization of higher-level health facilities and ineffective management of referral processes in resource-limited settings are becoming increasingly a concern in health care management in developing countries. This is characterized by self-referral and frequent bypassing of the nearest health facilities coupled with low formal referral mechanisms. This scenario lends itself to a situation where uncomplicated medical conditions are unnecessarily managed in a high-cost health facility. On July 1, 2021, Kenyatta National Hospital (KNH) enforced the Kenya Health Sector Referral Implementation Guidelines, 2014, which required patients to receive approval from the KNH referral office and a formal referral letter to be admitted at KNH to reduce the number of walk-ins and allow KNH to function as a referral facility as envisioned by the Kenya 2010 Constitution and KNH legal statue of 1987. OBJECTIVE: To determine the effect of enforcing the national referral guidelines on patterns of orthopaedic admissions to the KNH. This was a pre-post intervention study. Data abstraction was done for 459 and 446 charts before and after the enforcement of the national referral guidelines, respectively. RESULTS: Enforcement of the national referral guidelines reduced the proportion of walk-in admissions from 54.9% to 45.1%, while the proportion of facility referrals increased from 46.6% to 53.4% (p = 0.013). The percentage of non-trauma orthopaedic admissions doubled from 12.0% to 22.4% (p<0.001). There was also an increase in admissions through the Outpatient Clinic and Corporate Outpatient Clinic. The proportion of emergency admissions declined, while that of elective admissions increased. The increase in elective cases was mainly driven by the increase in female admissions with active insurance cover, tertiary education, non-trauma-related conditions and older age groups. However, the use of official formal written referral letters did not change despite the enforcement of the national referral guidelines. CONCLUSION: The enforcement of the national referral guidelines reduced the proportion of walk-ins' admissions to KNH. While the enforcement of the national referral guidelines had no effect on the use of official formal written referral letters, it did limit access and utilization of inpatient orthopedic services for young male patients with no active insurance cover and in need of emergency orthopedic care.

Transmission of SARS-CoV-2 among underserved pastoralist communities in Kajiado County, Kenya: 2020-2022.

Initial transmission of severe acute respiratory syndrome virus-2 (SARS-CoV-2) was highest in densely populated regions of Kenya. Transmission gradually trickled down to the less densely populated, remote and underserved regions such as the pastoral regions of Kajiado County which are characterized by poor healthcare systems. Molecular assays that were pivotal for COVID-19 diagnosis were not available in these regions. Serology is an alternative method for retrospectively tracking the transmission of SARS-CoV-2 in such populations. Dry blood spots (DBS) were prepared from consenting patients attending six health facilities in Kajiado County from March 2020 to March 2022. Upon elution, we conducted an enzyme-linked immunosorbent assay (ELISA) for the detection of SARS-Cov-2 IgG antibodies. Of the 908 DBSs we analyzed, 706 (78%) were from female participants. The overall seropositivity to SARS-Cov-2 antibodies was 7.3% (95% CI 5.7-9.1). The elderly (over 60 years) and male participants had a high likelihood of testing positive for SAR-CoV-2 infections. Mashuru (15.6%, 14/90) and Meto (15%, 19/127) health facilities registered the highest proportion of seropositive participants. Evidence of SARS-CoV-2 transmission among pastoralists in the remote and underserved regions of Kajiado County was established by DBS sampling and serologic testing.

Association of information technology ability, workplace social engagement, and successful ageing: validation of a short measure with three African samples.

This study examined the association of workplace social engagement (WSE) and information technology ability (ITA) with successful ageing and validated a brief scale measuring WSE. The interaction of WSE and ITA on successful ageing was also assessed. A cross-sectional design was adopted, and the participants were 1186 older adults living in Kenya (n = 350), Nigeria (n = 260), and Ghana (n = 576). Pearson's correlation and factor analyses of two datasets (i.e., waves 1 and 2) from the sample were utilised to validate the WSE scale. Hierarchical linear regression analysis with relevant sensitivity analyses were utilised to assess the associations with wave 2 data. The WSE scale produced satisfactory psychometric properties (i.e., reliability and validity) as a unidimensional measure. WSE and ITA were positively associated with successful ageing in Kenya and Ghana and in the consolidated data. The interaction between WSE and ITA was positively associated with successful ageing and its domains (i.e., illness avoidance, functioning, and engagement with life) in Kenya, Ghana, and consolidated data. At higher ITA or the use of information technologies, WSE is less strongly associated with successful ageing. WSE is more strongly associated with successful ageing only at moderate ITA.

