Brief Report: Recent HIV Infection Surveillance in Routine HIV Testing in Nairobi, Kenya: A Feasibility Study.

BACKGROUND: Serological tests can distinguish recent (in the prior 12 months) from long-term HIV infection. Integrating recency testing into routine HIV testing services (HTS) can provide important information on transmission clusters and prioritize clients for partner testing. This study assessed the feasibility and use of integrating HIV recency into routine testing. METHODS: We conducted a multi-method study at 14 facilities in Kenya, and key informant interviews with health care providers. We abstracted clinical record data, collected specimens, tested specimens for recent infection, returned results to participants, and conducted a follow-up survey for those recently infected. RESULTS: From March to October 2018, we enrolled 532 clients who were diagnosed HIV-positive for the first time. Of these, 46 (8.6%) were recently infected. Women aged 15-24 years had 2.9 (95% confidence interval: 1.46 to 5.78) times higher adjusted odds of recent infection compared with 15-24-year-old men and those tested within the past 12 months having 2.55 (95% confidence interval: 0.38 to 4.70) times higher adjusted odds compared with those tested ≥12 months previously. Fourteen of 17 providers interviewed found the integration of recency testing into routine HTS services acceptable and feasible. Among clients who completed the follow-up interview, most (92%) felt that the recency results were useful. CONCLUSIONS: Integrating recent infection testing into routine HTS services in Kenya is feasible and largely acceptable to clients and providers. More studies should be done on possible physical and social harms related to returning results, and the best uses of the recent infection data at an individual and population level.

People-centred health systems, a bottom-up approach: where theory meets empery.

BACKGROUND AND METHODS: Health systems are complex and constantly adapt to changing demands. These complex-adaptive characteristics are rarely considered in the current bureaucratic top-down approaches to health system reforms aimed to constrain demand and expenditure growth. The economic focus fails to address the needs of patients, providers and communities, and ultimately results in declining effectiveness and efficiency of the health care system as well as the health of the wider community. A needs-focused complex-adaptive health system can be represented by the 'healthcare vortex' model; how to build a needs-focused complex-adaptive health system is illustrated by Eastern Deanery AIDS Relief Program approaches in the poor neighbourhoods of Nairobi, Kenya. FINDINGS AND CONCLUSIONS: A small group of nurses and community health workers focused on the care of terminally ill HIV/AIDS patients. This work identified additional problems: tuberculosis (TB) was underdiagnosed and undertreated, a local TB-technician was trained to run a local lab, a courier services helped to reach all at need, collaboration with the Ministry of Health established local TB and HIV treatment programmes and philanthropists helped to supplement treatment with nutrition support. Maternal-to-child HIV-prevention and adolescent counselling services addressed additional needs. The 'theory of the healthcare vortex' indeed matches the 'empery of the real world experiences'. Locally developed and delivered adaptive, people-centred health systems, a bottom-up community and provider initiated approach, deliver highly effective and sustainable health care despite significant resource constraints.