Prevalence and incidence of HIV infection, trends, and risk factors among persons aged 15-64 years in Kenya: results from a nationally representative study

Applying the Effective Programme Coverage framework to assess gaps in HIV prevention programmes for female sex workers and men who have sex with men in Nairobi, Kenya: findings from an expanded Polling Booth Survey

INTRODUCTION

Measuring the coverage of HIV prevention services for key populations (KPs) has consistently been a challenge for national HIV programmes. The current frameworks and measurement methods lack emphasis on effective coverage, occur infrequently, lack timeliness and limit the participation of KPs. The Effective Programme Coverage framework, which utilizes a programme science approach, provides an opportunity to assess gaps in various coverage domains and explore the underlying reasons for these gaps, in order to develop targeted solutions. We have demonstrated the application of this framework in partnership with the KP community in Nairobi, Kenya, using an expanded Polling Booth Survey (ePBS) method.

METHODS

Data were collected between April and May 2023 among female sex workers (FSWs) and men who have sex with men (MSM) using (a) PBS, (b) bio-behavioural survey and (c) focus group discussions. Data collection and analysis involved both KP community and non-community researchers. Descriptive analysis was performed, and proportions were used to assess the programme coverage gaps. The data were weighted to account for the sampling design and unequal selection probabilities. Thematic analysis was conducted on the qualitative data.

RESULTS

The condom programme for FSW and MSM had low availability (60.2% and 50.9%), contact (68.8% and 65.9%) and utilization (52.1% and 43.9%) coverages. The pre-exposure prophylaxis (PrEP) programme had very low utilization coverage for FSW and MSM (4.4% and 2.8%), while antiretroviral therapy utilization coverage was higher (86.6% and 87.7%). Reasons for coverage gaps included a low peer educator-to-peer ratio, longer distance to the clinics, shortage of free condoms supplied by the government, experienced and anticipated side effects related to PrEP, and stigma and discrimination experienced in the facilities.

CONCLUSIONS

The Effective Programme Coverage framework allows programmes to assess coverage gaps and develop solutions and a research agenda targeted at specific domains of coverage with large gaps. The ePBS method works well in collecting data to understand coverage gaps rapidly and allows for the engagement of the KP community.

Predicting the individualized risk of human immunodeficiency virus infection among sexually active women in Ethiopia using a nomogram: prediction model development and validation

Introduction

Women are more vulnerable to HIV infection due to biological and socioeconomic reasons. Developing a predictive model for these vulnerable populations to estimate individualized risk for HIV infection is relevant for targeted preventive interventions. The objective of the study was to develop and validate a risk prediction model that allows easy estimations of HIV infection risk among sexually active women in Ethiopia.

Methods

Data from the 2016 Ethiopian Demographic and Health Survey, which comprised 10,253 representative sexually active women, were used for model development. Variables were selected using the least absolute shrinkage and selection operator (LASSO). Variables selected by LASSO were incorporated into the multivariable mixed-effect logistic regression model. Based on the multivariable model, an easy-to-use nomogram was developed to facilitate its applicability. The performance of the nomogram was evaluated using discrimination and calibration abilities, Brier score, sensitivity, and specificity. Internal validation was carried out using the bootstrapping method.

Results

The model selected seven predictors of HIV infection, namely, age, education, marital status, sex of the household head, age at first sex, multiple sexual partners during their lifetime, and residence. The nomogram had a discriminatory power of 89.7% (95% CI: 88.0, 91.5) and a calibration p-value of 0.536. In addition, the sensitivity and specificity of the nomogram were 74.1% (95% CI: 68.4, 79.2) and 80.9% (95% CI: 80.2, 81.7), respectively. The internally validated model had a discriminatory ability of 89.4% (95% CI: 87.7, 91.1) and a calibration p-value of 0.195. Sensitivity and specificity after validation were 72.9% (95% CI: 67.2, 78.2) and 80.1% (95% CI: 79.3, 80.9), respectively.

Conclusion

A new prediction model that quantifies the individualized risk of HIV infection has been developed in the form of a nomogram and internally validated. It has very good discriminatory power and good calibration ability. This model can facilitate the identification of sexually active women at high risk of HIV infection for targeted preventive measures.

