Diabetes mellitus and associated risk factors among HIV infected patients on HAART.

BACKGROUND: Understanding the impact of disease associations is becoming a priority in Kenya and other countries bearing the load of infectious diseases. With the increased incidences of non-communicable diseases and the endemicity of infectious diseases in Sub-Saharan Africa, their co-existence poses significant challenges to patients, health workers and an overwhelmed health sector. Classical risk factors for diabetes such as physical inactivity and unhealthy diet may not solely explain the current trends, suggesting the role of novel risk factors including infections/inflammation. HIV and its treatment have been identified as potential contributors especially to patients with family history of confirmed diabetes cases. Co-infections frequently observed during HIV infection also significantly influence both the epidemiological and pathophysiological of the link between HIV and diabetes. Understanding the correlates of HIV and diabetes is crucial to inform management and prevention strategies of the twin infections. We therefore aimed to determine the prevalence of diabetes mellitus and risk factors in a population of HIV infected patients on HAART. This study determined the association of diabetes/impaired glucose regulation in the context of HIV-1. A cross-sectional study was conducted at a comprehensive care clinic in Nairobi (Kenya). Participants were screened for diabetes and impaired glucose regulation using random blood glucose and glycated haemoglobin (HbA1c) This paper describes the prevalence of diabetes mellitus in Human Immunodeficiency Virus positive individuals and the associated risk factors. We have demonstrated that family history is a risk factor for diabetes. While age and BMI are known risk factors, they were not associated with diabetes in this study.

Childhood mortality and associated factors in Migori County, Kenya: evidence from a cross-sectional survey.

OBJECTIVES: The under-five mortality (U5M) rate in Kenya (41 per 1000 live births) remains significantly above international goals (25 per 1000 live births). This is further exacerbated by regional inequalities in mortality. We aimed to describe U5M in Migori County, Kenya, and identify associated factors that can serve as programming targets. DESIGN: Cross-sectional observational survey. SETTING: Areas served by the Lwala Community Alliance and control areas in Migori County, Kenya. PARTICIPANTS: This study included 15 199 children born to respondents during the 18 years preceding the survey. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was mortality in the first 5 years of life. The survey was powered to detect a 10% change in various health metrics over time with 80% power. RESULTS: A total of 15 199 children were included in the primary analyses, and 230 (1.5%) were deceased before the fifth birthday. The U5M rate from 2016 to 2021 was 32.2 per 1000 live births. Factors associated with U5M included year of birth (HR 0.926, p<0.001), female sex (HR 0.702, p=0.01), parental marriage (HR 0.642, p=0.036), multiple gestation pregnancy (HR 2.776, p<0.001), birth spacing less than 18 months (HR 1.894, p=0.005), indoor smoke exposure (HR 1.916, p=0.027) and previous familial contribution to the National Hospital Insurance Fund (HR 0.553, p=0.009). The most common cause of death was malaria. CONCLUSIONS: We describe factors associated with childhood mortality in a Kenyan community using survival analyses of complete birth histories. Mortality rates will serve as the baseline for future programme evaluation as a part of a 10-year study design. This provides both the hyperlocal information needed to improve programming and generalisable conclusions for other organisations working in similar environments.

Training and experience outperform literacy and formal education as predictors of community health worker knowledge and performance, results from Rongo sub-county, Kenya.

Introduction: There is a growing recognition that Community Health Workers are effective at improving health outcomes and expanding health access. However, the design elements that lead to high-quality Community Health Worker programing are relatively understudied. We looked at the predictors of Community Health Worker knowledge of obstetric and early infant danger signs as well as performance in achieving antenatal care and immunization uptake among their clients. Methods: The study takes place in the context of an intervention implemented jointly by Lwala Community Alliance and the Kenya Ministry of Health which sought to professionalize Community Health Worker cadres through enhanced training, payment, and supervision. There were four cohorts included in the study. Two cohorts started receiving the intervention prior to the baseline, one cohort received the intervention between the baseline and endline, and a final cohort did not receive the intervention. Data on Community Health Worker demographics, knowledge tests, and key performance indicators were collected for 234 Community Health Workers. Regression analyses were used to explore education, literacy, experience, training, and gender as potential predictors of CHW performance. Results: We found that clients of Community Health Workers trained through the intervention were 15% more likely to be fully immunized and 14% more likely to have completed four or more antenatal care visits. Additionally, recency of training and experience caring for pregnant women were associated with increased Community Health Worker knowledge. Finally, we found no association between gender and CHW competency and tenuous associations between education/literacy and Community Health Worker competency. Discussion: We conclude that the intervention was predictive of increased Community Health Worker performance and that recency of training and experience were predictive of increased knowledge. Though education and literacy are often used in the selection processes of Community Health Workers globally, the link between these characteristics and Community Health Worker knowledge and performance are mixed. Thus, we encourage further research into the predictive value of common Community Health Worker screening and selection tools. Further, we encourage policymakers and practitioners to reconsider the use of education and literacy as means of Community Health Worker selection.