Orchid species diversity across a forest disturbance gradient in west Mau forest, Kenya.

Orchidaceae is one of the most diverse and widespread groups of flowering plants. Despite their immense ecological and socio-economic value, their spatial distribution across forest disturbance gradient is not well understood, particularly in tropical montane forests. This study assessed the influence of forest degradation on orchid species richness and abundance in West Mau Forest, Kenya. Stratified systematic sampling was adopted across three different disturbance regimes consisting of relatively intact forest, moderately disturbed forest and highly degraded forest. A total of five orchid species were recorded from nine host-tree species. The intact forest had seven host tree species with five orchid species. The moderately degraded forest had four host-tree species with two orchid species, while the highly degraded forest that had no orchids. Polystachya confusa was the most abundant orchid species (600.0±227.9 clumps ha-1) followed by Bulbophyllum sp (340.0±112.2 clumps ha-1), Chamaeangis sp (300.0±115.5 clumps ha-1), Aerangis sp (200.0±57.7 clumps ha-1) and Tridactyle sp (100.0±0.0 clumps ha-1). The results of this study indicate that forest degradation reduces orchid species diversity in tropical montane forests. They also show that orchids are bioindicators of forest degradation status.

Telemedicine integration into the eye health ecosystem in scaling of effective refractive error coverage in Kenya.

This study explored the potential of telemedicine integration into the eye health ecosystem with an aim of scaling effective refractive error coverage in Kenya. This exploratory study was conducted telephonically and through online interviews with key opinion leaders, ophthalmologists, optometrists, ophthalmic clinical officers, optical technicians and beneficiaries of the optical technician's services in rural areas. A telemedicine workflow was developed and validated based on the comments from the key opinion leaders using the Delphi technique. Quantitative and qualitative data were analysed using SPSS and NVivo Software respectively. All of the key opinion leaders agreed that telemedicine is relevant in the eye health ecosystem and recognition of primary vision technicians is critical for effective telemedicine integration. The reasons for the need of telemedicine integration were categorized into; good relationship, organized refractive error service delivery, convenience and availability and cost reduction. The possible factors influencing integration of telemedicine identified were categorized into cost, unwillingness, dominance, perception, lack of technical team, policies and network coverage. The limited human resources in the eye health ecosystem in developing countries cannot effectively deliver refractive error services to the growing population. Hence, integration of telemedicine and establishment of policies recognizing telemedicine are desirable to strengthen task shifting and scale effective refractive error coverage.

Why Was the Policy Idea on the Health Benefits Package Advisory Panel Gazetted in Kenya? A Retrospective Policy Analysis.

BACKGROUND: In 2018, Kenya's Ministry of Health (MoH) gazetted the Health Benefits Package Advisory Panel (HBPAP) to develop a benefits package for its universal health coverage (UHC) programme. In this study, we examine the political process that led to the gazettement of the HBPAP. METHODS: We conducted a case study based on semi-structured interviews with 20 national-level participants and, reviews of documents such as organizational and media reports. We analyzed data from the interviews and documents thematically using the Braun and Clarke's six step approach. We identified codes and themes deductively using Kingdon's Multiple Streams Theory which postulates that the successful emergence of a policy follows coupling of three streams: the problem, policy, and politics streams. RESULTS: We found that the problem stream was characterized by fragmented and implicit healthcare priority-setting processes that led to unaffordable, unsustainable, and wasteful benefits packages. A potential policy solution for these problems was the creation of an independent expert panel that would use an explicit and evidence-based healthcare priority-setting process to develop an affordable and sustainable benefits package. The political stream was characterized by the re-election of the government and the appointment of a new Cabinet Secretary for Health. Coupling of the problem, policy, and political streams occurred during a policy window that was created by the political prioritization of UHC by the newly re-elected government. Policy entrepreneurs who included health economists, health financing experts, health policy analysts, and health systems experts leveraged this policy window to push for the establishment of an independent expert panel as a solution for the issues identified in the problem stream. They employed strategies such as forming networks, framing, marshalling evidence, and utilizing political connections. CONCLUSION: Applying Kingdon's theory in this study was valuable in explaining why the HBPAP policy idea was gazetted. It demonstrated the crucial role of policy entrepreneurs and the strategies they employed to couple the three streams during a favourable policy window. This study contributes to the body of literature on healthcare priority-setting processes with an unusual analysis focused on a key procedural policy for such processes.

