Incidences and factors associated with viral suppression or rebound among HIV patients on combination antiretroviral therapy from three counties in Kenya.

BACKGROUND: Limited data are available on the incidence and factors associated with viral rebound following viral suppression among HIV-infected individuals taking antiretroviral therapy (ART) in Kenya. Furthermore, the durability of viral suppression among HIV individuals taking ART is unknown. Information on incidence rates and factors associated with HIV viral load rebound and the durability of viral suppression (undetectable HIV copies in plasma) among HIV-infected individuals taking ART, will help improve the long-term management of HIV-infected individuals and explore approaches to long-term HIV remission or complete cure. OBJECTIVES: The objectives of this study were to investigate the incidence rates of viral rebound following viral suppression, factors associated with viral rebound, and the durability of viral suppression among HIV-infected individuals on ART from Kilifi, Meru, and Nakuru counties in Kenya. METHODS: This was a retrospective study involving 600 HIV-infected individuals taking combination ART (cART) and enrolled in comprehensive care centers (CCCs) at Malindi Sub-county Hospital, Nakuru Level 5 Hospital, and Meru Level 5 Hospital in Kenya. The medical files were inspected and medical history records abstracted for the selected participants. Participant laboratory data including HIV viral loads, types and history of ART, and treatment history of any opportunistic infections were abstracted using an abstraction checklist. Participants were grouped into those who achieved HIV viral suppression, with viral loads lower than the detection limit (LDL) (viral suppression), and those who experienced one or more detectable viral load measurements >40 copies/ml following the initial LDL (viral rebound). Durable viral suppression was defined as all viral load values at LDL over the 2-year period (2017-2019). Univariate and multivariate Poisson regression analyses were performed to assess the rates of viral rebound, as well as to investigate factors associated with it. RESULTS: Out of 549 HIV-positive patients, 324/549 (59%) achieved HIV viral suppression (Meru 159/194 (82%), Nakuru 21/178 (12%), and Malindi 144/177 (81%)). The overall viral rebound rate was 41%, with site-specific viral rebound of 88.2%, 18.6%, and 18.0% in Nakuru, Malindi, and Meru, respectively. There was an overall rate of first viral rebound of 3.9 (95% confidence interval (CI) 6.9-14.4), 0.7 (95% CI 0.5-1.0), and 0.89 (95% CI 0.64-1.24) per 100 person-months in Nakuru, Malindi, and Meru, respectively. Good ART adherence (p = 0.0002), widow status (p = 0.0062), and World Health Organization (WHO) stage I (p = 0.0002) were associated with viral suppression, while poor ART adherence (p < 0.0001), WHO stage II (p = 0.0024), and duration on ART of 36 months (p = 0.0350) were associated with viral rebound. CONCLUSIONS: The rate of viral suppression in patients on cART in the CCCs fell short of the WHO target. However, the study provides proof of evidence of undetectable viral load levels for more than 2 years, a sign that the United Nation's 2030 objective of controlling the risk of HIV transmission could be achieved.

Cellular immune responses against natural human papillomavirus infections among men in Kisumu, Kenya.

Human papillomavirus (HPV) is associated with ano-genital and cervical cancer. Persistence of oncogenic HPV genotypes is a requirement for development and progression of malignancies. Although, >70% of women clear incident HPV infections, data on natural history and HPV immunology among men is limited. To evaluate cell-mediated immune responses to natural HPV infections among men, we assessed cytokine responses on PBMCs collected from men with persistent or cleared HPV. Men with HPV clearance and those with HPV persistence had increased odds (6-times and 3-times respectively) of mounting cytokine responses compared to HPV uninfected men. Th1 cytokines IFN-γ (5.1-fold) and IL-2 (4.2-fold) were significantly (p < 0.0001) upregulated among men with HPV clearance compared to HPV uninfected men. Among men with HPV clearance compared to those with persistent HPV infection, only IFN-γ (2.4-fold) and IL-2 (3.0-fold) were significantly (p < 0.0001) upregulated. Th1 cell-mediated cytokine response was associated with natural HPV clearance in men.

Evaluating the effectiveness of the HIV adolescent package of care (APOC) training on viral load suppression in Kenya.

