Barriers to linkage and retention in HIV care still persist among adolescent girls and young women in western Kenya.

Adolescent girls and young women (AGYW) in sub-Saharan Africa experience delayed linkage to and poor retention in HIV care. Identifying and addressing specific barriers in HIV care programming is important to achieving the upgraded UNAIDS 95-95-95 targets and epidemic control. We examined these challenges among 103 HIV-positive AGYW in and out of HIV care in communities around Lake Victoria in western Kenya as part of a larger qualitative study to identify drivers of HIV testing and HIV care utilisation in key populations. We used the social-ecological model to guide development of interview guides. Individual-level barriers included denial and forgetfulness and gendered household responsibilities, medication side effects, especially if taken without food, pills being too big and difficult to swallow and the burden of a daily medication-taking regimen. Interpersonal barriers included troubled family relationships and pervasive fears of stigma and discrimination by friends and family. Communitylevel barriers were stigmatising attitudes toward people living with HIV. Health-system barriers included negative provider attitudes and confidentiality breaches. At the structural level, participants noted high costs due to long travel times to facilities, long clinic waiting times, household food insecurity and school and work commitments. AGYW's limited decision-making autonomy due to age and gender norms, including their reliance on the authority of older adults, makes these barriers especially troubling. Innovative treatment approaches that take into account the unique vulnerabilities of AGYW are urgently needed.

Social networks, mobility, and HIV risk among women in the fishing communities of Lake Victoria.

BACKGROUND: Population mobility is a demonstrated barrier to reducing HIV incidence. A clear understanding of social networks and their influence on mobility among women in the fishing communities of Lake Victoria may contribute to tailoring effective interventions that suit the needs of these mobile women. METHODS: A cross-sectional qualitative methods study was conducted to understand mobility patterns among women resident and or working in fishing communities of Lake Victoria in Kenya, Tanzania, and Uganda. The study was conducted in six fishing communities from March 2018 to June 2019. The communities were purposively selected, based on population size (1000 people or more) and HIV prevalence of > 15% among women aged 18 years or older who had lived in the fishing community for at least six months. In-depth interviews were conducted with 24 key informants and 72 women from the sites in the three countries. Questions focused on women's social networks and other factors that fuelled or facilitated women's mobility as well as challenges they faced due to mobility. Data analysis followed a thematic framework approach. RESULTS: Different social groupings/networks existed among women in the fishing communities of Lake Victoria. These included female sex workers, women fish processors/traders, women bar workers/owners, restaurant workers, and family networks. Networks encouraged mobility, supporting finding work opportunities, but also increased sexual risks through partner changes. The benefits of networks included information sharing, financial support, and group protection, especially against violence. CONCLUSION: Social networks and groupings among women in the fishing communities of Lake Victoria could be useful in tailoring HIV prevention and HIV care interventions to suit the needs of these highly mobile populations.

Acceptability and Feasibility of Pharmacy-Based Delivery of Pre-Exposure Prophylaxis in Kenya: A Qualitative Study of Client and Provider Perspectives.

As countries scale up pre-exposure prophylaxis (PrEP) for HIV prevention, diverse PrEP delivery models are needed to expand access to populations at HIV risk that are unwilling or unable to access clinic-based PrEP care. To identify factors that may influence implementation of retail pharmacy-based PrEP delivery in Kenya, we conducted in-depth interviews with 40 pharmacy clients, 16 pharmacy providers, 16 PrEP clients, and 10 PrEP providers from two provinces. Most participants expressed strong support for expanding PrEP to retail pharmacies, though conditioned their acceptance on assurances that care would be private, respectful, safe, and affordable. Participant-reported determinants of feasibility centered primarily on ensuring that the intervention is compatible with retail pharmacy operations (e.g., staffing levels, documentation requirements). Future research is needed to develop and test tailored packages of implementation strategies that are most effective at integrating PrEP delivery into routine pharmacy practice in Kenya and other high HIV prevalence settings.