Psychosocial and mental health challenges facing perinatally HIV-infected adolescents along the Kenyan coast: a qualitative inquiry using the socioecological model.

Background: The advent of antiretroviral therapy has led perinatally HIV-infected (PHI) adolescents to live long, fulfilling lives through lifelong treatment. However, there is limited knowledge about the lived experiences and psychosocial and mental health challenges faced by PHI adolescents in sub-Saharan Africa, where 80% of PHI adolescents reside. To address this gap, we adapted the socioecological model to investigate the challenges and lived experiences of PHI adolescents in rural coastal Kenya. Methods: Between October and November 2018, a sample of 40 participants (20 PHI adolescents and their 20 primary caregivers) participated in a qualitative study using an H-assessment data collection approach for adolescents and focus group discussions with caregivers. Data analysis was conducted using a framework approach on NVIVO 11 software. Results: PHI adolescents from this setting experience many challenges across various levels of the ecosystem. At the individual level, challenges include living in denial, HIV status disclosure, antiretroviral adherence, internalized stigma, and mental health issues. Within the family, challenges such as parental loss, insufficient care from parents, and unacceptance lead to threats of harm. In the broader community, key challenges such as gossip, unsupportive community members, long waiting times at the health facility, isolation, rejection, and an unresponsive school system fail to address the needs of PHI adolescents. Finally, HIV-related stigma and discrimination manifested across different levels of the socioecological framework. To cope with these challenges, PHI adolescents often rely on privacy and social support from their families. Conclusion: The findings underscore the need to develop and implement multi-level adolescent-friendly interventions to address PHI adolescent challenges and guide future investment in adolescent's health. Furthermore, there is a need to address internalized and interpersonal stigmas through individual-level interventions that promote resilience and the active involvement of adolescents, their caregivers, peers, and teachers who are their social support system.

Genetic characterization of group A rotavirus in children with acute gastroenteritis in Kericho County Referral Hospital, Kenya.

Introduction: approximately over 80% of mortalities due to rotavirus occur in countries that have limited resources, especially in sub-Saharan Africa and South Asia. The study was intended to determine the genetic characteristics of rotavirus A in children exhibiting gastroenteritis at Kericho County Referral Hospital. Methods: the study design was cross-sectional. Consecutive sampling was engaged obtaining a sample size of 200 stool samples. Genetic characterization of group A rotavirus strains was done using Enzyme-Linked Immunosorbent Assay. Positive samples underwent Sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Afterwards viewing of the RNA double strands of the rotavirus genome in gels was done using Silver Nitrate. The positive samples underwent RT-PCR amplification followed by sequencing on the pieces of the VP7 or VP4 gene obtained. Results: one hundred and six (53%) samples from males and 94 (47%) from females. Twenty-three samples were positive hence a prevalence of 11.5%. The most affected demographics were children of guardians with secondary school education (51%). The most affected social economic status was housewives (46.5%). The most affected age was 21-30 months at 26.5%. Long electropherotypes were in 22 samples (96%). The G3 genotype of rotavirus A was prevalent 16/23 (69.57%). Conclusion: rotavirus prevalence was 11.5%. The G3 genotype was the most prevalent in circulation. The occurrence of non-typable strains indicated that the strains may be diversified emphasizing the need to include emerging strains within the vaccines in use. Hence the need to continuously monitor the effects in older children.