OBJECTIVES: To evaluate the effectiveness of the implementation of the adolescent package of care (APOC) training on adolescent viral suppression at Family AIDS Care & Education Services (FACES)-supported sites. STUDY DESIGN: The effect of APOC training was evaluated based on viral load suppression (<1000 copies/mL) of 10-19-year-olds in 13 FACES-supported sites in six months before (January 2015-August 2016) and after (November 2015-March 2017) the APOC training for each site. METHODS: Patient-level data were abstracted from the FACES electronic medical records (OpenMRS) and the National AIDS and STI Control Programme viral load website. Information on adolescent clinic day implementation and utilization of an APOC checklist as a proxy for services provided at each site was collected. Generalized estimating equations with repeated measures clustered by patients were used for bivariate and multivariate modeling to assess factors associated with viral suppression. RESULTS: In the pretraining period, 60% of adolescents received services at clinics offering adolescent clinic days compared to 95% in the post-training period. Among those tested, 65% were virally suppressed during the pretraining period compared to 72% during the post-training period (odds ratio [OR] = 1.31, 95% confidence interval [CI] 1.12, 1.53, P < 0.01). In multivariable analysis, there was no statistically significant change in viral load suppression due to APOC training (adjusted OR [aOR] = 0.97, 95% CI: 0.72, 1.30, P = 0.84). However, at clinics offering adolescent-friendly clinic days, adolescents were nearly 2 times more likely to be virally suppressed than at facilities not offering these specialized clinic days (aOR = 1.86, 95% CI: 1.04, 3.32, P = 0.04). CONCLUSIONS: This study suggests that adolescent clinic days greatly improve adolescent viral load suppression and should be considered for implementation across HIV programs.

Impact of a Rapid Results Initiative Approach on Improving Male Partner Involvement in Prevention of Mother to Child Transmission of HIV in Western Kenya.

A rapid results initiative (RRI) aimed at increasing male involvement in prevention of mother-to-child transmission (PMTCT) and service uptake among pregnant women at 116 antenatal clinics in Western Kenya was compared at baseline, during the RRI, and 3-months post-RRI. Male involvement increased from 7.4 to 54.2% during RRI (risk difference [RD] 0.47, CI 0.45-0.48) then 43.4% post-RRI (RD 0.36, CI 0.35-0.37). Among HIV-infected women, facility delivery increased from 40.0 to 49.9% (RD 0.10, 95% CI 0.06-0.13) and 65.0% post-RRI (RD 0.25, 95% CI 0.22-0.28). HIV-infected pregnant women linkage to HIV care increased from 58.6 to 85.9% (RD 0.27, CI 0.24-0.30) and 97.3% post-RRI (RD 0.39, CI 0.36-0.41). Time to ART initiation reduced from 29 days (interquartile range [IQR] 6-56) to 14 days (IQR 0-28) to 7 days (IQR 0-20). A male-centered RRI can significantly increase men's engagement in antenatal care leading to improved partner utilization of PMTCT and antenatal services.

Suicidality and associated risk factors in outpatients attending a general medical facility in rural Kenya.

BACKGROUND: Low-and-Middle-Income-Countries (LMICs) account for 75% of global suicides. While primary care populations in high-income countries (HIC) typically have higher prevalence of suicidal behavior relative to general populations, few studies have explored suicidal behavior among general medical outpatients in LMICs. This study addresses the research gap by characterizing potential risk factors for suicidal ideation in a large general medical outpatient setting in rural Kenya. METHODS: A cross-sectional study of adult general medical outpatients attending a rural sub-county hospital in Kaloleni, Kenya. Primary outcomes included major depressive disorder (MDD), posttraumatic stress disorder (PTSD) and suicidal behavior measured by the Mini International Neuropsychiatric Interview (MINI 5.0). We use binary logistic regression to model suicidality, mental disorders, intimate partner violence, and lifetime abuse. RESULTS: 394 outpatients completed the assessment. The prevalence of SI over the past month was 20%. 18% of those with suicidal ideation over the past month also attempted suicide in the past month. Participants who met criteria for MDD (suicidality item removed) were 19 times [CI: 4.56, 79.05] more likely to report suicidal ideation compared to those without MDD (adjusted odds ratio 12.15 [CI: 2.66, 55.49]). LIMITATIONS: This was a cross sectional study design with convenience sampling and hence vulnerable to selection and recall bias. CONCLUSION: The prevalence of SI and its strong association with actual suicide attempt in this population, make an urgent public health case for intervention. These data identify MDD as a highly significant correlate of SI.