RESUMEN: Ya que varios países están ampliando sus programas de profilaxis previa a la exposición al VIH (PrEP, por sus siglas en inglés), se necesitan modelos diversos para ampliar el acceso a poblaciones que no están dispuestos a acceder, o que no pueden acceder, a los servicios de PrEP que se ofrecen en las instalaciones de salud. Para identificar los factores que pueden influir en la prestación de servicios de PrEP a través de farmacias privadas, realizamos entrevistas en profundidad con 40 clientes de farmacia, 16 proveedores de servicios de farmacia, 16 usuarios de PrEP, y 10 proveedores de PrEP. La mayoría de los participantes manifestó su firme apoyo a la propuesta de expandir la provisión de PrEP a las farmacias privadas, aunque condicionó su aceptación a la garantía de que la atención sea privada, respetuosa, segura, y asequible. Según los participantes, los factores determinantes de la viabilidad de ofrecer PrEP en las farmacias privadas se centran en asegurar de que la intervención sea compatible con las operaciones de las farmacias privadas (p. ej., el número de personal, los requisitos de documentación). Se necesitan investigaciones adicionales para desarrollar y evaluar diferentes paquetes de estrategias de implementación para descubrir cuáles son los más eficaces para integrar los servicios de PrEP en la prestación rutinaria de servicios de farmacia tanto en Kenia como en otros lugares de alta prevalencia del VIH.

Effects of a Home-Based Intervention on HIV Prevention Health Behaviors in Pregnant/Postpartum Kenyan Women: Estimating Moderating Effects of Depressive Symptoms.

We estimated effects of maternal depressive symptoms, utilizing the Patient Health Questionnaire-8 (PHQ-8), on women's HIV prevention behaviors in Migori County, Kenya. Pregnant women ≥ 18 years old, with gestational age of < 37 weeks, were randomized into standard care or three home visits (2 during pregnancy, 1 postpartum) promoting couple HIV testing and counseling (CHTC) and HIV prevention. Of 105 female participants, 37 (35.24%) reported depressive symptoms and 50 (47.62%) were HIV-positive. Three Poisson regressions with robust variance (univariable, multivariable, and multivariable with depressive symptoms/study arm interaction) were modeled for three outcomes: CHTC, infant HIV testing, health-seeking postpartum. In multivariable analysis with interaction, a moderating trend for the interaction between depressive symptoms and individual health-seeking was observed (p-value = 0.067). Women scoring ≤ 9 (n = 68) on the PHQ-8 and participating in home visits were 1.76 times more likely to participate in individual health-seeking compared to participants in standard care (ARR 1.76, 95% CI 1.17-2.66).

Educating men about vaginal microbicides: considerations from Kenya.

Men desire to be involved in their partner's decision-making about vaginal microbicide use. This coincides with women's desire to inform male partners about their microbicide use. Educating men about microbicides may enhance acceptability and generate critical support for the female participants of microbicide trials. In this multiphase mixed-methods study, we adapted an educational intervention on vaginal microbicides and tested it among men (n = 45) to determine its effect on men's knowledge regarding HIV/STI, vaginal microbicides and microbicide trials. We also conducted focus group discussions (FGDs) with the female partners (K = 3, n = 43) of the study participants and community representatives (K = 2, n = 24) to obtain their views on male partner microbicide education. We analysed FGD data for key themes using content analysis. HIV and vaginal microbicide knowledge scores increased significantly among men after the educational intervention. Both women and men highly supported male partner microbicide education, in the context of existing gender relations, to increase men's understanding about microbicides, promote adherence and help women gain their partners' trust. Complex gender dynamics should be considered when designing male partner educational interventions to improve acceptability and the use of microbicides and other female-initiated HIV prevention methods.

Forming a Kanyakla: A qualitative study to develop a novel social support intervention for adolescents living with HIV.