Profiling IgG and IgA antibody responses during vaccination and infection in a high-risk gonorrhoea population.

Development of a vaccine against gonorrhoea is a global priority, driven by the rise in antibiotic resistance. Although Neisseria gonorrhoeae (Ng) infection does not induce substantial protective immunity, highly exposed individuals may develop immunity against re-infection with the same strain. Retrospective epidemiological studies have shown that vaccines containing Neisseria meningitidis (Nm) outer membrane vesicles (OMVs) provide a degree of cross-protection against Ng infection. We conducted a clinical trial (NCT04297436) of 4CMenB (Bexsero, GSK), a licensed Nm vaccine containing OMVs and recombinant antigens, comprising a single arm, open label study of two doses with 50 adults in coastal Kenya who have high exposure to Ng. Data from a Ng antigen microarray established that serum IgG and IgA reactivities against the gonococcal homologs of the recombinant antigens in the vaccine peaked at 10 but had declined by 24 weeks. For most reactive OMV-derived antigens, the reverse was the case. A cohort of similar individuals with laboratory-confirmed gonococcal infection were compared before, during, and after infection: their reactivities were weaker and differed from the vaccinated cohort. We conclude that the cross-protection of the 4CMenB vaccine against gonorrhoea could be explained by cross-reaction against a diverse selection of antigens derived from the OMV component.

Family Health Clinical Officers: Key professionals to strengthen primary healthcare in Kenya.

Primary healthcare (PHC) is recognised as the means to achieve universal health coverage, a national priority for Kenya. With only approximately 200 family physicians for a population of over 54 million, innovative solutions for providing quality PHC are needed. Clinical Officers, as mid-level health workers, already provide much of the primary care across Kenya, but without specialised training. To provide highly trained Family Health practitioners, a Higher Diploma in Family Health for Clinical Officers (FHCO) was launched by the government in 2018. With experience in delivering innovative and strategic higher diplomas, AIC Kijabe Hospital has been involved in curriculum development of this new diploma since its inception, and in October 2021 the first cohort of FHCO trainees was admitted to Kijabe College of Health Science, graduating in 2023. The second cohort is underway with plans for an annual intake. The FHCO graduates are running Family Medicine clinics at AIC Kijabe Hospital and its satellite clinics and are heavily involved in teaching. They are well-trained to deliver comprehensive, evidence-based, cost-effective and holistic care. As the programme expands, we expect graduates to be working across the country and leading efforts in enhancing the health and well-being of individuals, families and communities within primary healthcare networks (PCNs). By training FHCOs, this higher diploma is an efficient and cost-effective way to improve PHC, particularly for underserved Kenyans, and thus is a key part of enabling the Kenyan Government to achieve universal health coverage. This model of training could easily be replicated in other countries.

Plasmodium falciparum population dynamics in East Africa and genomic surveillance along the Kenya-Uganda border.

East African countries accounted for ~ 10% of all malaria prevalence worldwide in 2022, with an estimated 23.8 million cases and > 53,000 deaths. Despite recent increases in malaria incidence, high-resolution genome-wide analyses of Plasmodium parasite populations are sparse in Kenya, Tanzania, and Uganda. The Kenyan-Ugandan border region is a particular concern, with Uganda confirming the emergence and spread of artemisinin resistant P. falciparum parasites. To establish genomic surveillance along the Kenyan-Ugandan border and analyse P. falciparum population dynamics within East Africa, we generated whole-genome sequencing (WGS) data for 38 parasites from Bungoma, Western Kenya. These sequences were integrated into a genomic analysis of available East African isolate data (n = 599) and revealed parasite subpopulations with distinct genetic structure and diverse ancestral origins. Ancestral admixture analysis of these subpopulations alongside isolates from across Africa (n = 365) suggested potential independent ancestral populations from other major African populations. Within isolates from Western Kenya, the prevalence of biomarkers associated with chloroquine resistance (e.g. Pfcrt K76T) were significantly reduced compared to wider East African populations and a single isolate contained the PfK13 V568I variant, potentially linked to reduced susceptibility to artemisinin. Overall, our work provides baseline WGS data and analysis for future malaria genomic surveillance in the region.

