'Mummy told me that I have HIV, that is the only thing she told me': Experiences of HIV status disclosure to children in Masaka Region, Uganda.

BACKGROUND: In sub-Saharan Africa (SSA), disclosure of HIV status to children remains low. Few studies have examined how children navigate and come to terms with their HIV status. The aim of this study was to explore experiences of children about disclosure of their HIV status. METHODS: Between October 2020 and July 2021, 18 purposively selected children aged between 12-17 whose HIV status had been disclosed to them by their caregivers or healthcare providers (HCPs) were recruited for this study. We conducted 18 in-depth interviews (IDIs) to collect data for this study. Data were analyzed using the semantic thematic analysis approach. RESULTS: Primary data obtained through IDIs revealed that disclosure of HIV status to children occurred as a one-time event without pre-disclosure preparatory planning or focused post disclosure follow-up counseling irrespective of the discloser. Post disclosure psycho-social experiences elicited mixed responses. Some children experienced insults and belittlement and stigma and discrimination in the family and community for out-of-school children and at school for school-going children. Positive disclosure experiences involved receiving support to improve ART adherence through constantly being reminded to take their medications timely at the workplace, by supervisors, for working children and by teachers, at school for school-going children. CONCLUSIONS: This research contributes to knowledge about children' s experiences of being HIV infected and can specifically be used to improve disclosure strategies.

Socio-Cultural Influencers of Disclosure of HIV Status to Children on Antiretroviral Therapy in the Masaka Region, Uganda: A Qualitative Study.

This study explored sociocultural influencers of disclosure of HIV status to children taking daily antiretroviral therapy (ART) in the Masaka region, Uganda using data collected from 26 key informant interviews with caregivers between October 2020 and July 2021. The findings revealed both positive and negative sociocultural influencers of disclosure. Beliefs that disclosure cultivates responsibility in the child to improve ART adherence and the culture of routine sexual health education conversations with children were positive socio-cultural influencers. Beliefs that disclosure increases children's loss of hope in life and breaks confidentiality with children inadvertently disclosing their HIV status to others leading to discrimination and social rejection, were key negative sociocultural influencers. These findings suggest a need for socio-culturally informed interventions that target caregiver negative socio-cultural disclosure influencers in this setting through contextualized sensitization and training to prepare children taking daily ART to receive disclosure progressively.

HIV status disclosure and antiretroviral therapy adherence among children in Masaka region, Uganda.

HIV-infected children are now living into adolescence and early adulthood in large numbers due to the availability and increased use of antiretroviral therapy (ART). However, receipt of HIV status disclosure among children remains low. We assessed the association between disclosure of HIV status and adherence to ART among children in the Masaka region of Uganda using multivariable logistic regression with generalised linear models with Poisson log-link function and robust variance in Stata software version 15.1. Data were collected from 524 assenting children aged 12-17 years between March and December 2020. Results show that, although not statistically significant, children who received disclosure of their HIV status reported improved ART adherence compared to children with no disclosure. Out-of-school children with post-primary education and children on first-line ART regimens were significantly more likely to report improved ART in both crude and adjusted analyses. Innovative interventions to promote progressive disclosure of HIV status to children on ART, in school, are needed to improve their ART adherence. There is also a need to evaluate the suitability of current counselling interventions provided to children being switched to second-line ART regimens to delay the need for third-line ART regimens.

Indigenous knowledge of Rift Valley Fever among Somali nomadic pastoralists and its implications on public health delivery approaches in Ijara sub-County, North Eastern Kenya.