INTRODUCTION: HIV is a leading cause of morbidity and mortality among youth in sub Saharan Africa. This study explores the adaptation of an adult social network intervention for adolescents, entitled Kanyakla. METHODS: The study was conducted in Kisumu, Kenya from July to November 2016. Data was collected from: (1) semi-structured interviews (n = 32) with adolescents living with HIV aged 15-19; and (2) two focus group discussions (n = 21). Transcripts were coded using thematic analysis through the lens of an Adolescent Development Model. RESULTS: Participants were interested in joining a Kanyakla to build social support, learn new skills, and partake in recreational activities. Many participants feared inadvertent disclosure related to stigma. Certain dichotomous themes emerged including the need for privacy versus the need for social support; and the desire for inclusion of elders versus preference for same-aged peers in the Kanyaklas. CONCLUSIONS: With this study, we have key information that can be applied to developing the Kanyakla intervention for adolescents. Further study is needed to reconcile the dichotomies that emerged.

Jaboya ("Sex for Fish"): A Qualitative Analysis of Contextual Risk Factors for Extramarital Partnerships in the Fishing Communities in Western Kenya.

Extramarital partnerships exacerbate high HIV prevalence rates in many communities in sub-Saharan Africa. We explored contextual risk factors and suggested interventions to reduce extramarital partnerships among couples in the fishing communities on Lake Victoria, Kenya. We conducted 12 focus group discussions with 9-10 participants each (N = 118) and 16 in-depth interviews (N = 16) with fishermen and their spouses. Couples who participated were consented and separated for simultaneous gender-matched discussions/interviews. Interview topics included courtship and marriage, relationship and sexual satisfaction, extramarital relationships and how to intervene on HIV risks. Coding, analysis, and interpretation of the transcripts followed grounded theory tenets that allow analytical themes to emerge from the participants. Our results showed that extramarital partnerships were perceived to be widespread and were attributed to factors related to sexual satisfaction such as women needing more foreplay before intercourse, discrepancies in sexual desire, and boredom with the current sexual repertoire. Participants also reported that financial and sociophysical factors such as family financial support and physical separation, contributed to the formation of extramarital partnerships. Participants made suggestions for interventions that reduce extramarital partnerships to minimize HIV risks at the community, couple, and individual level. These suggestions emphasized improving community education, spousal communication, and self-evaluation for positive behavior change. Future studies can draw upon these findings as a basis for designing community-owned interventions that seek to reduce community-level HIV risk through a reduction in the number of sexual partners.

A cross-sectional survey of prevalence and correlates of couple sexual concurrency among married couples in fishing communities along Lake Victoria in Kisumu, Kenya.

OBJECTIVE: Sexual concurrency has been associated with HIV infection. Since HIV in sub-Saharan Africa is mostly spread within the context of heterosexual couples, it is necessary that intervention is focused on such couples. We sought to establish the correlates of couple sexual concurrency in Kisumu, Kenya. METHODS: We conducted 1090 gender-matched interviews in 545 couples in a cross-sectional survey. A random sample of fishermen and their spouses from 33 fish-landing beaches along the shores of Lake Victoria in Kisumu were asked to enrol in the study. Couples were separated into different private rooms for simultaneous interviews that documented socioeconomic and behavioural characteristics, and information on number of sexual partnerships in the preceding 6 months and their status. Based on reported concurrency status of the spouses, a couple was categorised as either concurrent when at least one spouse reported a concurrent sexual relationship or non-concurrent. RESULTS: Overall, 32.1% of the men and 6.2% of the women had concurrent sexual relationships in the 6 months preceding the study, resulting in 37.6% of the couples being sexually concurrent. Unmet sexual desire, intra-spousal suspicions of infidelity, male dominance scripts, domestic violence, couples' children and women's age were the correlates of couple sexual concurrency. CONCLUSIONS: Unmet sexual desires, inter-spousal infidelity suspicions, male dominance scripts and domestic violence were the main correlates of couple sexual concurrency in these fishing communities.

Clinic presentation delay and tuberculosis treatment outcomes in the Lake Victoria region of East Africa: A multi-site prospective cohort study.