Plasma concentrations of transforming growth factor beta 1 in non-progressive HIV-1 infection correlates with markers of disease progression.

The human immunodeficiency virus (HIV) infection shows variable rate of disease progression. The underlying biological and molecular mechanisms involved in determining progression of HIV infection are not fully understood. The aims of this study were to determine plasma concentrations of active TGF ß 1, Th1 and Th2 cytokines in patients with non-progressive and those with progressive HIV-1 infection, as well as to determine if there is an association of these cytokines to disease progression. In a cross-sectional study of 61 HIV-1 infected individuals categorized according to disease progression as having non-progressive HIV-1 infection (n=14) and progressive infection (n=47), plasma levels of active TGF ß 1, INF-γ, TNF-α, IL-10, IL-1ß, IL-12p70 and IL-13 were compared with HIV uninfected healthy controls (n=12). Plasma concentration of these cytokines was measured using a highly sensitive luminex200 XMAP assay. Pearson correlation test was used to assess the correlation of cytokines with CD4+ and CD8+ T cells, CD4:CD8 ratio and plasma HIV-1 RNA in the different study groups. Plasma concentrations of TGF ß 1 and IL-10 were significantly decreased while IL-1ß, IL-12p70 and TNF-α were increased in patients with non-progressive HIV-1 infection compared to patients with progressive infection. Plasma levels of TGF ß 1 and IL-10 showed an inverse correlation with CD8+ T cell counts and CD4:CD8 ratios in patients with non-progressive HIV-1 infection, while plasma HIV-1 RNA positively correlated with CD4+ T cell counts. Plasma levels of TNF-α, IL-1ß, IL-12p70 and IL-13 positively correlated with CD4+ T cell counts and inversely correlated with plasma HIV-1 RNA, CD8+ T cell count and CD4:CD8 ratio in patients with non-progressive infection. The correlation of cytokines to the state of T-lymphocyte and plasma HIV-1 RNA found in this study may provide insight into the role of cytokines in both progressive and non-progressive HIV-1 infection. Additionally, these findings may have implications for systemic cytokine-based therapies in HIV-1 infection.

Loss to follow-up among youth accessing outpatient HIV care and treatment services in Kisumu, Kenya.

Youth are particularly vulnerable to acquiring HIV, yet reaching them with HIV prevention interventions and engaging and retaining those infected in care and treatment remains a challenge. We sought to determine the incidence rate of loss to follow-up (LTFU) and explore socio-demographic and clinical characteristics associated with LTFU among HIV-positive youth aged 15-21 years accessing outpatient care and treatment clinics in Kisumu, Kenya. Between July 2007 and September 2010, youth were enrolled into two different HIV care and treatment clinics, one youth specific and the other family oriented. An individual was defined as LTFU when absent from the HIV treatment clinic for ≥ 4 months regardless of their antiretroviral treatment status. The incidence rate of LTFU was calculated and Cox regression analysis used to identify factors associated with LTFU. A total of 924 youth (79% female) were enrolled, with a median age of 20 years (IQR 18-21). Over half, (529 (57%)), were documented as LTFU, of whom 139 (26%) were LTFU immediately after enrolment. The overall incidence rate of LTFU was 52.9 per 100 person-years (p-y). Factors associated with LTFU were pregnancy during the study period (crude HR 0.68, 95% CI 0.53-0.89); CD4 cell count >350 (adjusted hazard ratios (AHR) 0.59, 95% CI 0.39-0.90); not being on antiretroviral therapy (AHR 4.0, 95% CI 2.70-5.88); and non-disclosure of HIV infection status (AHR 1.43, 95% CI 1.10-1.89). The clinic of enrolment, age, marital status, employment status, WHO clinical disease stage and education level were not associated with LTFU. Interventions to identify and enrol youth into care earlier, support disclosure, and initiate ART earlier may improve retention of youth and need further investigation. Further research is also needed to explore the reasons for LTFU from care among HIV-infected youth and the true outcomes of these patients.