Trends of HIV Infection and Progress Towards the 95-95-95 Targets in Gambella Regional State from 2019 to 2023, Southwest ETHIOPIA

Background

In 2022, there were 1.3 million new HIV infections, 630,000 AIDS-related deaths, and 39.0 million HIV-positive individuals worldwide. To put the world on track to eradicate AIDS by 2030, there are ambitious goals and commitments for 2025. However, the likelihood of these goals being met or even close to being met is highly dependent on the trend of new HIV infection, the prevalence of the disease, the commitment and capability of leaders, and the application of the planned strategies to achieve the goal.

Objective

To look trend of HIV infection is changing and how far we have come toward the three 95-95-95 goals in Gambella Regional State, Southwest Ethiopia, 2023.

Methods

From August 1 to August 20, 2023, a descriptive cross-sectional study was carried out. This study included all HIV testing service clients who were enrolled in HIV care and treatment and had viral load records or tests. The data were gathered from the electronic form of the territorial reports of District Health Information Software 2 (DHIS-2). Reviewing regional DHIS-2, a standardized checklist was used. Epi-Data version 3.1 software was used to enter the data. SPSS version 25 was used for the analysis. The proposed objectives' trend was described using a descriptive statistic.

Results

The number of people living with HIV decreased by 4.5%, new HIV infections decreased by 42.28% and adult HIV prevalence decreased from 4.37% to 3.69% between 2019 and 2023. The finding showed that the region progress toward the 95-95-95 goals was 73%, 75% and 95% in 2023.

Conclusion

In the Gambella region, HIV testing services and linking HIV-positive cases to HIV treatment have increased. Despite the good progress toward achieving the three 95 targets; first 95 targets for HIV diagnosis are impractical. As a result, adequate attention is required.

Cervical cancer management in a low resource setting: A 10-year review in a tertiary care hospital in Kenya

Background

Cervical cancer is one of the leading causes of cancer mortality among women in Kenya due to late presentations, poor access to health care, and limited resources. Across many low- and middle-income countries infrastructure and human resources for cervical cancer management are currently insufficient to meet the high population needs therefore patients are not able to get appropriate treatment.

Objective

This study aimed to describe the clinicopathological characteristics and the treatment profiles of cervical cancer cases seen at Moi Teaching and Referral Hospital (MTRH).

Methods

This was a retrospective cross-sectional study conducted at MTRH involving the review of the electronic database and medical charts of 1541 patients with a histologically confirmed diagnosis of cervical cancer between January 2012 and December 2021.

Results

Of the 1541 cases analyzed, 91% were squamous cell carcinomas, 8% were adenocarcinomas, and 1% were other histological types. Thirty-eight percent of the patients were HIV infected and less than 30% of the women had health insurance. A majority (75%) of the patients presented with advanced-stage disease (stage IIB-IV). Only 13.9% received chemoradiotherapy with curative intent; of which 33.8% received suboptimal treatment. Of the 13% who received surgical treatment, 45.3% required adjuvant therapy, of which only 27.5% received treatment. Over 40% of the women were lost to follow-up.

Conclusion

Most of the patients with cervical cancer in Kenya present at advanced stages with only a third receiving the necessary treatment while the majority receive only palliative treatment or supportive care.

Peer PrEP referral + HIV self-test delivery for PrEP initiation among young Kenyan women: study protocol for a hybrid cluster-randomized controlled trial

BACKGROUND

Oral HIV pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but uptake remains low in Africa, especially among young women who are a priority population for HIV prevention services. HIV self-testing (HIVST) has been proven to increase HIV testing in diverse populations but has been underutilized to support linkage to HIV prevention services. Most young women who initiate PrEP in Africa do so through informal peer referral. We wanted to test a model of formalized peer referral enhanced with HIVST delivery among young Kenyan women.

METHODS

The Peer PrEP Trial is a two-arm hybrid effectiveness-implementation cluster-randomized controlled trial being conducted in central Kenya. Eligible participants (i.e., peer providers, n = 80) are women (≥ 16-24 years) refilling or initiating PrEP at public healthcare clinics who can identify at least four peers who could benefit from PrEP and not enrolled in another HIV study. Peer providers will be 1:1 randomized to (1) formal peer PrEP referral + HIVST delivery, where they will be encouraged to refer four peers (i.e., peer clients, ≥ 16-24 years) using educational materials and HIVST kits (two per peer client), or (2) informal peer PrEP referral, where they are encouraged to refer four peer clients using informal word-of-mouth referral. In both arms, peer providers will deliver a standard PrEP referral card with information on nearby public clinics delivering PrEP services. Peer providers will complete surveys at baseline and 3 months; peer clients will complete surveys at 3 months. Our primary outcome is PrEP initiation among peer clients, as reported by peer providers at 3 months. Secondary outcomes include PrEP continuation (any refilling), HIV testing (past 3 months), sexual behaviors (past month), and PrEP adherence (past month) among peer clients, as reported by both peer providers and clients at 3 months. Implementation outcomes will include participants' perceived acceptability, appropriateness, and feasibility of the intervention as well assessments of the intervention's fidelity and cost.