In the Lake Victoria region of East Africa, little is known about delays between tuberculosis (TB) symptom onset and presentation at a clinic. Associations between clinic presentation delay and TB treatment outcomes are also poorly understood. In 2019, we abstracted data from routine TB treatment records for all adults (n = 776) initiating TB treatment in a 6-month period across 12 health facilities near Lake Victoria. We interviewed 301 cohort members and assessed whether they experienced a clinic presentation delay longer than 6 weeks. We investigated potential clinical and demographic correlates of clinic presentation delay and examined the association between clinic presentation delay and an unfavorable TB treatment outcome (death, loss to follow-up, or treatment failure). Clinic presentation delay was common, occurring among an estimated 54.7% (95% CI: 48.9%, 61.2%) of cohort members, though no specific correlates were identified. Clinic presentation delay was slightly associated with unfavorable TB treatment outcomes. The 180-day risk of an unfavorable outcome was 14.2% (95% CI: 8.0%, 20.4%) among those with clinic presentation delay, compared to 12.7% (95% CI: 5.1%, 20.3%) among those presenting earlier. Multi-level community-based interventions may be necessary to reduce clinic presentation delays in communities near Lake Victoria.

Geographic mobility and treatment outcomes among people in care for tuberculosis in the Lake Victoria region of East Africa: A multi-site prospective cohort study.

Geographic mobility may disrupt continuity of care and contribute to poor clinical outcomes among people receiving treatment for tuberculosis (TB). This may occur especially where health services are not well coordinated across international borders, particularly in lower and middle income country settings. In this work, we describe mobility and the relationship between mobility and unfavorable TB treatment outcomes (i.e., death, loss to follow-up, or treatment failure) among a cohort of adults who initiated TB treatment at one of 12 health facilities near Lake Victoria. We abstracted data from health facility records for all 776 adults initiating TB treatment during a 6-month period at the selected facilities in Kenya, Tanzania, and Uganda. We interviewed 301 cohort members to assess overnight travel outside one's residential district/sub-county. In our analyses, we estimated the proportion of cohort members traveling in 2 and 6 months following initiation of TB treatment, explored correlates of mobility, and examined the association between mobility and an unfavorable TB treatment outcome. We estimated that 40.7% (95% CI: 33.3%, 49.6%) of people on treatment for TB traveled overnight at least once in the 6 months following treatment initiation. Mobility was more common among people who worked in the fishing industry and among those with extra-pulmonary TB. Mobility was not strongly associated with other characteristics examined, however, suggesting that efforts to improve TB care for mobile populations should be broad ranging. We found that in this cohort, people who were mobile were not at increased risk of an unfavorable TB treatment outcome. Findings from this study can help inform development and implementation of mobility-competent health services for people with TB in East Africa.

Many Cooks in the Kitchen: Iterating a Qualitative Analysis Process Across Multiple Countries, Sites, and Teams.

Establishing and proving methodological rigor has long been a challenge for qualitative researchers where quantitative methods prevail, but much published literature on qualitative analysis assumes a relatively small number of researchers working in relative proximity. This is particularly true for research conducted with a grounded theory approach. Different versions of grounded theory are commonly used, but this methodology was originally developed for a single researcher collecting and analyzing data in isolation. Although grounded theory has evolved since its development, little has been done to reconcile this approach with the changing nature and composition of international research teams. Advances in technology and an increased emphasis on transnational collaboration have facilitated a shift wherein qualitative datasets have been getting larger and the teams collecting and analyzing them more diverse and diffuse. New processes and systems are therefore required to respond to these conditions. Data for this article are drawn from the experiences of the Innovations for Choice and Autonomy (ICAN) Research Consortium. ICAN aims to understand how self-injectable contraceptives can be implemented in ways that best meet women's needs in Kenya, Uganda, Malawi, and Nigeria. We found that taking a structured approach to analysis was important for maintaining consistency and making the process more manageable across countries. However, it was equally important to allow for flexibility within this structured approach so that teams could adapt more easily to local conditions, making data collection and accompanying analysis more feasible. Meaningfully including all interested researchers in the analysis process and providing support for learning also increased rigor. However, competing priorities in a complex study made it difficult to adhere to planned timelines. We conclude with recommendations for both funders and study teams to design and conduct global health studies that ensure more equitable contributions to analysis while remaining logistically feasible and methodologically sound.