Outcomes of different steroid dosing regimens in critical Covid-19 pneumonia at a Kenyan hospital: A retrospective cohort study.

BACKGROUND: Among therapeutic options for severe and critical COVID- 19 infection, dexamethasone six milligrams once daily for ten days has demonstrated mortality benefit and is guideline recommended at this dose. In practice, variable doses of steroids have been used, especially in critical care settings. Our study aimed to determine the pattern of steroid dosing and outcomes in terms of critical care mortality, occurrence of dysglycaemias, and occurrence of superadded infections in patients with critical COVID-19. METHODS: A retrospective cohort study was carried out on all eligible patients admitted to the Aga Khan University Hospital, Nairobi, with critical COVID-19 between 1st March 2020 and 31st December 2021. The intervention of interest was corticosteroids quantified as the average daily dose in milligrams of dexamethasone. A steroid dose of six milligrams once a day was compared to high dose steroid dosing, which was defined as any dose greater than this. The primary outcome measure was ICU mortality and secondary outcomes included occurrence of dysglycaemias, superadded infections and duration of critical care admission. RESULTS: The study included 288 patients. The median age was 61.2 years (IQR: 49.7, 72.5), with 71.2% of patients being male. The most common comorbidities were diabetes mellitus (60.7%), hypertension (58%), and heart disease (12.2%). The average oxygen saturation and C-reactive protein at admission were 82% [IQR: 70.0-89.0]and 113.0 [IQR: 54.0-186.0], respectively. Fifty-eight percent of patients received a standard dose (6mg) of steroids. The mortality rate was higher in the high-dose group compared to the standard-dose group; however, the difference was not statistically significant (47.9% vs 43.7% p = 0.549). The two most common steroid associated adverse effects were uncomplicated hyperglycemia (62.2%) and superimposed bacterial pneumonia (20.1%). The high-dose group had a higher incidence of uncomplicated hyperglycemia compared to the standard-dose group (63.6% vs 61.1%). However, the incidence of diabetic ketoacidosis was lower in the high dose group (0.6% vs 6.6%). Oxygen saturation at admission was associated with survival where it was lower among non-survivor patients with critical COVID-19. CONCLUSION: The study found that high-dose steroids in the treatment of critically ill patients with COVID-19 pneumonia did not confer any mortality benefit and were associated with an increased risk of dysglycemia and superimposed infections.

Factors Associated With Non-Uptake of Implantable Cardioverter-Defibrillator (ICD) Among Eligible Patients at a Tertiary Hospital in Kenya.

Background: Efficacy of Implantable Cardioverter-Defibrillator (ICD) implantation in both primary and secondary prevention of Sudden Cardiac Death (SCD) in at-risk population is well established. ICD implantation rates remain low particularly in Africa with a paucity of data regarding factors associated with non-uptake. Objectives: The primary study objective was to determine the factors associated with non-uptake of ICD among heart failure (HF) patients with reduced ejection fraction (EF<35%). Reasons for ICD refusal among eligible patients were reviewed as a secondary objective. Methods: This was a retrospective study among HF patients eligible for ICD implantation evaluated between 2018 to 2020. Comparison between ICD recipient and non-recipient categories was made to establish determinants of non-uptake. Results: Of 206 eligible patients, only 69 (33.5%) had an ICD. Factors independently associated with non-uptake were lack of private insurance (42.3% vs 63.8%; p = 0.005), non-cardiology physician (16.1% vs 5.8%; p = 0.045) and non-ischemic cardiomyopathy (54.7% vs 36.4% p = 0.014). The most common (75%) reason for ICD refusal was inability to pay for the device. Conclusion: ICDs are underutilized among eligible HF with reduced EF patients in Kenya. The majority of patients without ICD had no private insurance, had non-ischemic cardiomyopathy and non-cardiology primary physician. Early referral of HF with reduced EF patients to HF specialists to optimize guideline-directed medical therapy and make ICD recommendation is needed.