CD4+ T cell counts in initiation of antiretroviral therapy in HIV infected asymptomatic individuals; controversies and inconsistencies.

The primary goal when devising strategies to define the start of therapy in HIV infected individuals is to avoid HIV disease progression and toxicity from antiretroviral therapy (ART). Intermediate goals includes, avoiding resistance by suppressing HIV replication, reducing transmission, limiting spread and diversity of HIV within the body and protecting the immune system from harm. The question of how early or late to start ART and achieve both primary and intermediate goals has dominated HIV research. The distinction between early and late treatment of HIV infection is currently a matter of CD4+ T cells count, a marker of immune status, rather than on viral load, a marker of virus replication. Discussions about respective benefits of early or delayed therapy, as well as the best CD4+ T cell threshold during the course of HIV infection at which ART is initiated remains inconclusive. Guidelines issued by various agencies, provide different initiation recommendations. This can be confusing for clinicians and policy-makers when determining the best time to initiate therapy. Optimizing ART initiation strategies are clearly complex and must be balanced between individual and broader public health needs. This review assesses available data that contributes to the debate on optimal time to initiate therapy in HIV-infected asymptomatic individuals. We also review reports on CD4+ T cell threshold to guide initiation of ART and finally discuss arguments for and against early or late initiation of ART.

Impact of loop electrosurgical excision procedure for cervical intraepithelial neoplasia on HIV-1 genital shedding: a prospective cohort study.

OBJECTIVE: We sought to examine the impact of the loop electrosurgical excision procedure (LEEP) on the rate and magnitude of HIV-1 genital shedding among women undergoing treatment for cervical intraepithelial neoplasia 2/3 (CIN2/3). DESIGN: Prospective cohort study. POPULATION: Women infected with HIV-1 undergoing LEEP for CIN2/3 in Kisumu, Kenya. METHODS: Participants underwent specimen collection for HIV-1 RNA prior to LEEP and at 1, 2, 4, 6, 10, and 14 weeks post-LEEP. HIV-1 viral load was measured in cervical and plasma specimens using commercial real-time polymerase chain reaction (PCR) assays, to a lower limit of detection of 40 copies per specimen. MAIN OUTCOME MEASURES: Presence and magnitude of HIV-1 RNA (copies per specimen or cps) in post-LEEP specimens, compared with baseline. RESULTS: Among women on highly active antiretroviral therapy (HAART), we found a statistically significant increase in cervical HIV-1 RNA concentration at week 2, with a mean increase of 0.43 log10 cps (95% CI 0.03-0.82) from baseline. Similarly, among women not receiving HAART, we found a statistically significant increase in HIV-1 shedding at week 2 (1.26 log10 cps, 95% CI 0.79-1.74). No other statistically significant increase in concentration or detection of cervical HIV-1 RNA at any of the remaining study visits were noted. CONCLUSIONS: In women infected with HIV undergoing LEEP, an increase in genital HIV shedding was observed at 2 but not at 4 weeks post-procedure. The current recommendation for women to abstain from vaginal intercourse for 4 weeks seems adequate to reduce the theoretical increased risk of HIV transmission following LEEP.

The impact of routine cryptococcal antigen screening on survival among HIV-infected individuals with advanced immunosuppression in Kenya.

OBJECTIVES: To test the hypothesis that a screening and treatment intervention for early cryptococcal infection would improve survival among HIV-infected individuals with low CD4 cell counts. METHODS: Newly enrolled patients at Family AIDS Care and Education Services (FACES) in Kenya with CD4 ≤ 100 cells/µl were tested for serum cryptococcal antigen (sCrAg). Individuals with sCrAg titre ≥ 1:2 were treated with high-dose fluconazole. Cox proportional hazard models of Kaplan-Meier curves were used to compare survival among individuals with CD4 ≤ 100 cells/µl in the intervention and historical control groups. RESULTS: The median age was 34 years [IQR: 29,41], 54% were female, and median CD4 was 43 cells/µl [IQR: 18,71]. Follow-up time was 1224 person-years. In the intervention group, 66% (514/782) were tested for sCrAg; of whom, 11% (59/514) were sCrAg positive. Mortality was 25% (196/782) in the intervention group and 25% (191/771) in the control group. There was no significant difference between the intervention and control group in overall survival [hazard ratio (HR): 1.1 (95%CI:0.9,1.3)] or three-month survival [HR: 1.0 (95%CI:0.8,1.3)]. Within the intervention group, sCrAg-positive individuals had significantly lower survival rates than sCrAg-negative individuals [HR:1.8 (95%CI: 1.0, 3.0)]. CONCLUSIONS: A screening and treatment intervention to identify sCrAg-positive individuals and treat them with high-dose fluconazole did not significantly improve overall survival among HIV-infected individuals with CD4 counts ≤ 100 cells/µl compared to a historical control, perhaps due to intervention uptake rates or poor efficacy of high-dose oral fluconazole.