Testing a social network approach to promote HIV self-testing and linkage to care among fishermen at Lake Victoria: study protocol for the Owete cluster randomized controlled trial.

BACKGROUND: Nearly 50% of men living with HIV in many countries are unaware of their HIV status; men also have lower uptake of HIV treatment and pre-exposure prophylaxis (PrEP). In SSA, highly mobile men such as those working in fishing communities alongside Lake Victoria have low uptake of HIV testing and low rates of linkage to HIV treatment and PrEP, despite increasing availability of these services. HIV self-testing (HIVST) kits hold promise for overcoming barriers to HIV testing and linkage to services for HIV-positive and HIV-negative men. We describe here a protocol for an HIV status-neutral, social network-based approach to promote HIV testing, linkage to care and prevention, and better health outcomes, including adherence, in fishermen around Lake Victoria. METHODS: Utilizing beach management unit (BMU) registries of fishermen operating in three Lake Victoria fishing communities in Siaya County, Kenya, we completed a census and social network mapping to identify close social networks of men. Network clusters identified by a socially-central lead ("promotor") and selected to ensure maximal separation between treatment and control will be randomized. Promotors in both arms will receive basic HIV training; intervention promotors are further trained in HIVST to distribute kits to their cluster, while control promotors will distribute to their cluster vouchers for free HIVST at nearby clinics. We will test whether these promoters can enhance linkage to ART and PrEP after self-testing, thereby addressing a key limitation of HIVST. We will also measure 6- and 12-month viral load in those living with HIV and PrEP adherence among those without HIV via urine tenofovir levels as objective markers of adherence. DISCUSSION: This study has the potential to improve HIV health and promote HIV prevention among a hard to reach, at-risk, and highly mobile population of men in Western Kenya-a critical population in Kenya's HIV prevention and treatment program. Further, if successful, this innovative social networks-based model could be scaled at the regional level to address HIV prevention and care among similarly at-risk populations of men in eastern Africa and inland fisheries settings across the continent. TRIAL REGISTRATION: Self-Test Strategies and Linkage Incentives to Improve ART and PrEP Uptake in Men, registered on February 26, 2021, registration # NCT04772469 .

Doxycycline post-exposure prophylaxis for prevention of sexually transmitted infections among Kenyan women using HIV pre-exposure prophylaxis: study protocol for an open-label randomized trial.

BACKGROUND: Women in Africa face disproportionate risk of human immunodeficiency virus (HIV) acquisition, accounting for more than half of new infections in Africa and similarly face a disproportionate burden of sexually transmitted infections (STIs). Very high STI prevalence is being observed globally, especially among people taking pre-exposure prophylaxis (PrEP) for HIV prevention. Doxycycline post-exposure prophylaxis (dPEP) has been proposed as an STI prevention strategy to reduce chlamydia, syphilis, and possibly gonorrhea, and trials are ongoing among cisgender men who have sex with men (MSM) and transgender women who are taking PrEP in high-income settings. We designed and describe here the first open-label trial to determine the effectiveness of dPEP to reduce STI incidence among cisgender women. METHODS: We are conducting an open-label 1:1 randomized trial of dPEP versus standard of care (STI screening and treatment and risk-reduction counseling without dPEP) among 446 Kenyan women aged ≥ 18 and ≤ 30 years old women taking PrEP. Women are followed for 12 months, with quarterly STI testing, treatment, and adherence counseling. The primary trial outcome will be the combined incidence of Chlamydia trachomatis, Neisseria gonorrhoeae, and Treponema pallidum, compared between the randomized groups. We will also assess dPEP acceptability, tolerability, safety, impact on sexual behavior, adherence, and occurrence of antimicrobial resistance (AMR) in N. gonorrhoeae and C. trachomatis isolates. Finally, we will estimate cost per incident STI case and complications averted accounting for nonadherence and benefits relative AMR or side effects. DISCUSSION: The results of this trial may have immediate implications for the global epidemic of STIs and sexual health. If effective, dPEP could put STI prevention into women's hands. While dPEP may be able to prevent STIs, it carries important risks that could counter its benefits; global debate about the balance of these potential risks and benefits requires data to inform policy and implementation and our study aims to fill this gap. TRIAL REGISTRATION: ClinicalTrials.gov NCT04050540 .