Yellow fever vaccine coverage and associated factors among under-five children in Kenya: Data from Kenyan Demographic and Health Survey 2022.

Yellow fever is a vaccine preventable hemorrhagic disease that leads to morbidity and mortality in the affected individuals. The only options for preventing and controlling its spread are through vaccination. Therefore, this study was conducted to estimate yellow fever vaccination coverage and associated factors among under-five children in Kenya. The total weighted samples of 2,844 children aged under-five were included in this study. The data were taken from the Kenyan Demographic and Health Survey 2022. In the multivariable analysis, the adjusted odds ratio with a 95% CI was used to declare significant associations of yellow fever vaccine. The yellow fever vaccine coverage among children aged under-five in Kenya was 18.50%. The significant factors associated with yellow fever vaccine coverage were: the age of the child older than 24 months (AOR = 1.7; 95% CI (1.17-2.58)); higher odds of yellow fever vaccination coverage was observed among older children, place of residence (AOR = 1.76; 95% CI (1.04-2.97)); higher odds was observed among urban residents, maternal education; primary education (AOR = 1.99; 95% CI (1.04-2.97)), secondary education (AOR = 2.85; 95% CI (1.41-5.76)), mothers who attended primary or secondary education have higher odds of yellow fever vaccination coverage, wealth index (AOR = 2.38; 95% CI (1.15-4.91)); higher odds of vaccination coverage was observed among poor households. Yellow fever vaccine coverage among under-five children in Kenya was low and has become an important public health concern. Policymakers and other stakeholders are recommended to focus on vaccination programs to prevent yellow fever disease.

"I was given PrEP, but had no privacy": Mystery shopper perspectives of PrEP counseling for adolescent girls and young women in Kisumu County, Kenya.

Pre-exposure prophylaxis (PrEP) is being scaled up to prevent HIV acquisition among adolescent girls and young women (AGYW) in Eastern and Southern Africa. In a prior study more than one-third of AGYW 'mystery shoppers' stated they would not return to care based on interactions with health providers. We examined the experiences of AGYW in this study to identify main barriers to effective PrEP services. Unannounced patient actors (USP/'mystery shoppers') posed as AGYWs seeking PrEP using standardized scenarios 8 months after providers had received training to improve PrEP services. We conducted targeted debriefings using open-ended questions to assess PrEP service provision and counseling quality with USPs immediately following their visit. Debriefings were audio-recorded and transcribed. Transcripts were analyzed using thematic analysis to explore why USPs reported either positive or negative encounters. We conducted 91 USP debriefings at 24 facilities and identified three primary influences on PrEP service experiences: 1) Privacy improved likelihood of continuing care, 2) respectful attitudes created a safe environment for USPs, and 3) patient-centered communication improved the experience and increased confidence for PrEP initiation among USPs. Privacy and provider attitudes were primary drivers that influenced decision-making around PrEP in USP debriefs. Access to privacy and improving provider attitudes is important for scale-up of PrEP to AGYW.

Lactoferrin and lysozyme to promote nutritional, clinical and enteric recovery: a protocol for a factorial, blinded, placebo-controlled randomised trial among children with diarrhoea and malnutrition (the Boresha Afya trial).