DISCUSSION

Evidence from this trial will help us understand how HIVST could support health systems by facilitating linkage to PrEP services among young women who could benefit in Kenya and similar settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04982250. Registered on July 29, 2021.

Optimizing HIV case identification: investigating client characteristics predictive of HIV positivity from provider-initiated testing (PITC) in central Kenya

BACKGROUND

Routine program data indicates positivity rates under 2% from HIV testing services (HTS) at sites supported by Centre for Health Solutions-Kenya in Central Kenya. Achieving the UNAIDS 95:95:95 goals requires continuous identification of people living with HIV in an environment of diminishing resources. We assessed non-clinical and clinical characteristics of persons who tested HIV-positive aimed at improving the process of HTS through Provider-Initiated HIV Testing & Counseling (PITC).

METHODS

We conducted a retrospective analysis of routine PITC program data collected between October 2018 and September 2019 from six health facilities located in three counties in central Kenya. Stratification was based on county and facility volume. A multivariable logistic regression model, clustered adjusted for facility using robust standard errors, was used to determine predictors of a positive HIV result.

RESULTS

The total sample was 80,693 with an overall positivity rate of 1.2%. Most, (65.5%), were female and 6.1% were < 15 years. Most clients, 55,464 (68.7%), had previously tested for HIV. Client characteristics associated with a higher odds of positivity on multivariable analysis included: being female (adjusted odds ratio [aOR] 1.27, 95% confidence interval [CI] (1.03-1.57); adults 15 years and above compared to children < 15 years, divorced and married polygamous compared to married monogamous [aOR 3.98, 95% CI (2.12-7.29) and aOR 2.41 95% CI (1.48-3.94) respectively]; clients testing for the first time compared to repeat testers in less than 12 months [aOR 1.39, 95% CI (1.27-1.51)]. Similarly, repeat testers in more than 12 months compared to repeat testers in less than 12 months [aOR 1.90, 95% CI (1.55-2.32)]; presumptive TB clients compared to those without signs of TB [aOR 16.25, 95% CI (10.63-24.84)]. Clients tested at inpatient departments (IPD) were more likely to get a positive HIV result compared to those tested at outpatient departments (OPD), and other departments.

CONCLUSIONS

The study findings highlight client characteristics such as age, marital status, HIV test entry point, first-time test, repeat test after 12 months, and TB status as factors that could influence PITC results and could be used to develop a screening tool to target eligible clients for HTS in low HIV prevalence settings.

Burden of HIV and treatment outcomes among TB patients in rural Kenya: a 9-year longitudinal study

BACKGROUND

Although tuberculosis (TB) patients coinfected with HIV are at risk of poor treatment outcomes, there is paucity of data on changing trends of TB/HIV co-infection and their treatment outcomes. This study aims to estimate the burden of TB/HIV co-infection over time, describe the treatment available to TB/HIV patients and estimate the effect of TB/HIV co-infection on TB treatment outcomes.

METHODS

This was a retrospective data analyses from TB surveillance in two counties in Kenya (Nyeri and Kilifi): 2012‒2020. All TB patients aged ≥ 18 years were included. The main exposure was HIV status categorised as infected, negative or unknown status. World Health Organization TB treatment outcomes were explored; cured, treatment complete, failed treatment, defaulted/lost-to-follow-up, died and transferred out. Time at risk was from date of starting TB treatment to six months later/date of the event and Cox proportion with shared frailties models were used to estimate effects of TB/HIV co-infection on TB treatment outcomes.