HIV prevalence, spatial distribution and risk factors for HIV infection in the Kenyan fishing communities of Lake Victoria.

INTRODUCTION: Global efforts to end HIV by 2030 focus on reducing and eventually eliminating new infections in priority populations. Identifying these populations and characterizing their vulnerability factors helps in guiding investment of scarce HIV prevention resources to achieve maximum impact. We sought to establish HIV prevalence, spatial distribution and risk factors for HIV infection in the Kenyan fishing communities of Lake Victoria. METHODS: We conducted a cross-sectional survey of 2637 people from all the 308 fish-landing beaches on the Kenyan shore of Lake Victoria. The number of participants enrolled at each beach were weighted based on the size of the beach, determined by the number of functional registered boats. We used simple random sampling to select those to be approached for study participation. Consenting participants were privately interviewed about their socio-economic and demographic characteristics and sexual behavior, and were invited for HIV test using the Kenya rapid HIV testing protocol. We used descriptive statistics and multivariate logistic and linear regression for analysis. RESULTS: We found high HIV prevalence of 32% with significant differences between men (29%) and women (38%). Among men, having an HIV negative sexual partner, being circumcised, increasing number of condom protected sex acts in the preceding month, being younger and being a resident of Homa Bay, Kisumu, Siaya and Busia counties compared to Migori County reduced the risk of HIV infection. For women, being married, having more children with the current spouse, having an HIV negative sexual partner and being a resident of Busia compared to Migori County reduced the risk of HIV infection. We also found that longer distance from the beaches to the nearest public health facilities was associated with increasing cumulative HIV prevalence at the beaches. CONCLUSION: Fishing communities have high HIV prevalence and may greatly benefit from interventions such as wider ART coverage, couple HIV risk reduction counseling, PrEP use for HIV negative partner at substantial continuous risk, alongside other HIV prevention services that the Kenyan government is currently rolling out. This will additionally require adequate plans to synchronize the provision of these services with the population's routine schedules for all these options to be reasonably accessible to them.

Methods for sampling geographically mobile female traders in an East African market setting.

BACKGROUND: The role of migration in the spread of HIV in sub-Saharan Africa is well-documented. Yet migration and HIV research have often focused on HIV risks to male migrants and their partners, or migrants overall, often failing to measure the risks to women via their direct involvement in migration. Inconsistent measures of mobility, gender biases in those measures, and limited data sources for sex-specific population-based estimates of mobility have contributed to a paucity of research on the HIV prevention and care needs of migrant and highly mobile women. This study addresses an urgent need for novel methods for developing probability-based, systematic samples of highly mobile women, focusing on a population of female traders operating out of one of the largest open air markets in East Africa. Our method involves three stages: 1.) identification and mapping of all market stall locations using Global Positioning System (GPS) coordinates; 2.) using female market vendor stall GPS coordinates to build the sampling frame using replicates; and 3.) using maps and GPS data for recruitment of study participants. RESULTS: The location of 6,390 vendor stalls were mapped using GPS. Of these, 4,064 stalls occupied by women (63.6%) were used to draw four replicates of 128 stalls each, and a fifth replicate of 15 pre-selected random alternates for a total of 527 stalls assigned to one of five replicates. Staff visited 323 stalls from the first three replicates and from these successfully recruited 306 female vendors into the study for a participation rate of 94.7%. Mobilization strategies and involving traders association representatives in participant recruitment were critical to the study's success. CONCLUSION: The study's high participation rate suggests that this geospatial sampling method holds promise for development of probability-based samples in other settings that serve as transport hubs for highly mobile populations.