Rift Valley Fever (RVF) is a zoonotic disease whose outbreak results in heavy economic and public health burdens. In East Africa, RVF is mainly experienced in arid and semi-arid areas predominantly inhabited by the pastoralists. These areas experience sudden, dramatic epidemics of the disease at intervals of approximately 10 years, associated with widespread flooding and the resultant swarms of mosquitoes. Pastoralists' indigenous knowledge and experience of RVF is critical for public health interventions targeting prevention and control of RVF. The study adopted a descriptive cross-sectional design combining both quantitative and qualitative methods of data collection. A total of 204 respondents participated in questionnaire survey and 15 key informants and 4 focus group discussions were interviewed and conducted respectively. In addition, secondary data mainly journal publications, books, policy documents and research reports from conferences and government departments were reviewed. Findings indicated that the Somali pastoralists possess immense knowledge of RVF including signs and symptoms, risk factors, and risk pathways associated with RVF. Ninety eight percent (98%) of respondents identified signs and symptoms such as bloody nose, diarrhea, foul smell and discharge of blood from the orifices which are consistent with RVF. Heavy rains and floods (85%) and sudden emergence of mosquito swarms (91%) were also cited as the major RVF risk factors while mosquito bites (85%), drinking raw milk and blood (78%) and contact with animal fluids during mobility, slaughter and obstetric procedures (77%) were mentioned as the RVF entry risk pathways. Despite this immense knowledge, the study found that the pastoralists did not translate the knowledge into safer health practices because of the deep-seated socio-cultural practices associated with pastoralist production system and religious beliefs. On top of these practices, food preparation and consumption practices such as drinking raw blood and milk and animal ritual sacrifices continue to account for most of the mortality and morbidity cases experienced in humans and animals during RVF outbreaks. This article concludes that pastoralists' indigenous knowledge on RVF has implications on public health delivery approaches. Since the pastoralists' knowledge on RVF was definitive, integrating the community into early warning systems through training on reporting mechanisms and empowering the nomads to use their mobile phone devices to report observable changes in their livestock and environment could prove very effective in providing information for timely mobilization of public health responses. Public health advocacy based on targeted and contextually appropriate health messaging and disseminated through popular communication channels in the community such as the religious leaders and local radio stations would also be needed to reverse the drivers of RVF occurrence in the study area.

Is polygyny a risk factor in the transmission of HIV in sub- Saharan Africa? A systematic review.

Using a systematic literature review approach, this paper focused on the role of polygyny in the spread of HIV/AIDS in sub-Saharan Africa (SSA) countries. The widespread practice of polygyny is one feature of many SSA contexts that may be relevant to understanding patterns of HIV prevalence. Building on the conflicting studies on the importance of polygyny, this study investigated whether or not polygyny is a conduit for elevating HIV transmission in SSA countries. Findings showed that polygyny as an institution is perhaps less of a concern; rather the implication that men and women who are in polygamous relationships are also more likely to engage in extra-marital sex - raises secondary questions about their patterns of sexual networking and concurrent sexual partnerships. The findings however show that polygyny amplifies risky sexual behaviours such as sexual networking and concurrent sexual partnerships, all of which were found to be significantly associated with the risk of HIV transmission. This demonstrates that targeting risky sexual behaviours in a broader marital context may be more important for HIV risk reduction than targeting polygyny as an institution.

Understanding acceptance of and adherence to a new formulation of paediatric antiretroviral treatment in the form of pellets (LPV/r)-A realist evaluation.

BACKGROUND: Improving access to paediatric HIV treatment requires large-scale antiretroviral treatment programmes and medication adapted to infants and children's needs. The World Health Organisation recommends lopinavir/ritonavir plus two nucleoside reverse transcriptase inhibitors as first-line treatment for all HIV-infected children younger than three years, usually given as a syrup. A pellet formulation (i.e. tiny cylinders of compressed medication put in capsules) was developed to overcome the syrup formulation's disadvantages such as bitterness, toxicity and cold storage. This study assessed multi-level factors influencing caregivers' acceptance of and adherence to lopinavir/ritonavir pellets as well as their underlying mechanisms. METHODS: A realist evaluation (a theory-driven evaluation method considering the social context and mechanisms of change), embedded in a clinical trial was carried out in three hospital settings in Kenya. Data were collected through document review, observations (n = 34) in home and clinic settings and semi-structured interviews (n = 44) with caregivers and providers. Data analysis was based on realist principles. RESULTS: High levels of treatment initiation and adherence were observed. Taste masking, neutral packaging and easy storage made the new formulation highly acceptable. Caregivers developed individual strategies to deliver the treatment, particularly to overcome specific problems e.g. in case of just-weaned babies or food shortage. A refined program theory emerged from the triangulated findings showing that ease of administration combined with increased self-efficacy and competences of the caregivers, and effective provider support contributed to high levels of adherence. CONCLUSIONS: Formulating combined antiretroviral treatment in the form of pellets is clearly a more acceptable solution for infants and children and their caregivers compared to the syrup. Further research in non-trial settings may shed light on factors related to providers, services and the health system that contribute to better adherence of such formulations.