Pregnancy and HIV transmission among HIV-discordant couples in a clinical trial in Kisumu, Kenya.

OBJECTIVES: A large proportion of new HIV infections in sub-Saharan Africa occur in stable HIV-discordant partnerships. In some couples, the strong desire to conceive a child may lead to risky behaviour despite knowledge of discordant serostatus. Our objective was to compare HIV transmission between discordant couples who did and did not conceive during participation in a clinical trial. METHODS: Five hundred and thirty-two HIV-discordant couples were followed for up to 2 years in Kisumu, Kenya as part of the Partners in Prevention HSV/HIV Transmission Study. Quarterly HIV-1 antibody and urine pregnancy test results were analysed. RESULTS: Forty-one HIV-1 seroconversions occurred over 888 person-years of follow-up, resulting in an annual incidence of 4.6/100 person-years. Twenty seroconversions occurred among 186 HIV-1-uninfected individuals in partnerships in which pregnancy occurred (10.8% of HIV-1-negative partners in this group seroconverted), in comparison to 21 seroconversions among 353 uninfected individuals in partnerships in which pregnancy did not occur (5.9% of HIV-1-negative partners seroconverted), resulting in a relative risk of 1.8 [95% confidence interval (CI) 1.01-3.26; P<0.05]. CONCLUSIONS: Pregnancy was associated with an increased risk of HIV seroconversion in discordant couples. These data suggest that the intention to conceive among HIV discordant couples may be contributing to the epidemic.

Use of personal digital assistants for data collection in a multi-site AIDS stigma study in rural south Nyanza, Kenya.

OBJECTIVES: To describe the development, cost effectiveness and implementation of a PDA based electronic system to collect, verify and manage data from a multi-site study on HIV/AIDS stigma and pregnancy in a rural, resource-poor area. METHODS: We worked within a large prevention of mother-to-child-transmission (PMTCT) program in nine rural health facilities to implement a PDA-based data collection system and to study the feasibility of its use in a multisite HIV research study in rural Kenya. The PDAs were programmed for collecting screening and eligibility data, and responses to structured interviews on HIV/AIDS stigma and violence in three local languages. RESULTS: Between November 2007 and December 2008, nine PDAs were used by Clinic and Community Health Assistants to enrol 1,270 participants on to the PMTCT program. Successes included: capacity-building of interviewers, low cost of implementation, quick turnaround time of data entry with good data quality, and convenience. CONCLUSION: Our study demonstrated the feasibility of utilizing PDAs for data collection in a multi-site observational study on HIV/AIDS stigma conducted in remote rural health facilities in Kenya. However, appropriate and frequent data backup protocols need to be established and paper forms are still needed as backup tools in resource-poor settings.

Prevalence and risk factors for sexually transmitted infections in a high-risk occupational group: the case of fishermen along Lake Victoria in Kisumu, Kenya.