Predictors of under-five healthcare utilization in Rongo sub-county of Migori County, Kenya: results of a population-based cross-sectional survey.

Introduction: to achieve the sustainable development goal for child survival, we must better understand the socioeconomic characteristics, household behaviors and access to community health services which predict care utilization for children. This study assessed predictors of health care utilization for children under five in Migori County, Kenya. Methods: we used multivariable logistic regression in the context of an integrated health intervention which employed paid, trained, and supervised community health workers (CHWs), inclusive of traditional birth attendants (TBAs). The intervention was delivered with Ministry of Health in one of five geographies included in the study. Results: community health workers (CHW) home visits were associated with a two-fold increase in care seeking for children with respiratory symptoms. Following implementation of a CHW-led malaria intervention, the use of malaria rapid diagnostic tests increased, while fever prevalence decreased. Households in the intervention area were three times more likely to seek care for their child´s fever. Increased care utilization for children with fever was positively associated with male partner attendance at antenatal care visits and negatively associated with skilled delivery and recognition of warning signs. Care utilization for respiratory symptoms was positively associated with caregiver education and negatively associated with household size. Care utilization for diarrhea was positively associated with having a recent under-five death in the household. Conclusion: the study suggests that trained and motivated CHWs may be an effective tool for improving care utilization for children. Further, the study builds on evidence of male partner involvement and caregiver education as predictors of child care utilization.

The Prevalence of Interpersonal Violence (IPV) Against Women and its Associated Variables: An Exploratory Study in the Rongo Sub-County of Migori County, Kenya.

Interpersonal violence (IPV) within intimate partner relationships and gender-based violence remain major public health problems worldwide; 44.8% of Kenyan women have reported experiencing IPV beginning after the age of 15 years (National Bureau of Statistics Nairobi, Kenya, 2015). Combatting IPV and its sequelae is integral to promoting gender equality, a key target of the Sustainable Development Goals. We quantify the lifetime prevalence of IPV among women in two rural Kenyan communities, as well as factors associated with IPV in this area, such as educational attainment and severe depression. We conducted a cross-sectional population-based survey of households in the North and East Kamagambo wards of Migori County, Kenya in May 2018. A questionnaire regarding IPV was given to female respondents. Group-wise comparisons and multiple logistic regression analyses were performed to describe community prevalence and factors associated with IPV against women. A total of 873 women completed questions about IPV, representing a population estimate of 11,252 women in the study area. Lifetime IPV prevalence in the study area was 60.3%. Variables associated with IPV included involvement in a polygamous marriage (adjusted odds ratio [aOR]: 1.81; 95% confidence interval [CI]: [1.13, 2.88]; p = .013), attaining six or fewer years of education (aOR: 1.84; 95% CI: [1.27, 2.66]; p = .001), and IPV exposure in girlhood (aOR: 1.59; 95% CI: [1.12, 2.28]; p = .011). IPV was independently associated with experience of emotional abuse (OR: 11.22; 95% CI: [7.02, 17.95]; p < .001) and severe depression (OR: 3.51; 95% CI: [1.03, 11.97]; p = .045). Violence against women is a public health emergency in Migori County, Kenya. Low educational attainment, IPV exposure in girlhood, and polygamy were significantly associated with experience of IPV. Our results provide hyper-local data necessary for targeted interventions and generalizable data with sampling methods for use by other implementing organizations in sub-Saharan Africa.

Characterizing multidimensional poverty in Migori County, Kenya and its association with depression.