Knowledge, Attitudes and Practices (KAP) on Rift Valley Fever among Pastoralist Communities of Ijara District, North Eastern Kenya.

Outbreaks of Rift Valley fever (RVF), a mosquito-borne viral zoonosis, have previously been associated with unusually heavy rainfall and extensive flooding. The disease is a serious public health problem in Africa and the Middle East, and is a potential global health threat. In Kenya, outbreaks of the disease have disproportionately affected impoverished pastoralist communities. This study sought to assess the knowledge, attitudes and practices (KAP) regarding RVF among the pastoralists of North Eastern Kenya, and to establish the determinants of KAP on RVF. A cross-sectional study involving 392 pastoralists living in Ijara district (Masalani and Ijara wards) was carried out using an interview questionnaire. All respondents interviewed (100%) had heard about RVF disease. They recognized that the disease is dangerous (99%), and had a positive attitude towards vaccination of animals (77%). However, few respondents knew that abortion (11%) and high mortality of young animals (10%) were key signs of RVF in animals. Very few (4%) use any form of protection when handling sick animals to avoid infection. Significant factors associated with knowledge were being in a household with a history of RVF infection (OR = 1.262, 95% CI = 1.099-1.447), having more livestock (OR = 1.285, 95% CI = 1.175-1.404) and the place of residence, Masalani (OR = 0.526, 95% CI = 0.480-0.576). Overall knowledge score on RVF was found to be a significant predictor of good preventive practice of the disease (OR = 1.073, 95% CI = 1.047-1.101). Despite the positive attitude that pastoralist communities have towards the prevention of RVF, there exist gaps in knowledge and good practices on the disease. Therefore there is need for public health education to address these gaps, and to identify and facilitate the removal of barriers to behavioural change related to the prevention of RVF.

Sociocultural and economic dimensions of Rift Valley fever.

Health researchers have advocated for a cross-disciplinary approach to the study and prevention of infectious zoonotic diseases, such as Rift Valley Fever. It is believed that this approach can help bring out the social determinants and effects of the zoonotic diseases for the design of appropriate interventions and public health policy. A comprehensive literature review using a systematic search strategy was undertaken to explore the sociocultural and economic factors that influence the transmission and spread of Rift Valley Fever. Although the findings reveal a paucity of social research on Rift Valley Fever, they suggest that livestock sacrificial rituals, food preparation and consumption practices, gender roles, and inadequate resource base for public institutions are the key factors that influence the transmission. It is concluded that there is need for cross-disciplinary studies to increase the understanding of Rift Valley Fever and facilitate appropriate and timely response and mitigation measures.

New pneumococcal conjugate vaccine introductions in four sub-Saharan African countries: a cross-country analysis of health systems' impacts.