Implementation of repeat HIV testing during pregnancy in southwestern Kenya: progress and missed opportunities.

INTRODUCTION: Repeat HIV testing during the late antenatal period is crucial to identify and initiate treatment for pregnant women with incident HIV infection to prevent perinatal HIV transmission and keep mothers alive. In 2012, the Kenya Ministry of Health adopted international guidelines suggesting that pregnant women be offered retesting three months after an initial negative HIV test. Our objectives were to determine the current rate of antenatal repeat HIV testing; identify successes, missed opportunities and factors associated with retesting; and estimate the incidence of HIV during pregnancy. METHODS: Retrospective analysis of longitudinal data was conducted for a cohort of 2145 women attending antenatal care clinic at a large district hospital in southwestern Kenya. Data were abstracted from registers for all women who attended the clinic from the years 2011 to 2014. RESULTS: Although 90.2% of women first came to clinic prior to their third trimester and 27.5% had at least four clinic visits, 58.0% of all women went to delivery without a retest. Missed opportunities for retesting included not returning to clinic at all, not returning when eligible, or late gestational age (>28 weeks) at first clinic visit making them ineligible for retesting (accounting for 14.2%, 26.8% and 9.6% of all clinic attendees respectively); and failure to be retested even when eligible at one or more visits (accounting for 73.2% of eligible returnees). Being unmarried and aged 20 or younger was associated with an increase in mean gestational age of first visit by 2.52 weeks (95% CI: 1.56, 3.48) and a 2.59 increased odds (95% CI: 1.90, 3.54) of failing to return to clinic, compared to those who were married and over 20 years of age. On retest, two women tested HIV positive, suggesting an incidence rate of 4.4 per 100 person-years. After adjusting for potential confounders, only later year of last menstrual period (2013 vs. 2012 and 2011) was associated with retesting. CONCLUSIONS: Adoption of retesting guidelines in 2012 appears to have successfully increased retesting rates, but missed opportunities to identify incident HIV infection during pregnancy may contribute to continuing high rates of perinatal HIV transmission in southwestern Kenya.

High Mobility and HIV Prevalence Among Female Market Traders in East Africa in 2014.

BACKGROUND: The contribution of women's mobility to the HIV/AIDS epidemic in Africa is poorly understood, despite women's high mobility and evidence that it is associated with higher-risk sexual behavior. We sought to measure levels of mobility, HIV prevalence, and related risk behaviors among female traders in Kisumu, Kenya. METHODS: We used global positioning system mapping to develop a probability-based sample and recruited 305 female market traders for participation in a survey and voluntary HIV counseling and testing in 2014. We estimated HIV prevalence and fitted logistic regression models to measure associations between mobility, risk behaviors, and HIV infection. RESULTS: HIV prevalence was 25.6% (95% confidence interval: 21.0 to 30.8); 11.5% had migrated (changed residence, over county, or national boundary) in the past year and 39.3% in the past 5 years. More than one-third (38.3%) spent nights away from main residence in the past month, with 11.4% spending more than a week away. Multiple partners were reported by 13.1% of women in the last year; 16% of married women reported a concurrent partnership. Mobility was not significantly associated with HIV prevalence, although recent short-term mobility was significantly correlated with higher numbers of sexual partners in the past year. CONCLUSIONS: Female market traders were highly mobile, and HIV prevalence among traders was higher than in the general population of women of reproductive age in Kisumu (15.3% in 2013), and Nyanza Province, Kenya (16.1% in 2012). High HIV prevalence and risk behavior among women in this study warrant accelerated attention to HIV prevention and care needs of mobile women, including market traders.

The feasibility, time savings and economic impact of a designated time appointment system at a busy HIV care clinic in Kenya: a randomized controlled trial.