RESULTS

The study includes 27,285 patients, median (IQR) 37 (29‒49) years old and 64% male. 23,986 (88%) were new TB cases and 91% were started on 2RHZE/4RH anti-TB regimen. Overall, 7879 (29%, 95% 28‒30%) were HIV infected. The proportion of HIV infected patient was 32% in 2012 and declined to 24% in 2020 (trend P-value = 0.01). Uptake of ARTs (95%) and cotrimoxazole prophylaxis (99%) was high. Overall, 84% patients completed six months TB treatment, 2084 (7.6%) died, 4.3% LTFU, 0.9% treatment failure and 2.8% transferred out. HIV status was associated with lower odds of completing TB treatment: infected Vs negative (aOR 0.56 (95%CI 0.52‒0.61) and unknown vs negative (aOR 0.57 (95%CI 0.44‒0.73). Both HIV infected and unknown status were associated with higher hazard of death: (aHR 2.40 (95%CI 2.18‒2.63) and 1.93 (95%CI 1.44‒2.56)) respectively and defaulting treatment/LTFU: aHR 1.16 (95%CI 1.01‒1.32) and 1.55 (95%CI 1.02‒2.35)) respectively. HIV status had no effect on hazard of transferring out and treatment failure.

CONCLUSION

The overall burden of TB/HIV coinfection was within previous pooled estimate. Our findings support the need for systematic HIV testing as those with unknown status had similar TB treatment outcomes as the HIV infected.

The long-term impact of HIV/AIDS on socio-economic status: a comparative analysis of households headed by HIV-positive and HIV-negative individuals in Western Kenya

HIV/AIDS is known to have adverse effects on individual and family socio-economic status due to the loss of productive time and over-expenditure in treatment. However, empirical data on how HIV/AIDS affects households' socio-economic status are insufficient. We linked socio-economic data from a Health and Demographic Surveillance System (HDSS) that implements an HIV/AIDS Longitudinal bio-behavioural survey (LBBS) to understand the long-term impact of HIV/AIDS on households' socio-economic status between 2010 and 2018. We compared changes in socio-economic status between households headed by HIV-negative and -positive individuals. A logistic regression was used to assess factors that influence socio-economic status. The level of education and household size were not significant predictors of households' socio-economic status. Households headed by HIV-positive individuals could maintain their baseline socio-economic status (unadjusted RRR = 1.17, 95% CI: 1.01, 1.36) but improvement chances were reduced despite a non-significant association (unadjusted RRR = 0.98, 95% CI: 0.80, 1.20). While HIV/AIDS is known to disrupt economic growth, in this setting, being a male household head, old and widowed reduces chances of improved socio-economic status. The elderly people, widows and widowers are disadvantaged. Consequently, there is a need for special programmes, which seek to empower the identified vulnerable groups economically. .

Evidence of Histoplasma capsulatum seropositivity and exploration of risk factors for exposure in Busia county, western Kenya: Analysis of the PAZ dataset

BACKGROUND

Despite recognition of histoplasmosis as a disease of national public health concern in Kenya, the burden of Histoplasma capsulatum in the general population remains unknown. This study examined the human seroprevalence of anti-Histoplasma antibody and explored associations between seropositivity and demographic and environmental variables, in Busia county, western Kenya.

METHODOLOGY

Biobanked serum samples and associated data, from a previous cross-sectional survey, were examined. Latex agglutination tests to detect the presence of anti-Histoplasma antibody were performed on serum samples from 670 survey respondents, representing 178 households within 102 sub-locations. Potential epidemiologic risk factors for H. capsulatum exposure were explored using multi-level multivariable logistic regression analysis with household and sub-location included as random effects.

PRINCIPAL FINDINGS

The apparent sample seroprevalence of anti-Histoplasma antibody was 15.5% (n = 104/670, 95% Confidence Interval (CI) 12.9-18.5%). A multivariable logistic regression model identified increased odds of H. capsulatum seropositivity in respondents reporting rats within the household within the previous 12 months (OR = 2.99 90% CI 1.04-8.55, p = 0.04). Compared to respondents aged 25-34 years, the odds of seropositivity were higher in respondents aged 15-24 years (OR = 2.70 90% CI 1.04-6.97, p = 0.04).

CONCLUSIONS

The seroprevalence result provides a baseline for sample size approximations for future epidemiologic studies of the burden of H. capsulatum exposure in Busia county. The final model explored theoretically plausible risk factors for H. capsulatum exposure in the region. A number of factors may contribute to the complex epidemiological picture impacting H. capsulatum exposure status at the human-animal-environment interface in western Kenya. Focussed H. capsulatum research is warranted to determine the contextual significance of identified associations, and in representative sample populations.

Online HIV prophylaxis delivery: Protocol for the ePrEP Kenya pilot study

Background

Online pharmacies in Kenya provide sexual and reproductive health products (e.g., HIV self-testing, contraception) and could be leveraged to increase the reach of HIV pre-exposure and post-exposure prophylaxis (PrEP/PEP) to populations who do not frequently attend health facilities. To date, evidence is limited for operationalizing online PrEP/PEP delivery and the type of populations reached with this differential service delivery model.