BACKGROUND: Pneumonia is a main cause of under-five mortality in low-income settings. The pneumococcal conjugate vaccine (PCV) has been introduced in many countries as a tool in the disease's prevention. Although PCV's effectiveness has been established, less is known about the effects of introducing additional injectable vaccines into routine immunisation programmes, particularly in the context of resource-constrained settings. OBJECTIVES: To explore the effects of PCV introduction on the immunisation programmes and health systems in four low-income countries. METHODS: This study was carried out in Cameroon, Ethiopia, Kenya and Mali. Three to four regions and nine to 10 districts were selected within each country. Semi-structured interviews were carried out at national, regional and district levels (n=173). Researcher-administered questionnaires were completed with facility staff (n=124). Routine data on monthly vaccination activities were collected at district and facility levels. RESULTS: PCV was generally well integrated into existing routine immunisation. Little or no impact was found in most areas of the health systems. Some minor effects were found on immunisation programmes, particularly in areas with either planning activities or investments e.g. staff skills were strengthened and there were limited improvements in surveillance. Although health sector workers perceived increases in the coverage of other vaccines following the introduction of PCV, routine service data did not confirm this claim. No substantial impacts were seen in health system management, service delivery or performance. CONCLUSIONS: The introduction of PCV had marginal impacts on the Expanded Programme for Immunisation and little to none on broader health systems.

The impact of introducing new vaccines on the health system: case studies from six low- and middle-income countries.

OBJECTIVE: We aimed to explore the impacts of new vaccine introductions on immunization programmes and health systems in low- and middle-income countries. METHODS: We conducted case studies of seven vaccine introductions in six countries (Cameroon, PCV;Ethiopia, PCV; Guatemala, rotavirus; Kenya, PCV; Mali, Meningitis A; Mali, PCV; Rwanda, HPV). Inter-views were conducted with 261 national, regional and district key informants and questionnaires were completed with staff from 196 health facilities. Routine data from districts and health facilities were gathered on vaccination and antenatal service use. Data collection and analysis were structured around the World Health Organisation health system building blocks. FINDINGS: The new vaccines were viewed positively and seemed to integrate well into existing health systems. The introductions were found to have had no impact on many elements within the building blocks framework. Despite many key informants and facility respondents perceiving that the new vaccine introductions had increased coverage of other vaccines, the routine data showed no change. Positive effects perceived included enhanced credibility of the immunisation programme and strengthened health workers' skills through training. Negative effects reported included an increase in workload and stock outs of the new vaccine, which created a perception in the community that all vaccines were out of stock in a facility. Most effects were found within the vaccination programmes; very few were reported on the broader health systems. Effects were primarily reported to be temporary, around the time of introduction only. CONCLUSION: Although the new vaccine introductions were viewed as intrinsically positive, on the whole there was no evidence that they had any major impact, positive or negative, on the broader health systems.

Healthcare priority setting in Kenya: a gap analysis applying the accountability for reasonableness framework.

In resource-poor settings, the accountability for reasonableness (A4R) has been identified as an important advance in priority setting that helps to operationalize fair priority setting in specific contexts. The four conditions of A4R are backed by theory, not evidence, that conformance with them improves the priority setting decisions. This paper describes the healthcare priority setting processes in Malindi district, Kenya, prior to the implementation of A4R in 2008 and evaluates the process for its conformance with the conditions for A4R. In-depth interviews and focus group discussions with key players in the Malindi district health system and a review of key policy documents and national guidelines show that the priority setting process in the district relies heavily on guidelines from the national level, making it more of a vertical, top-down orientation. Multilateral and donor agencies, national government, budgetary requirements, traditions and local culture influence the process. The four conditions of A4R are present within the priority setting process, albeit to varying degrees and referred to by different terms. There exists an opportunity for A4R to provide a guiding approach within which its four conditions can be strengthened and assessed to establish whether conformance helps improve on the priority setting process.

Perceived risk factors and risk pathways of Rift Valley fever in cattle in Ijara district, Kenya.

