Persistence of oral pre-exposure prophylaxis (PrEP) among adolescent girls and young women initiating PrEP for HIV prevention in Kenya.

The Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) Initiative aims to reduce HIV infections among adolescent girls and young women (AGYW) in Africa. Oral pre-exposure prophylaxis (PrEP) is offered through DREAMS in Kenya to eligible AGYW in high burden counties including Kisumu and Homa Bay. This study examines PrEP persistence among AGYW in high burden community-based PrEP delivery settings. We evaluated PrEP persistence among AGYW in the DREAMS PrEP program in Kisumu and Homa Bay using survival analysis and programmatic PrEP refill data collected between March through December 2017. Among 1,259 AGYW who initiated PrEP during the study period, the median persistence time in the program was 56 days (95% CI: 49-58 days) and the proportion who persisted 3 months later was 37% (95% CI: 34-40%). Persistence varied by county (p < 0.001), age at PrEP initiation (p = 0.002), marital status (p = 0.008), transactional sex (p = 0.002), gender-based violence (GBV) experience (p = 0.009) and current school attendance (p = 0.001) at DREAMS enrollment. Persistence did not vary with orphan status, food insecurity, condom use, age at first sexual encounter or engagement in age-disparate sex at DREAMS enrollment. Targeted strategies are needed to improve AGYW retention in the PrEP program.

A risk scoring tool for predicting Kenyan women at high risk of contraceptive discontinuation.

OBJECTIVE: We developed and validated a pragmatic risk assessment tool for identifying contraceptive discontinuation among Kenyan women who do not desire pregnancy. STUDY DESIGN: Within a prospective cohort of contraceptive users, participants were randomly allocated to derivation (n = 558) and validation (n = 186) cohorts. Risk scores were developed by selecting the Cox proportional hazards model with the minimum Akaike information criterion. Predictive performance was evaluated using time-dependent receiver operating characteristic curves and area under the curve (AUC). RESULTS: The overall contraceptive discontinuation rate was 36.9 per 100 woman-years (95% confidence interval [CI] 30.3-44.9). The predictors of discontinuation selected for the risk score included use of a short-term method or copper intrauterine device (vs. injectable or implant), method continuation or switch (vs. initiation), < 9 years of completed education, not having a child aged < 6 months, and having no spouse or a spouse supportive of family planning (vs. having a spouse who has unsupportive or uncertain attitudes towards family planning). AUC at 24 weeks was 0.76 (95% CI 0.64-0.87) with 70.0% sensitivity and 78.6% specificity at the optimal cut point in the derivation cohort. Discontinuation was 3.8-fold higher among high- vs. low-risk women (95% CI 2.33-6.30). AUC was 0.68 (95% CI 0.47-0.90) in the validation cohort. A simplified score comprising routinely collected variables demonstrated similar performance (derivation-AUC: 0.73 [95% CI 0.60-0.85]; validation-AUC: 0.73 [95% CI 0.51-0.94]). Positive predictive value in the derivation cohort was 31.4% for the full and 28.1% for the simplified score. CONCLUSIONS: The risk scores demonstrated moderate predictive ability but identified large proportions of women as high risk. Future research is needed to improve sensitivity and specificity of a clinical tool to identify women at high risk for experiencing method-related challenges. IMPLICATIONS: Contraceptive discontinuation is a major driver of unmet contraceptive need globally. Few tools exist for identifying women who may benefit most from additional support in order to meet their contraceptive needs and preferences. This study developed and assessed the validity of a provider-focused risk prediction tool for contraceptive discontinuation among Kenyan women using modern contraception. High rates of early discontinuation observed in this study emphasize the necessity of investing in efforts to develop new contraceptive technologies and stronger delivery systems to better align with women's needs and preferences for voluntary family planning.

Cost-effectiveness of condom uterine balloon tamponade to control severe postpartum hemorrhage in Kenya.

OBJECTIVE: To evaluate the cost-effectiveness of condom uterine balloon tamponade (UBT) for control of severe postpartum hemorrhage (PPH) due to uterine atony versus standard PPH care in Kenya. METHODS: A cross-sectional analysis was conducted using cost data collected from 30 facilities in Western Kenya from April 15 to July 16, 2015. Effectiveness data were derived from the published literature. The modeling analysis was performed from the health-system perspective for a cohort of women who gave birth in 2015. Sensitivity analyses tested the robustness of model estimates. Costs were in 2015 US dollars. RESULTS: Compared with standard care with no uterine packing, condom UBT could prevent 1255 hospital transfers, 430 hysterectomies, and 44 maternal deaths. At $5 or $15 per UBT device, the incremental cost per disability-adjusted life year (DALY) averted was $26 or $40, respectively. If uterine packing was assumed to be done with standard care, the cost per DALY averted was $164 when the UBT price was $5 and $199 when the price was $15. CONCLUSION: Condom UBT was a highly cost-effective intervention for controlling severe PPH. This finding remained robust even when key model inputs were varied by wide margins.