Methods

The ePrEP Kenya Pilot will deliver daily oral PrEP and PEP via MYDAWA, a private online pharmacy retailer, to clients in Nairobi for 18 months. Potential clients will obtain information about PrEP/PEP on MYDAWA's sexual wellness page and self-screen for HIV risk. Individuals ≥18 years, identified as at HIV risk, and willing to pay for a blood-based HIV self-test and PrEP/PEP delivery will be eligible for enrollment. To continue with online PrEP/PEP initiation, eligible clients will purchase a blood-based HIV self-test for 250 KES (~USD 2) [delivered to their setting of choice for 99 KES (~USD 1)], upload an image of their self-test result, and attend a telemedicine visit with a MYDAWA provider. During the telemedicine visit, providers will screen clients for PrEP/PEP eligibility, including clinical concerns (e.g., kidney disease), discuss self-test results, and complete counseling on PrEP/PEP use and safety. Providers will refer clients who self-test HIV positive or report any existing medical conditions to the appropriate services at healthcare facilities that meet their preferences. Eligible clients will be prescribed PrEP (30-day PrEP supply at initiation; 90-day PrEP supply at follow-up visits) or PEP (28-day supply) for free and have it delivered for 99 KES (~USD 1). We will measure PrEP and PEP initiation among eligible clients, PEP-to-PrEP transition, PrEP continuation, and implementation outcomes (e.g., feasibility, acceptability, and costs).

Discussion

Establishing pathways to increase PrEP and PEP access is crucial to help curb new HIV infections in settings with high HIV prevalence. The findings from this study will provide evidence on the implementation of online pharmacy PrEP and PEP service delivery that can help inform guidelines in Kenya and similar settings.

Estimating age specific prevalence and force of infection in Zimbabwe using combined cross-sectional surveys from 2005 to 2015

Objective

Age structured sexual mixing patterns have been noted to be associated with HIV prevalence and force of infection. Therefore, this study aimed to estimate the age dependent HIV force of infection using survey cross-sectional data from Zimbabwe.

Methods

We fit generalized additive models namely; linear, semi-parametric, non-parametric and non-proportional hazards models. Using the 2005-06, 2010-11 and 2015 Zimbabwe Demographic Health Surveys data. The Akaike Information Criteria was used to select the best model. The best model was then used to estimate the age dependent HIV prevalence and force-of-infection.

Results

Based on birth year cohort-specific prevalence, the female HIV prevalence reaches the highest peak at around 29 years of age, then declines thereafter. Males have a lower cohort specific prevalence between 15 and 30 years than females. Male cohort-specific prevalence slightly decreases between the ages of 33 and 39, then peaks around the age of 40. The cohort-specific FOI is greater in females than in males throughout all age categories. In addition, the cohort-specific HIV FOI peaked at ages 22 and 40 for females and males, respectively. The observed 18-year age difference between the HIV FOI peaks of males and females.

Conclusion

Our model was appealing because we did not assume that the FOI is stationary over time; however, we used serological survey data to distinguish the FOI's age-and-time effect. The cohort-specific FOI peaked 18 years earlier in females than males, indicative of age-mixing patterns. We recommend interventions that target younger females so as to reduce HIV transmission rates.

Methods for conducting trends analysis: roadmap for comparing outcomes from three national HIV Population-based household surveys in Kenya (2007, 2012, and 2018)

BACKGROUND

For assessing the HIV epidemic in Kenya, a series of independent HIV indicator household-based surveys of similar design can be used to investigate the trends in key indicators relevant to HIV prevention and control and to describe geographic and sociodemographic disparities, assess the impact of interventions, and develop strategies. We developed methods and tools to facilitate a robust analysis of trends across three national household-based surveys conducted in Kenya in 2007, 2012, and 2018.