The aim of this study was to assess prevalence and risk factors for sexually transmitted infections (STIs) among fishermen along Lake Victoria, Kenya. This cross-sectional study surveyed 250 fishermen from beaches in Kisumu District using proportional-to-size sampling based on the number of registered boats per beach. Participants provided demographic and sexual behaviour information, blood for HIV-1 herpes simplex virus type 2 (HSV-2) and syphilis serological tests urine for transcription-mediated amplification assays for Neisseria gonorrhoeae and Chlamydia trachomatis and penile and scrotal swabs for human papillomavirus (HPV) DNA assay. Consistent condom use with the three most recent sexual partners was reported by 30%; 38% reported concurrent sexual partnerships and 65% reported ever having transactional sex. HIV seroprevalence was 26%, HSV-2 seroprevalence by Western blot assay was 58% and 9.5% were rapid plasma reagin and Treponema pallidum particle agglutination assay positive. Genital HPV DNA of any type was detected in 57.2% with 74% of these having two or more HPV types. C. trachomatis and N. gonorrhoeae were detected in 3.2% and 1.2% respectively. Risk factors for syphilis seropositivity included working on multiple beaches during the past year (adjusted odds ratio [AOR] 3.81; 95% confidence interval [CI] 1.29-11.28). HPV infection was associated with owning a radio which is a marker for higher socioeconomic status (AOR 6.33; 95% CI 2.94-7.14) and reporting transactional sex with the most recent sexual partner (AOR 3.03; 95% CI 1.23-7.69). In conclusion, 90% of fishermen had evidence of one or more STIs. This exceptionally high-risk occupational group represents a high priority for preventive interventions.

Genital hygiene practices of fishermen targeted for a topical microbicide intervention against sexually transmitted infections in Kisumu, Kenya.

Research on hygiene has been relatively limited in the current era of rigorous observational studies and clinical trials. We set out to investigate the perception and practices of genital hygiene among fishermen working on the beaches along Lake Victoria, targeted for a topical male microbicide hygiene intervention. We conducted 12 focus group discussions involving fishermen (n = 130), recording the discussions in Dholuo (the local language) and transcribing them verbatim before translating into English. Transcripts were double-coded and analysed using constant comparative analysis. Despite easy access to lake water and recognition of a link that may exist between poor genital hygiene and the risk of penile infection and poor sexual relationships, few fishermen regularly washed their genitalia due to fear/embarrassment from cleaning their genitalia in public, traditional Luo beliefs such as that washing with soap would reduce the fish catch, lack of time because of their busy schedules, laziness and lack of responsibility, and excessive consumption of alcohol and illicit drugs. Hygiene practices of the fishermen were poor and could contribute to genital infections including sexually transmitted infections. Given the fishermen's poor genital hygiene practices, they may benefit from hygiene intervention, including that provided by penile microbicides, which can be applied in the privacy of their bedrooms.

Acyclovir and transmission of HIV-1 from persons infected with HIV-1 and HSV-2.

BACKGROUND: Most persons who are infected with human immunodeficiency virus type 1 (HIV-1) are also infected with herpes simplex virus type 2 (HSV-2), which is frequently reactivated and is associated with increased plasma and genital levels of HIV-1. Therapy to suppress HSV-2 reduces the frequency of reactivation of HSV-2 as well as HIV-1 levels, suggesting that suppression of HSV-2 may reduce the risk of transmission of HIV-1. METHODS: We conducted a randomized, placebo-controlled trial of suppressive therapy for HSV-2 (acyclovir at a dose of 400 mg orally twice daily) in couples in which only one of the partners was seropositive for HIV-1 (CD4 count, > or = 250 cells per cubic millimeter) and that partner was also infected with HSV-2 and was not taking antiretroviral therapy at the time of enrollment. The primary end point was transmission of HIV-1 to the partner who was not initially infected with HIV-1; linkage of transmissions was assessed by means of genetic sequencing of viruses. RESULTS: A total of 3408 couples were enrolled at 14 sites in Africa. Of the partners who were infected with HIV-1, 68% were women, and the baseline median CD4 count was 462 cells per cubic millimeter. Of 132 HIV-1 seroconversions that occurred after randomization (an incidence of 2.7 per 100 person-years), 84 were linked within couples by viral sequencing: 41 in the acyclovir group and 43 in the placebo group (hazard ratio with acyclovir, 0.92, 95% confidence interval [CI], 0.60 to 1.41; P=0.69). Suppression with acyclovir reduced the mean plasma concentration of HIV-1 by 0.25 log(10) copies per milliliter (95% CI, 0.22 to 0.29; P<0.001) and the occurrence of HSV-2-positive genital ulcers by 73% (risk ratio, 0.27; 95% CI, 0.20 to 0.36; P<0.001). A total of 92% of the partners infected with HIV-1 and 84% of the partners not infected with HIV-1 remained in the study for 24 months. The level of adherence to the dispensed study drug was 96%. No serious adverse events related to acyclovir were observed. CONCLUSIONS: Daily acyclovir therapy did not reduce the risk of transmission of HIV-1, despite a reduction in plasma HIV-1 RNA of 0.25 log(10) copies per milliliter and a 73% reduction in the occurrence of genital ulcers due to HSV-2. (ClinicalTrials.gov number, NCT00194519.)