INTRODUCTION: Narrow, unidimensional measures of poverty often fail to measure true poverty and inadequately capture its drivers. Multidimensional indices of poverty more accurately capture the diversity of poverty. There is little research regarding the association between multidimensional poverty and depression. METHODS: A cross-sectional survey was administered in five sub-locations in Migori County, Kenya. A total of 4,765 heads of household were surveyed. Multidimensional poverty indices were used to determine the association of poverty with depression using the Patient Health Questionnaire (PHQ-8) depression screening tool. RESULTS: Across the geographic areas surveyed, the overall prevalence of household poverty (deprivation headcount) was 19.4%, ranging from a low of 13.6% in Central Kamagambo to a high of 24.6% in North Kamagambo. Overall multidimensional poverty index varied from 0.053 in Central Kamagambo to 0.098 in North Kamagambo. Of the 3,939 participants with depression data available, 481 (12.2%) met the criteria for depression based on a PHQ-8 depression score ≥10. Poverty showed a dose-response association with depression. CONCLUSIONS: Multidimensional poverty indices can be used to accurately capture poverty in rural Kenya and to characterize differences in poverty across areas. There is a clear association between multidimensional poverty and depressive symptoms, including a dose effect with increasing poverty intensity. This supports the importance of multifaceted poverty policies and interventions to improve wellbeing and reduce depression.

Population-based socio-demographic household assessment of livelihoods and health among communities in Migori County, Kenya over multiple timepoints (2021, 2024, 2027): A study protocol.

Migori County is located in western Kenya bordering Lake Victoria and has traditionally performed poorly on important health metrics, including child mortality and HIV prevalence. The Lwala Community Alliance is a non-governmental organization that serves to promote the health and well-being of communities in Migori County through an innovative model utilizing community health workers, community committees, and high-quality facility-based care. This has led to improved outcomes in areas served, including improvements in childhood mortality. As the Lwala Community Alliance expands to new programming areas, it has partnered with multiple academic institutions to rigorously evaluate outcomes. We describe a repeated cross-sectional survey study to evaluate key health metrics in both areas served by the Lwala Community Alliance and comparison areas. This will allow for longitudinal evaluation of changes in metrics over time. Surveys will be administered by trained enumerators on a tablet-based platform to maintain high data quality.

Determinants of modern contraceptive prevalence and unplanned pregnancies in Migori County, Kenya: results of a cross-sectional household survey.

Family planning and contraceptive utilization can have significant effects in reducing unplanned pregnancies and improving maternal and child health indicators. We conducted a retrospective cross-sectional study analyzing survey response data within six sub-locations of Migori County, Kenya in 2018 and 2019. We utilize this survey data to estimate both the prevalence of contraceptive uptake and unwanted pregnancies in the study populations, and to examine the potential role that different factors play in meeting related family planning targets. Descriptive statistics were calculated, and multivariable logistic regression was used to model determinants of contraceptive use and reported unplanned pregnancy. A total of 3,642 female heads of household were included. 63% of respondents reported that they currently use some form of contraception, and the prevalence of unplanned pregnancy was 36.7%. Our findings reflect the need for family planning programs to focus interventions on those at highest risk. There is a need for additional research and investigation into community and individual beliefs surrounding family planning in order to ensure that interventions are culturally sensitive and locally responsive.

Under-five mortality in the Rongo Sub-County of Migori County, Kenya: Experience of the Lwala Community Alliance 2007-2017 with evidence from a cross-sectional survey.

INTRODUCTION: Childhood mortality remains a pressing problem in rural Kenya, and reducing under-five deaths is a key target of the Sustainable Development Goals. We aim to describe the reduction in under-five mortality in a rural Kenyan community served by the Lwala Community Alliance and factors associated with under-five mortality in this community. METHODS: A cross-sectional survey containing a complete birth history was administered to a representative sample of the catchment area of the Lwala Community Alliance. Survival analysis techniques were used to describe temporal trends and risk factors related to under-five mortality. RESULTS: 1,362 children were included in the study, and 91 children died before the fifth birthday. The most common causes of death among children under five were malaria (19%), respiratory infection (13%), and anemia (11%). The under-five mortality rate was 104.8 per 1,000 live births from 1999 to 2006 and 53.0 per 1,000 after the founding of the Lwala Community Alliance in 2007. Factors associated with under-five mortality included year of birth (HR 0.931; 95% CI: 0.877, 0.988; p = 0.019), multiple-gestation pregnancy (HR 6.201; 95% CI: 2.073, 18.555; p < 0.001), and birth in the long rain season (HR 1.981; 95% CI: 1.350, 2.907; p < 0.001). Birth spacing greater than 18 months was negatively associated with under-five mortality (HR 0.345; 95% CI: 0.203, 0.587; p < 0.001). CONCLUSIONS: There was a significant decrease in under-five mortality before and after the presence of the Lwala Community Alliance. Multiple-gestation pregnancies, birth season, and short birth spacing were associated with under-five mortality and provide possible targets to further reduce mortality in the region. This provides both hyper-local data necessary for implementation efforts and generalizable data and sampling methods that may be useful for other implementing organizations in sub-Saharan Africa.