METHODS

We used data from the 2007 and 2012 Kenya AIDS Indicator surveys (KAIS 2007 and KAIS 2012) and the 2018 Kenya Population-based HIV Impact Assessment (KENPHIA 2018). To assess the design and other variables of interest from each study, variables were recoded to ensure that they had equivalent meanings across the three surveys. After assessing weighting procedures for comparability, we used the KAIS 2012 nonresponse weighting procedure to revise normalized KENPHIA weights. Analyses were restricted to geographic areas covered by all three surveys. The revised analysis files were then merged into a single file for pooled analysis. We assessed distributions of age, sex, household wealth, and urban/rural status to identify unexpected changes between surveys. To demonstrate how a trend analysis can be carried out, we used continuous, binary, and time-to-event variables as examples. Specifically, temporal trends in age at first sex and having received an HIV test in the last 12 months were used to demonstrate the proposed analytical approach. These were assessed with respondent-specific variables (age, sex, level of education, and marital status) and household variables (place of residence and wealth index). All analyses were conducted in SAS 9.4, but analysis files were created in Stata and R format to support additional analyses.

RESULTS

This study demonstrates trends in selected indicators to illustrate the approach that can be used in similar settings. The incidence of early sexual debut decreased from 11.63 (95% CI: 10.95-12.34) per 1,000 person-years at risk in 2007 to 10.45 (95% CI: 9.75-11.2) per 1,000 person-years at risk in 2012 and to 9.58 (95% CI: 9.08-10.1) per 1,000 person-years at risk in 2018. HIV-testing rates increased from 12.6% (95% CI: 11.6%-13.6%) in 2007 to 56.1% (95% CI: 54.6%-57.6%) in 2012 but decreased slightly to 55.6% [95% CI: 54.6%-56.6%) in 2018. The decrease in incidence of early sexual debut could be convincingly demonstrated between 2007 and 2012 but not between 2012 and 2018. Similarly, there was virtually no difference between HIV Testing rates in 2012 and 2018.

CONCLUSIONS

Our approach can be used to support trend comparisons for variables in HIV surveys in low-income settings. Independent national household surveys can be assessed for comparability, adjusted as appropriate, and used to estimate trends in key indicators. Analyzing trends over time can not only provide insights into Kenya's progress toward HIV epidemic control but also identify gaps.

Contrasting Comprehension of HIV Research by Adolescents, Young Adults, and Caregivers in Western Kenya: A Cross-sectional Analysis

ABSTRACT

Adolescent participation in research is critical to inform interventions that improve outcomes for this group. Adolescents and young adults living with HIV often present to care without caregivers, yet caregiver permission is typically required for those younger than 18 years. We evaluated whether understanding of key consent information differed between adolescents (n = 1,393) and caregiver adults (n = 169). Compared with caregivers, adolescents aged 10-14 years showed significantly lower understanding, whereas understanding for older adults living with HIV did not differ significantly from caregivers. Risks were the least understood consent information for all age groups. Our findings suggest that for low-risk research, waiving caregiver permission requirements will not compromise the ethical need to ensure understanding of research before enrollment and may allow adolescents greater access to potential research benefits.

Magnitude of Peripheral Sensory Neuropathy and Associated Factors Among HIV/AIDS Clients Receiving Care at Public Health Institutions, Northwest Ethiopia

Background: In the mid-1990s, the development of combination antiretroviral therapy converted HIV infection into a chronic condition, with newly diagnosed patients now living longer than the general population. HIV affects both the central and peripheral nerve systems, resulting in a variety of clinical problems, including peripheral neuropathy, which is a common neurological consequence. Despite this, there is a scarcity of data on the extent of peripheral sensory neuropathy and its underlying factors in Ethiopia, necessitating this study. Objective: The primary goal of this study is to assess the degree of peripheral sensory neuropathy and its related factors among HIV/AIDS clients on follow up at public health institutions in Northwest Ethiopia. Methodology: Institution based cross-sectional study was conducted from November 1 to 30 December 2020 at selected south Gondar zone public health institutions ART clinic. Multistage sampling technique was used to select the study participants. Standardized Questioner adapted from other study was used to collect the data. Moreover, Brief Peripheral Neuropathy Screening tool (BPNS) was used to assess peripheral sensory neuropathy. The data were entered with epi-data manager version 4.4 and analyzed using STATA version 16. Result: A total of 555 adult PLWHIV agreed to participate in the study, resulting in a response rate of 96.8%. The prevalence of Peripheral sensory neuropathy was 32.25, 95% CI (28.28, 36.26). The participant’s age, DM comorbidity, viral load level, and disease clinical stage were all found to have a statistically significant association with peripheral sensory neuropathy. Conclusion: Peripheral sensory neuropathy was incredibly common. Accordingly, peripheral sensory neuropathy was found considerably associated with age, viral load level, stage of the disease, and DM comorbidity. It is vital to integrate routine peripheral sensory neuropathy screening strategies for clients who are on ART follow up for prevention and early identification of the problem.