INTRODUCTION: Children with moderate or severe wasting are at particularly high risk of recurrent or persistent diarrhoea, nutritional deterioration and death following a diarrhoeal episode. Lactoferrin and lysozyme are nutritional supplements that may reduce the risk of recurrent diarrhoeal episodes and accelerate nutritional recovery by treating or preventing underlying enteric infections and/or improving enteric function. METHODS AND ANALYSIS: In this factorial, blinded, placebo-controlled randomised trial, we aim to determine the efficacy of lactoferrin and lysozyme supplementation in decreasing diarrhoea incidence and improving nutritional recovery in Kenyan children convalescing from comorbid diarrhoea and wasting. Six hundred children aged 6-24 months with mid-upper arm circumference <12.5 cm who are returning home after an outpatient visit or inpatient hospital stay for diarrhoea will be enrolled. Children will be randomised to 16 weeks of lactoferrin, lysozyme, a combination of the two, or placebo and followed for 24 weeks, with biweekly home visits by community health workers and clinic visits at 4, 10, 16 and 24 weeks. The primary analysis will compare the incidence of moderate-to-severe diarrhoea and time to nutritional recovery between each intervention arm and placebo. The trial will also test whether these interventions reduce enteric pathogen carriage, decrease enteric permeability and/or increase haemoglobin concentration in enrolled children. Finally, we will evaluate the acceptability, adherence and cost-effectiveness of lactoferrin and/or lysozyme. ETHICS AND DISSEMINATION: The trial has been approved by the institutional review boards of the Kenya Medical Research Institute, the University of Washington, the Kenyan Pharmacy and Poisons Board, and the Kenyan National Commission on Science, Technology and Innovation. The results of this trial will be shared with local and international stakeholders and published in peer-reviewed journals, and the key findings will be presented at relevant conferences. TRIAL REGISTRATION NUMBER: NCT05519254, PACTR202108480098476.

HIV Self-Testing for Efficient PrEP Delivery Is Highly Acceptable and Feasible in Public Health HIV Clinics in Kenya: A Mixed Methods Study.

HIV self-testing (HIVST) has the potential to reduce barriers associated with clinic-based preexposure prophylaxis (PrEP) delivery. We conducted a substudy nested in a prospective, pilot implementation study evaluating patient-centered differentiated care services. Clients chose either a blood-based or oral fluid HIVST kit at the first refill visit. Data were abstracted from program files and surveys were administered to clients. We purposively sampled a subset of PrEP clients and their providers to participate in in-depth interviews. We surveyed (n = 285). A majority (269/285, 94%) reported HIV risk. Blood-based HIVST was perceived as easy to use (76/140, 54%), and (41/140, 29%) perceived it to be more accurate. Oral fluid-based HIVST was perceived to be easy to use (95/107, 89%), but almost all (106/107, 99%) perceived it as less accurate. HIVST improved privacy, reduced workload, and saved time. HIVST demonstrates the potential to streamline facility-based PrEP care in busy African public health facilities.

Molecular Detection of Virulence-Associated Markers in Campylobacter coli and Campylobacter jejuni Isolates From Water, Cattle, and Chicken Faecal Samples From Kajiado County, Kenya.

Campylobacter is a zoonotic foodborne pathogen that is often linked with gastroenteritis and other extraintestinal infections in humans. This study is aimed at determining the genetic determinants of virulence-encoding genes responsible for flagellin motility protein A (flaA), Campylobacter adhesion to fibronectin F (cadF), Campylobacter invasion antigen B (ciaB) and cytolethal distending toxin (cdt) A (cdtA) in Campylobacter species. A total of 29 Campylobacter coli isolates (16 from cattle, 9 from chicken, and 4 from water samples) and 74 Campylobacter jejuni isolates (38 from cattle, 30 from chicken, and 6 from water samples) described in an earlier study in Kajiado County, Kenya, were examined for the occurrence of virulence-associated genes using polymerase chain reaction (PCR) and amplicon sequencing. The correlations among virulence genes were analyzed using Pearson's correlation coefficient (R) method. Among the 103 Campylobacter strains screened, 89 were found to harbour a single or multiple virulence gene(s), giving an overall prevalence of 86.4%. C. jejuni strains had the highest prevalence of multivirulence at 64.9% (48/74), compared to C. coli (58.6%, 17/29). The ciaB and flaA genes were the most common virulence genes detected in C. jejuni (81.1% [60/74] and 62.2% [46/74], respectively) and in C. coli (each at 62.1%; 18/29). Campylobacter isolates from chicken harboured the most virulence-encoding genes. C. jejuni strains from chicken and cattle harboured the highest proportions of the cdtA and ciaB genes, respectively. All the C. coli strains from water samples harboured the cadF and flaA genes. The results obtained further revealed a significant positive correlation between cadF and flaA (R = 0.733). C. jejuni and C. coli strains from cattle, chicken, and water harbour virulence markers responsible for motility/colonization, invasion, adherence, and toxin production, evoking their important role in campylobacteriosis development among humans and livestock. The identification of cattle, chicken, and water samples as reservoirs of virulent Campylobacter spp. highlights the possible risk to human health. These data on some virulence genes of Campylobacter will assist food safety and public health officials in formulating policy statements.