Predictors of Infant Age at Enrollment in Early Infant Diagnosis Services in Kenya.

Despite the importance of early detection to signal lifesaving treatment initiation for HIV+ infants, early infant diagnosis (EID) services have received considerably less attention than other aspects of prevention of mother to child transmission care. This study draws on baseline data from an on-going cluster randomized study of an intervention to improve EID services at six government hospitals across Kenya. Two logistic regressions examined potential predictors of "on time" (infant ≤6 weeks of age) vs. "late" (≥7 weeks) and "on time" versus "very late" (≥12 weeks) EID engagement among 756 mother-infant pairs. A quarter of the infants failed to get "on time" testing. Predictors of "on time" testing included being informed about EID by providers when pregnant, perceiving less HIV stigma, and mother's level of education. Predictors of "very late" testing (≥12 weeks of age) included not being informed about EID by providers when pregnant and living farther from services. Findings highlight the importance of ensuring that health care providers actively and repeatedly inform HIV+ mothers of the availability of EID services, reduce stigma by frequently communicating judgment free support, and assisting mothers in early planning for accessing EID services. Extra care should be focused on engaging mothers with less formal education who are at increased risk for seeking "late" EID testing. This study offers clear targets for improving services so that all HIV-exposed infants can be properly engaged in EID services, thus increasing the potential for the best possible outcomes for this vulnerable population.

Progress Toward Eliminating Mother to Child Transmission of HIV in Kenya: Review of Treatment Guideline Uptake and Pediatric Transmission at Four Government Hospitals Between 2010 and 2012.

We analyzed prevention of mother-to-child transmission (PMTCT) data from a retrospective cohort of n = 1365 HIV+ mothers who enrolled their HIV-exposed infants in early infant diagnosis services in four Kenyan government hospitals from 2010 to 2012. Less than 15 and 20 % of mother-infant pairs were provided with regimens that met WHO Option A and B/B+ guidelines, respectively. Annually, the gestational age at treatment initiation decreased, while uptake of Option B/B+ increased (all p's < 0.001). Pediatric HIV infection was halved (8.6-4.3 %), yet varied significantly by hospital. In multivariable analyses, HIV-exposed infants who received no PMTCT (AOR 4.6 [2.49, 8.62], p < 0.001), mixed foods (AOR 5.0 [2.77, 9.02], p < 0.001), and care at one of the four hospitals (AOR 3.0 [1.51, 5.92], p = 0.002) were more likely to be HIV-infected. While the administration and uptake of WHO PMTCT guidelines is improving, an expanded focus on retention and medication adherence will further reduce pediatric HIV transmission.

Chemokine Coreceptor-2 Gene Polymorphisms among HIV-1 Infected Individuals in Kenya.

Chemokine Coreceptor-2 (CCR2) is an entry coreceptor for HIV-1. A mutation in the coding gene for this coreceptor, CCR2-64I, has been shown to be an important factor for delaying disease progression. In Kenya no studies have been done to determine the status of CCR2 gene polymorphisms among HIV-1 infected individuals. To determine the existence and distribution of CCR2 gene mutations and identify polymorphic groups of the coreceptor gene in the population, a cross-sectional study was conducted to analyze the differences in allelic frequencies of CCR2-64I among HIV-1 seropositive individuals. Blood samples were collected from HIV/AIDS screening centers and analyzed for the presence of CCR2-64I using restriction fragment length polymorphism (RFLP). One hundred and eighteen samples collected from different regions of the country were genotyped for the CCR2-64I mutation. Of these, 4 (3.4%) were homozygous mutants (I/I) and 21 (17.8%) were heterozygous (V/I). Ninety-three subjects (78.8%) were wild type (V/V). With the search for a preventive/therapeutic HIV vaccine elusive, the presence of CCR-2 gene polymorphisms that delay disease progression and prolong the lives of the infected in the Kenyan population may contribute to the growing evidence that host genetic factors are important in predicting susceptibility to HIV-1 infection.