HIV Prevalence and Associated Factors Among Men in South Africa 30 Years into the Epidemic: The Fifth Nationwide Cross-Sectional Survey

We investigated HIV prevalence and associated factors among men ≥ 15 years in South Africa using data from a 2017 nationwide cross-sectional survey. HIV prevalence was 10.5% among 6 646 participants. Prevalence increased from 4.1% in the younger men (15-24 years), 12.5% in young men (25-34 years) to 12.7% in older men (≥ 35 years). Odds of being infected with HIV were lower among younger men who had secondary level education and those who reported poor/fair self-rated health. Young and older men of other race groups had lower odds of HIV infection. Odds of infection were lower among young men who had moderate/high exposure to HIV communication programmes. Men not aware of their HIV status had higher odds of HIV infection, including older men who never married. Improved access to education, behavioral change programmes, and awareness of HIV status are necessary to reduce the risk of HIV infection among Black African men.

Performance evaluation of the Asante Rapid Recency Assay for verification of HIV diagnosis and detection of recent HIV-1 infections: Implications for epidemic control

We previously described development of a rapid test for recent infection (RTRI) that can diagnose HIV infection and detect HIV-1 recent infections in a single device. This technology was transferred to a commercial partner as Asante Rapid Recency Assay (ARRA). We evaluated performance of the ARRA kits in the laboratory using a well-characterized panel of specimens. The plasma specimen panel (N = 1500) included HIV-1 (N = 570), HIV-2 (N = 10), and HIV-negatives (N = 920) representing multiple subtypes and geographic locations. Reference diagnostic data were generated using the Bio-Rad HIV-1-2-O EIA/Western blot algorithm with further serotyping performed using the Multispot HIV-1/2 assay. The LAg-Avidity EIA was used to generate reference data on recent and long-term infection for HIV-1 positive specimens at a normalized optical density (ODn) cutoff of 2.0 corresponding to a mean duration of about 6 months. All specimens were tested with ARRA according to the manufacturer's recommendations. Test strips were also read for line intensities using a reader and results were correlated with visual interpretation. ARRA's positive verification line (PVL) correctly classified 575 of 580 HIV-positive and 910 of 920 negative specimens resulting in a sensitivity of 99.1% (95% CI: 98.0-99.6) and specificity of 98.9% (95% CI: 98.1-99.4), respectively. The reader-based classification was similar for PVL with sensitivity of 99.3% (576/580) and specificity of 98.8% (909/920). ARRA's long-term line (LTL) classified 109 of 565 HIV-1 specimens as recent and 456 as long-term compared to 98 as recent and 467 as long-term (LT) by LAg-Avidity EIA (cutoff ODn = 2.0), suggesting a mean duration of recent infection (MDRI) close to 6 months. Agreement of ARRA with LAg recent cases was 81.6% (80/98) and LT cases was 93.8% (438/467), with an overall agreement of 91.7% (kappa = 0.72). The reader (cutoff 2.9) classified 109/566 specimens as recent infections compared to 99 by the LAg-Avidity EIA for recency agreement of 81.8% (81/99), LT agreement of 9% (439/467) with overall agreement of 91.9% (kappa = 0.72). The agreement between visual interpretation and strip reader was 99.9% (95% CI: 99.6-99.9) for the PVL and 98.1% (95% CI: 96.6-98.9) for the LTL. ARRA performed well with HIV diagnostic sensitivity >99% and specificity >98%. Its ability to identify recent infections is comparable to the LA-Avidity EIA corresponding to an MDRI of about 6 months. This point-of-care assay has implications for real-time surveillance of new infections among newly diagnosed individuals for targeted prevention and interrupting ongoing transmission thus accelerating epidemic control.

Mapping geographic clusters of new HIV diagnoses to inform granular-level interventions for HIV epidemic control in western Kenya

BACKGROUND

As countries make progress towards HIV epidemic control, there is increasing need to identify finer geographic areas to target HIV interventions. We mapped geographic clusters of new HIV diagnoses, and described factors associated with HIV-positive diagnosis, in order to inform targeting of HIV interventions to finer geographic areas and sub-populations.

METHODS

We analyzed data for clients aged > 15 years who received home-based HIV testing as part of a routine public health program between May 2016 and July 2017 in Siaya County, western Kenya. Geospatial analysis using Kulldorff's spatial scan statistic was used to detect geographic clusters (radius < 5 kilometers) of new HIV diagnoses. Factors associated with new HIV diagnosis were assessed in a spatially-integrated Bayesian hierarchical model.