Preferences and uptake of home-based HIV self-testing for maternal retesting in Kenya.

OBJECTIVE: To compare preferences, uptake, and cofactors for unassisted home-based oral self-testing (HB-HIVST) versus clinic-based rapid diagnostic blood tests (CB-RDT) for maternal HIV retesting. DESIGN: Prospective cohort. METHODS: Between November 2017 and June 2019, HIV-negative pregnant Kenyan women receiving antenatal care were enrolled and given a choice to retest with HB-HIVST or CB-RDT. Women were asked to retest between 36 weeks gestation and 1-week post-delivery if the last HIV test was <24 weeks gestation or at 6 weeks postpartum if ≥24 weeks gestation, and self-report on retesting at a 14-week postpartum. RESULTS: Overall, 994 women enrolled and 33% (n = 330) selected HB-HIVST. HB-HIVST was selected because it was private (n = 224, 68%), convenient (n = 211, 63%), and offered flexibility in the timing of retesting (n = 207, 63%), whereas CB-RDT was selected due to the trust of providers to administer the test (n = 510, 77%) and convenience of clinic testing (n = 423, 64%). Among 905 women who reported retesting at follow-up, 135 (15%) used HB-HIVST. Most (n = 595, 94%) who selected CB-RDT retested with this strategy, compared to 39% (n = 120) who selected HB-HIVST retesting with HB-HIVST. HB-HIVST retesting was more common among women with higher household income and those who may have been unable to test during pregnancy (both retested postpartum and delivered <37 weeks gestation) and less common among women who were depressed. Most women said they would retest in the future using the test selected at enrollment (99% [n = 133] HB-HIVST; 93% [n = 715] CB-RDT-RDT). CONCLUSIONS: While most women preferred CB-RDT for maternal retesting, HB-HIVST was acceptable and feasible and could be used to expand HIV retesting options.

Isoniazid preventive therapy during infancy does not adversely affect growth among HIV-exposed uninfected children: Secondary analysis of data from a randomized controlled trial.

BACKGROUND: Isoniazid preventive therapy (IPT) decreases risk of tuberculosis (TB) disease; impact on long-term infant growth is unknown. In a recent randomized trial (RCT), we assessed IPT effects on infant growth without known TB exposure. METHODS: The infant TB Infection Prevention Study (iTIPS) trial was a non-blinded RCT among HIV-exposed uninfected (HEU) infants in Kenya. Inclusion criteria included age 6-10 weeks, birthweight ≥2.5 kg, and gestation ≥37 weeks. Infants in the IPT arm received 10 mg/kg isoniazid daily for 12 months, while the control trial received no intervention; post-trial observational follow-up continued through 24 months of age. We used intent-to-treat linear mixed-effects models to compare growth rates (weight-for-age z-score [WAZ] and height-for-age z-score [HAZ]) between trial arms. RESULTS: Among 298 infants, 150 were randomized to IPT, 47.6% were females, median birthweight was 3.4 kg (interquartile range [IQR] 3.0-3.7), and 98.3% were breastfed. During the 12-month intervention period and 12-month post-RCT follow-up, WAZ and HAZ declined significantly in all children, with more HAZ decline in male infants. There were no growth differences between trial arms, including in sex-stratified analyses. In longitudinal linear analysis, mean WAZ (ß = 0.04 [95% CI:-0.14, 0.22]), HAZ (ß = 0.14 [95% CI:-0.06, 0.34]), and WHZ [ß = -0.07 [95% CI:-0.26, 0.11]) z-scores were similar between arms as were WAZ and HAZ growth trajectories. Infants randomized to IPT had higher monthly WHZ increase (ß to 24 months 0.02 [95% CI:0.01, 0.04]) than the no-IPT arm. CONCLUSION: IPT administered to HEU infants did not significantly impact growth outcomes in the first two years of life.