Assessment of acute trauma care training in Kenya.

An Acute Trauma Care (ATC) course was adapted for resource-limited healthcare systems based on the American model of initial care for injured patients. The course was taught to interested medical personnel in Kenya. This study undertook a survey of the participants' healthcare facilities to maximize the applicability of ATC across healthcare settings. The ATC course was conducted three times in Kenya in 2006. A World Health Organization (WHO) Needs Assessment survey was administered to 128 participants. The data were analyzed qualitatively and quantitatively. Ninety-two per cent had a physician available in the emergency department and 63 per cent had a clinical officer. A total of 71.7 per cent reported having a designated trauma room. A total of 96.7 per cent reported running water, but access was uninterrupted more often in private hospitals as opposed to public facilities (92.5 vs 63.6%, P = 0.0005). Private and public employees equally had an oxygen cylinder (95.6 vs 98.5%, P > 0.05), oxygen concentrator (69.2 vs 54.2%, P = 0.12), and oxygen administration equipment (95.7 vs 91.4%, P > 0.05) at their facilities. However, private employees were more likely to report that "all" of their equipment was in working order (53 vs 7.9%, P < 0.0001). Private employees were also more likely to report that they had access to information on emergency procedures and equipment (64.4 vs 33.3%, P = 0.001) and that they had learned new procedures (54.8 vs 25.4%, P = 0.002). Despite a perception of public facility lack, this survey showed that public institutions and private institutions have similar basic equipment availability. Yet, problems with equipment malfunction, lack of repair, and availability of required information and training are far greater in the public sector. The content of the ATC course is valid for both private and public sector institutions, but refinements of the course should focus on varying facets of inexpensive and alternative equipment resources. Furthermore, the implementation of this course should create a setting that advocates, promotes, and investigates resources. The WHO survey can guide future research in understanding impediments to implementing essential trauma care courses for resource limited healthcare systems.

HIV/AIDS and maternity care in Kenya: how fears of stigma and discrimination affect uptake and provision of labor and delivery services.

Although policies and programs exist to promote safe motherhood in sub-Saharan Africa, maternal health has not improved and may be deteriorating in some countries. Part of the explanation may be the adverse effects of HIV/AIDS on maternity care. We conducted a study in Kisumu, Kenya to explore how fears related to HIV/AIDS affect women's uptake and health workers' provision of labor and delivery services. In-depth qualitative interviews with 17 maternity workers, 14 pregnant or postpartum women, four male partners and two traditional birth attendants; as well as structured observations of 22 births; were conducted at four health facilities. Participants reported that fears of HIV testing; fears of involuntary disclosure of HIV status to others, including spouses; and HIV/AIDS stigma are among the reasons that women avoid delivering in health facilities. Maternity workers now have to take into account the HIV status of the women they serve (as well as their own fears of becoming infected and stigmatized) but do not seem to be adequately prepared to handle issues related to consent, confidentiality and disclosure. Importantly, it appeared that women of unknown HIV status during labor and delivery were likely to be targets of stigma and discriminatory practices and that these women were not receiving needed counseling services. The findings suggest that increasing infection control precautions will not be enough to address the challenges faced by maternity care providers in caring for women in high-HIV-prevalence settings. Maternity workers need enhanced culturally sensitive training regarding consent, confidentiality and disclosure. Furthermore, this study points to the necessity of paying more attention to the care of women of unknown HIV-serostatus during labor and delivery. Such interventions may improve the quality of maternity care, increase utilization and contribute to overall improvements in maternal health, while also enhancing prevention of mother-to-child-transmission and HIV care.

Sexual and demographic determinants for herpes simplex virus type 2 among fishermen along Lake Victoria, Kenya.