Ijara district in Kenya was one of the hotspots of Rift Valley fever (RVF) during the 2006/2007 outbreak, which led to human and animal deaths causing major economic losses. The main constraint for the control and prevention of RVF is inadequate knowledge of the risk factors for its occurrence and maintenance. This study was aimed at understanding the perceived risk factors and risk pathways of RVF in cattle in Ijara to enable the development of improved community-based disease surveillance, prediction, control and prevention. A cross-sectional study was carried out from September 2012 to June 2013. Thirty-one key informant interviews were conducted with relevant stakeholders to determine the local pastoralists' understanding of risk factors and risk pathways of RVF in cattle in Ijara district. All the key informants perceived the presence of high numbers of mosquitoes and large numbers of cattle to be the most important risk factors contributing to the occurrence of RVF in cattle in Ijara. Key informants classified high rainfall as the most important (12/31) to an important (19/31) risk factor. The main risk pathways were infected mosquitoes that bite cattle whilst grazing and at watering points as well as close contact between domestic animals and wildlife. The likelihood of contamination of the environment as a result of poor handling of carcasses and aborted foetuses during RVF outbreaks was not considered an important pathway. There is therefore a need to conduct regular participatory community awareness sessions on handling of animal carcasses in terms of preparedness, prevention and control of any possible RVF epizootics. Additionally, monitoring of environmental conditions to detect enhanced rainfall and flooding should be prioritised for preparedness.

Accountable priority setting for trust in health systems--the need for research into a new approach for strengthening sustainable health action in developing countries.

Despite multiple efforts to strengthen health systems in low and middle income countries, intended sustainable improvements in health outcomes have not been shown. To date most priority setting initiatives in health systems have mainly focused on technical approaches involving information derived from burden of disease statistics, cost effectiveness analysis, and published clinical trials. However, priority setting involves value-laden choices and these technical approaches do not equip decision-makers to address a broader range of relevant values - such as trust, equity, accountability and fairness - that are of concern to other partners and, not least, the populations concerned. A new focus for priority setting is needed.Accountability for Reasonableness (AFR) is an explicit ethical framework for legitimate and fair priority setting that provides guidance for decision-makers who must identify and consider the full range of relevant values. AFR consists of four conditions: i) relevance to the local setting, decided by agreed criteria; ii) publicizing priority-setting decisions and the reasons behind them; iii) the establishment of revisions/appeal mechanisms for challenging and revising decisions; iv) the provision of leadership to ensure that the first three conditions are met.REACT - "REsponse to ACcountable priority setting for Trust in health systems" is an EU-funded five-year intervention study started in 2006, which is testing the application and effects of the AFR approach in one district each in Kenya, Tanzania and Zambia. The objectives of REACT are to describe and evaluate district-level priority setting, to develop and implement improvement strategies guided by AFR and to measure their effect on quality, equity and trust indicators. Effects are monitored within selected disease and programme interventions and services and within human resources and health systems management. Qualitative and quantitative methods are being applied in an action research framework to examine the potential of AFR to support sustainable improvements to health systems performance.This paper reports on the project design and progress and argues that there is a high need for research into legitimate and fair priority setting to improve the knowledge base for achieving sustainable improvements in health outcomes.

Engaging men who have sex with men in operations research in Kenya.

Research on men who have sex with men (MSM) in Africa is severely constrained. This paper examines the process of engaging MSM in research in a context where same-sex relationships are criminalised and socially stigmatised. Despite difficulties in researching MSM in Kenya, a convenient sample of 500 men was enrolled into a study aimed at understanding HIV/STI risks and prevention needs. Lessons drawn from this study highlight innovative methodological approaches and processes to working with and researching MSM in homophobic communities. Researchers willing to venture into MSM research in such contexts should be prepared to deal with among others, issues such as, seeking ethical approval for a study whose subjects are considered to engage in illegal activities, assuring study participants of their privacy and confidentiality and questioning of their own integrity. This study shows that despite difficulties, research of this kind can be carried out in Kenya.

Changing household composition and food security among the elderly caretakers in rural western Kenya.

A descriptive cross-sectional study including quantitative and qualitative methods was carried out in rural western Kenya to examine household composition and food security among the elderly caretakers. The findings indicate that the deteriorating economic conditions and HIV/AIDS pandemic have led to the increase in the number of children in need of care and the unprecedented involvement of the elderly in caretaking responsibilities. The presence of children in households of the elderly have changed household composition and introduced a different social context in which intergenerational relationships between grandparents and grandchildren have been redefined. Contrary to the past, it is no longer a desire but a routine responsibility of the elderly to provide food for the increasing number of dependant children in their households.