Improving early infant HIV diagnosis in Kenya: study protocol of a cluster-randomized efficacy trial of the HITSystem.

BACKGROUND: Early infant diagnosis among human immunodeficiency virus (HIV)-exposed infants is a critical component of prevention of mother-to-child transmission programs. Barriers to early infant diagnosis include poor uptake, low retention at designated re-testing intervals, delayed test results, passive systems of communication, and poor linkage to treatment. This study will evaluate the HIV Infant Tracking System (HITSystem), an eHealth intervention that streamlines communication and accountability between the key early infant diagnosis stakeholders: HIV+ mothers and their HIV-exposed infants, healthcare providers, and central laboratory personnel. It is hypothesized that the HITSystem will significantly improve early infant diagnosis retention at 9 and 18 months postnatal and the timely provision of services. METHODS/DESIGN: Using a phased cluster-randomized controlled trial design, we will evaluate the impact of the HITSystem on eight primary benchmarks in the 18-month long cascade of care for early infant diagnosis. Study sites are six government hospitals in Kenya matched on geographic region, resource level, and patient volume. Early infant diagnosis outcomes of mother-infant dyads (n = 120 per site) at intervention hospitals (n = 3) where the HITSystem is deployed at baseline will be compared to the matched control sites providing standard care. After allowing for sufficient time for enrollment and 18-month follow-up of dyads, the HITSystem will be deployed at the control sites in the end of Year 3. Primary outcomes are retention among mother-infant dyads, initiation of antiretroviral therapy among HIV-infected infants, and the proportion of services delivered within the optimal time window indicated by national and study guidelines. Satisfaction interviews with participants and providers will inform intervention improvements. Cost-effectiveness analyses will be conducted to inform the sustainability of the HITSystem. Hypothesized outcomes include significantly higher retention throughout the 18-month early infant diagnosis process, significantly more services provided on-time at intervention sites, and a potential savings to the healthcare system. DISCUSSION: This study will evaluate the public health impact of the HITSystem to improve critical early infant diagnosis outcomes in low-resource settings. Cost-effectiveness analyses will inform the feasibility of scale-up in other settings. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02072603.

Hepatitis B, Hepatitis C and HIV-1 Coinfection in Two Informal Urban Settlements in Nairobi, Kenya.

BACKGROUND: HIV-1 and Hepatitis B and C viruses coinfection is common in Sub-Saharan Africa due to similar routes of transmission and high levels of poverty. Most studies on HIV-1 and Hepatitis B and C viruses have occurred in hospital settings and blood transfusion units. Data on Hepatitis B and C viruses and HIV-1 coinfection in informal urban settlements in Kenya are scanty, yet they could partly explain the disproportionately high morbidity and mortality associated with HIV-1 infections in these slums. OBJECTIVES: The objective of this study was to determine the prevalence of HIV and Hepatitis B and C dual infection in urban slums in Nairobi. METHODS: Blood samples were collected from residents of Viwandani and Korogocho between 2006 and 2007. A structured questionnaire was used to obtain socio-demographic data from participants. Samples were screened for Hepatitis B surface antigen (HBsAg), anti-HCV and anti-HIV-1. Statistical analysis was done using STATA. RESULTS: Samples were successfully collected from 418 (32%) men and 890 (68%) females. The HIV-1, HBV and HCV prevalence was 20.4%, 13.3% and 0.76% respectively at the time of the study. Of the 268 (20.4%) HIV-1 positive participants, 56 (4.26%) had HBV while 6 (0.46%) had HCV. Of the 1041 HIV-1 negative participants, 117 (8.9%) had HBV while 4 (0.31%) had HCV. Only two people (0.15%) were co-infected with all the three viruses together. DISCUSSION: The odds of getting hepatitis infection were higher in HIV-1 participants (for HBV OR 2.08,p<0.005 and for HCV OR 5.93, p<0.005). HIV prevalence rates were similar in both informal settlements. HIV infection was highest in age group 35-39 years and among the divorced/separated or widowed. Prevalence of all viruses was highest in those who did not have any formal education. CONCLUSION: The HIV prevalence in these informal settlements suggests a higher rate than what is observed nationally. The prevalence rates of HBV are significantly higher in the HIV-1 positive and negative populations. HCV as well as triple HIV-1, HBV and HCV coinfection are uncommon in Korogocho and Viwandani. This clearly indicates the need for HIV-1 control programmes and hepatitis B virus vaccination to be promoted through public awareness as preventive strategy.