INTRODUCTION: As efforts are made to reach universal access to ART in Kenya, the problem of congestion at HIV care clinics is likely to worsen. We evaluated the feasibility and the economic benefits of a designated time appointment system as a solution to decongest HIV care clinics. METHODS: This was an explanatory two-arm open-label randomized controlled trial that enrolled 354 consenting participants during their normal clinic days and followed-up at subsequent clinic appointments for up to nine months. Intervention arm participants were given specific dates and times to arrive at the clinic for their next appointment while those in the control arm were only given the date and had the discretion to decide on the time to arrive as is the standard practice. At follow-up visits, we recorded arrival and departure times and asked the monetary value of work participants engaged in before and after clinic. We conducted multiple imputation to replace missing data in our primary outcome variables to allow for intention-to-treat analysis; and analyzed the data using Mann-Whitney U test. RESULTS: Overall, 72.1% of the intervention participants arrived on time, 13.3% arrived ahead of time and 14.6% arrived past scheduled time. Intervention arm participants spent a median of 65 [interquartile range (IQR), 52-87] minutes at the clinic compared to 197 (IQR, 173-225) minutes for control participants (p<0.01). Furthermore, intervention arm participants were more productively engaged on their clinic days valuing their cumulative work at a median of USD 10.5 (IQR, 60.0-16.8) compared to participants enrolled in the control arm who valued their work at USD 8.3 (IQR, 5.5-12.9; p=0.02). CONCLUSIONS: A designated time appointment system is feasible and provides substantial time savings associated with greater economic productivity for HIV patients attending a busy HIV care clinic.

"She mixes her business": HIV transmission and acquisition risks among female migrants in western Kenya.

Migration and HIV research in sub-Saharan Africa has focused on HIV risks to male migrants, yet women's levels of participation in internal migration have met or exceeded those of men in the region. Moreover, studies that have examined HIV risks to female migrants found higher risk behavior and HIV prevalence among migrant compared to non-migrant women. However, little is known about the pathways through which participation in migration leads to higher risk behavior in women. This study aimed to characterize the contexts and processes that may facilitate HIV acquisition and transmission among migrant women in the Kisumu area of Nyanza Province, Kenya. We used qualitative methods, including 6 months of participant observation in women's common migration destinations and in-depth semi-structured interviews conducted with 15 male and 40 female migrants selected from these destinations. Gendered aspects of the migration process may be linked to the high risks of HIV observed in female migrants - in the circumstances that trigger migration, livelihood strategies available to female migrants, and social features of migration destinations. Migrations were often precipitated by household shocks due to changes in marital status (as when widowhood resulted in disinheritance) and gender-based violence. Many migrants engaged in transactional sex, of varying regularity, from clandestine to overt, to supplement earnings from informal sector trading. Migrant women are at high risk of HIV transmission and acquisition: the circumstances that drove migration may have also increased HIV infection risk at origin; and social contexts in destinations facilitate having multiple sexual partners and engaging in transactional sex. We propose a model for understanding the pathways through which migration contributes to HIV risks in women in high HIV prevalence areas in Africa, highlighting potential opportunities for primary and secondary HIV prevention at origins and destinations, and at key 'moments of vulnerability' in the migration process.

Jaboya vs. jakambi: Status, negotiation, and HIV risks among female migrants in the "sex for fish" economy in Nyanza Province, Kenya.

In Nyanza Province, Kenya, HIV incidence is highest (26.2%) in the beach communities along Lake Victoria. Prior research documented high mobility and HIV risks among fishermen; mobility patterns and HIV risks faced by women in fishing communities are less well researched. This study aimed to characterize forms of mobility among women in the fish trade in Nyanza; describe the spatial and social features of beaches; and assess characteristics of the "sex-for-fish" economy and its implications for HIV prevention. We used qualitative methods, including participant observation in 6 beach villages and other key destinations in the Kisumu area of Nyanza that attract female migrants, and we recruited individuals for in-depth semi-structured interviews at those destinations. We interviewed 40 women, of whom 18 were fish traders, and 15 men, of whom 7 were fishermen. Data were analyzed using Atlas.ti software. We found that female fish traders are often migrants to beaches; they are also highly mobile. They are at high risk of HIV acquisition and transmission via their exchange of sex for fish with jaboya fishermen.