OBJECTIVES: To determine the prevalence and correlates of herpes simplex virus type 2 (HSV-2) seropositivity among fishermen along the shores of Lake Victoria in Kisumu district, Kenya. METHODS: Sera from a random sample of 250 fishermen from 18 beaches were collected after a detailed sociodemographic interview. HSV-2 infection was tested by Kalon HSV-2 ELISA. RESULTS: The HSV-2 seroprevalence was 63.9%. In multivariate analysis, fishermen were more likely to be infected with HSV-2 if they were HIV positive (prevalence ratio (PR) 1.27; 95% CI 1.06 to 1.52) compared with those testing HIV negative, were aged 18-20 (PR 0.49; 95% CI 0.24 to 0.99) and older than 40 (PR 1.66; 95% CI 1.30 to 2.14) years compared with those aged 21-25 years, perceived their last two sexual partners to have a sexually transmitted infection (STI; PR 1.27; 95% CI 1.06 to 1.52) compared with those who did not and were more likely to be circumcised (PR 1.49; 95% CI 1.19 to 1.86). CONCLUSIONS: HSV-2 seroprevalence is high among this population and is associated with HIV serostatus, age, perception about partner's STI status and circumcision.

Management of simulated patients with sexually transmitted infections by staff of retail pharmacies in Kibera slums of Nairobi.

OBJECTIVE: To evaluate the treatment suggested to sexually transmitted infections (STI) self-medicating patients in retail pharmacies. DESIGN: A descriptive cross-sectional survey. SETTING: Kibera slum, Nairobi City, Kenya. SUBJECTS: Staff of 50 convenient randomly selected retail pharmacies. RESULTS: The majority (97%) of the pharmacy staff who attended to self-medicating patients asked questions. Most of these questions centered around the onset of the stated symptoms, the health of the partner, patient's current health status and previous medications taken. Of the 99 staff evaluated, 60% correctly diagnosed gonorrhoea and 82% correctly diagnosed genital ulcer disease (GUD). Only nine out of fifty (18%) offered the recommended treatment for gonorrhoea and only one individual offered recommended treatment for GUD. The most commonly offered treatment for gonorrhoea and GUD was metronidazole and penicillin, respectively. Overall, only 10% correctly diagnosed both conditions and offered appropriate treatment. The staff also counselled patients on a wide range of issues including condom use, abstinence and being faithful, contact treatment, seeking prompt treatment and completing treatment. CONCLUSION: With only about 10% offering appropriate government recommended treatment for gonorrhoea and GUD, these pharmacy staff working in retail pharmacies in Kibera slum put slum dwellers seeking care at an increased risk of STI related morbidity and transmission due to inappropriate or inadequate treatment. RECOMMENDATION: To improve management of these conditions, in-service training and enforcement of the relevant legislation and policy is needed.

Epidemiology of human papillomavirus infection among fishermen along Lake Victoria Shore in the Kisumu District, Kenya.

OBJECTIVES: The epidemiology of human papillomavirus (HPV) infection in men in Kenya is largely uncharacterized. We set out to determine the prevalence and determinants of HPV infection among sexually active fishermen along Lake Victoria in the Kisumu district of Kenya. METHODS: Genital swabs were obtained from 250 consenting fishermen from 18 beaches and a detailed sociodemographic questionnaire was administered. HPV positivity was determined by polymerase chain reaction amplification and detected by dot blot hybridisation with generic HPV and beta-globin probes. HPV positive samples were genotyped using the Roche Linear array assay. RESULTS: Overall, 144 (57.6%) fishermen had detectable HPV DNA, 106 (42.4%) were infected with oncogenic HPV types, with HPV-16 being the most frequent type (12.4%). Among HPV positive men, 105 (72.9%) were infected with more than one HPV type and 20 (13.9%) were infected with more than six different types. HIV seropositive men (PR 1.49, 95% CI 1.19 to 1.86) and those divorced or separated (PR 1.62, 95% CI 1.13 to 2.33) were more likely to be infected with HPV. HIV infection (PR 1.22, 95% CI 1.01 to 1.47) was the only factor independently associated with infection with multiple types of HPV. CONCLUSION: The prevalence of oncogenic HPV infection is high among this population and is associated with HIV serostatus and marital status. This community could benefit from enhanced sexually transmitted infection and HIV prevention interventions.