If you text them, they will come: using the HIV infant tracking system to improve early infant diagnosis quality and retention in Kenya.

OBJECTIVE: The objective of this study is to evaluate the impact of the HIV Infant Tracking System (HITSystem) for quality improvement of early infant diagnosis (EID) of HIV services. DESIGN AND SETTING: This observational pilot study compared 12 months of historical preintervention EID outcomes at one urban and one peri-urban government hospital in Kenya to 12 months of intervention data to assess retention and time throughout the EID cascade of care. PARTICIPANTS: Mother-infant pairs enrolled in EID at participating hospitals before (n = 320) and during (n = 523) the HITSystem pilot were eligible to participate. INTERVENTION: The HITSystem utilizes Internet-based coordination of the multistep PCR cycle, automated alerts to trigger prompt action from providers and laboratory technicians, and text messaging to notify mothers when results are ready or additional action is needed. MAIN OUTCOME MEASURES: The main outcome measures were retention throughout EID services, meeting time-sensitive targets and improving results turn-around time, and increasing early antiretroviral therapy (ART) initiation among HIV-infected infants. RESULTS: The HITSystem was associated with an increase in the proportion of HIV-exposed infants retained in EID care at 9 months postnatal (45.1-93.0% urban; 43.2-94.1% peri-urban), a decrease in turn-around times between sample collection, PCR results and notification of mothers in both settings, and a significant increase in the proportion of HIV-infected infants started on antiretroviral therapy at each hospital(14 vs. 100% urban; 64 vs. 100% peri-urban). CONCLUSION: The HITSystem maximizes the use of easily accessible technology to improve the quality and efficiency of EID services in resource-limited settings.

Population specific reference ranges of CD3, CD4 and CD8 lymphocyte subsets among healthy Kenyans.

BACKGROUND: The enumeration of absolute CD4 counts is of primary importance for many medical conditions especially HIV infection where therapeutic initiation depends on the count. These ranges tend to vary across populations. However, these ranges have not been comprehensively established in the Kenyan population. Therefore, this study aimed at establishing the reference ranges for the CD4 and CD8 T-lymphocytes in normal healthy individuals in Kenya. METHODS: A total of 315 individuals of the ages between 16 and 60 years old, in 5 different regions of the country, were recruited into the study. They were screened for diseases that potentially cause lymphocyte homeostasis perturbation. CD4/CD8 Counts were performed by use of a FACSCalibur flow cytometer (Becton-Dickinson, NJ) equipped with automated acquisition and analysis software. Results were analysed according to age, sex and region. RESULTS: Results were presented as means and ranges (in parenthesis) generated non parametrically as 2.5 and 97.5 percentiles as follows; In general population; CD3 1655 (614-2685 cells/µL ), CD4 920 (343-1493 cells/µL), and CD8 646 (187-1139 cells/µL), while according to sex, females; CD3 1787 (697-2841 cells/µL), CD4 1010 (422-1572 cells/µL), CD8 659 (187-1180 cells/µL); males; CD3 1610 (581-2641 cells/µL), CD4 889(320-1459 cells/µL) and CD8 644 (185-1140 cells/µL). The general reference ranges for CD4/CD8 ratios were as follows; general population 1.57(0.50-2.74), males 1.51(0.49-2.64) and females 1.69(0.55-2.95). CONCLUSION: The lymphocyte reference ranges for the Kenyan population are fairly comparable to those established in other African populations. The ranges also differ appreciably from those established in Germany, Italy and Switzerland. Furthermore, the study reported significant differences in the ranges of different population clusters within Kenya, as well us between males and females.

Are slum dwellers at heightened risk of HIV infection than other urban residents? Evidence from population-based HIV prevalence surveys in Kenya.

In 2008, the global urban population surpassed the rural population and by 2050 more than 6 billion will be living in urban centres. A growing body of research has reported on poor health outcomes among the urban poor but not much is known about HIV prevalence among this group. A survey of nearly 3000 men and women was conducted in two Nairobi slums in Kenya between 2006 and 2007, where respondents were tested for HIV status. In addition, data from the 2008/2009 Kenya Demographic and Health Survey were used to compare HIV prevalence between slum residents and those living in other urban and rural areas. The results showed strong intra-urban differences. HIV was 12% among slum residents compared with 5% and 6% among non-slum urban and rural residents, respectively. Generally, men had lower HIV prevalence than women although in the slums the gap was narrower. Among women, sexual experience before the age of 15 compared with after 19 years was associated with 62% higher odds of being HIV positive. There was ethnic variation in patterns of HIV infection although the effect depended on the current place of residence.

HIV type 1 gag genetic diversity among antenatal clinic attendees in North Rift Valley, Kenya.

HIV genetic recombination and high mutation rate increase diversity allowing it to escape from host immune response or antiretroviral drugs. This diversity has enabled specific viral subtypes to be predominant in specific regions. To determine HIV-1 subtypes among seropositive antenatal clinic attendees in Kenya's North Rift Valley, a cross-sectional study was carried out on 116 HIV-1-positive blood samples. Proviral DNA was extracted from peripheral blood mononuclear cells by DNAzol lysis and ethanol precipitation. Polymerase chain reactions using specific primers for HIV-1 gag and population sequencing on resulting amplicons were carried out. Phylogenetic analysis revealed that 81 (70%) were subtype A1, 13 (11%) subtype D, 8 (7%) subtype C, 3 (3%) subtype A2, 1 (1%) subtype G, and 10 showed possible recombinants: 5 (4%) subtype A1D, 4 (3%) subtype A1C, and 1 (1%) subtype A2C. These data support the need to establish circulating subtypes for better evaluation of effective HIV diagnostic and treatment options in Kenya.

Discrepant test findings in early infant diagnosis of HIV in a national reference laboratory in Kenya: challenges and opportunities for programs.

BACKGROUND: In Kenya, the availability of a cheap diagnostic service for HIV-exposed infants has helped scale-up access to treatment, and provided a means by which programs that support Prevention of Mother to Child Transmission of HIV can be evaluated. As expected for any large testing program, discrepant and indeterminate results present a significant challenge. METHODS: Dried Blood Spots were collected from health centers countrywide and couriered to four laboratories for tests. Results were dispatched either by email, telephone, GSM SMS printer or courier. Between 2006 and 2009, tests were conducted with the Manual Roche v. 1.5 Assay. In 2010 the labs switched fully to the Cobas® AmpliPrep/ Cobas® TaqMan® HIV-1 Qual automated Roche Test. RESULTS: Between 2006 and 2010, the KEMRI CVR EID Lab conducted 64 591 HIV tests in on children <18 months of age. HIV tests (38 834) used the manual assay, while 17 133 tests used the automated assay. Overall, 10.7% (6915) of the samples tested positive, while 86.6% (55 967) tested negative. A total of 1.6% (1041) tested indeterminate and required a re-bleed of the infant. Two hundred positive tests by the manual assay were retrieved randomly and retested using the automated assay. Among them, 192 (96%) remained positive, 5 (2.5%) were negative while 3 (1.5%) failed. A total of 160 negative samples by the manual assay were retrieved and retested with the automated assay. Among them, 154 (96.24%) remained negative, 3 (1.88%) tested positive while 3 (1.88%) failed. A total of 215 samples that gave indeterminate results by the manual assay were retested using the automated system. Among them, 62 (28.8%) gave positive results, 144 (66.97%) negative and 6 (2.8%) samples still gave discrepant results. Three (1.4%) did not amplify successfully. A few infants who were apparently positive appeared to test HIV negative with age. CONCLUSIONS: Indeterminate results are a significant challenge for HIV diagnostic services, as seen in the Kenyan EID Program. In our experience, they are more often negative than they are positive. False positive and false negative results can arise from clerical error, contamination and limitations of the technologies available. To forestall the consequences of such outcomes, the sensitivity and specificity of available assays must be further improved. All HIV positive samples should be retested for confirmation, and if confirmed, a new sample must be drawn and tested for DNA at the time the infant receives their initial results or starts antiretroviral therapy. Viral clearance is a phenomenon that requires further studies.