RESULTS

Of 268,153 clients with HIV test results, 2906 (1.1%) were diagnosed HIV-positive. We found spatial variation in the distribution of new HIV diagnoses, and identified nine clusters in which the number of new HIV diagnoses was significantly (1.56 to 2.64 times) higher than expected. Sub-populations with significantly higher HIV-positive yield identified in the multivariable spatially-integrated Bayesian model included: clients aged 20-24 years [adjusted relative risk (aRR) 3.45, 95% Bayesian Credible Intervals (CI) 2.85-4.20], 25-35 years (aRR 4.76, 95% CI 3.92-5.81) and > 35 years (aRR 2.44, 95% CI 1.99-3.00); those in polygamous marriage (aRR 1.84, 95% CI 1.55-2.16), or separated/divorced (aRR 3.36, 95% CI 2.72-4.08); and clients who reported having never been tested for HIV (aRR 2.35, 95% CI 2.02-2.72), or having been tested > 12 months ago (aRR 1.53, 95% CI 1.41-1.66).

CONCLUSION

Our study used routine public health program data to identify granular geographic clusters of higher new HIV diagnoses, and sub-populations with higher HIV-positive yield in the setting of a generalized HIV epidemic. In order to target HIV testing and prevention interventions to finer granular geographic areas for maximal epidemiologic impact, integrating geospatial analysis into routine public health programs can be useful.

Two-fold increase in the HIV viral load suppression rate along with decreased incidence over six years in Ndhiwa sub-county, Kenya

Background

HIV‐positive individuals who maintain an undetectable viral load cannot transmit the virus to others. In 2012, an HIV population‐based survey was conducted in Ndhiwa sub‐county (Kenya) to provide information on the HIV local epidemic. We carried out a second survey 6 years after the first one, to assess progress in HIV diagnosis and care and differences in the HIV prevalence and incidence between the two surveys.

Methods

A cross‐sectional, population‐based survey using cluster sampling and geospatial random selection was implemented in 2018, using the same design as 2012. Consenting participants aged 15–59 years were interviewed and tested for HIV at home. HIV‐positive individuals received viral load testing (viral suppression defined as <1000 copies/ml) and Lag‐Avidity EIA assay (to measure recent infection). The 90–90–90 UNAIDS indicators were also assessed.

Results

Overall, 6029 individuals were included in 2018. HIV prevalence was 16.9%. Viral suppression among all HIV‐positive was 88.3% in 2018 (vs. 39.9% in 2012, p < 0.001). HIV incidence was 0.75% in 2018 vs. 1.90% in 2012 (p = 0.07). In 2018, the 90–90–90 indicators were 93%–97%–95% (vs. 60%–68%–83% in 2012).

Conclusion

A two‐fold increase in the HIV viral load suppression rate along with a decreasing trend in incidence was observed over 6 years in Ndhiwa sub‐county. Achieving high rates of viral suppression in HIV populations that can lead to reducing HIV transmission in sub‐Saharan contexts is feasible. Nevertheless, we will need further efforts to sustain this progress.

A Comprehensive Approach to Assuring Quality of Laboratory Testing in HIV Surveys: Lessons Learned From the Population-Based HIV Impact Assessment Project

BACKGROUND

Conducting HIV surveys in resource-limited settings is challenging because of logistics, limited availability of trained personnel, and complexity of testing. We described the procedures and systems deemed critical to ensure high-quality laboratory data in the population-based HIV impact assessments and large-scale household surveys.

METHODS

Laboratory professionals were engaged in every stage of the surveys, including protocol development, site assessments, procurement, training, quality assurance, monitoring, analysis, and reporting writing. A tiered network of household, satellite laboratories, and central laboratories, accompanied with trainings, optimized process for blood specimen collection, storage, transport, and real-time monitoring of specimen quality, and test results at each level proved critical in maintaining specimen integrity and high-quality testing. A plausibility review of aggregate merged data was conducted to confirm associations between key variables as a final quality check for quality of laboratory results.

RESULTS

Overall, we conducted a hands-on training for 3355 survey staff across 13 surveys, with 160-387 personnel trained per survey on biomarker processes. Extensive training and monitoring demonstrated that overall, 99% of specimens had adequate volume and 99.8% had no hemolysis, indicating high quality. We implemented quality control and proficiency testing for testing, resolved discrepancies, verified >300 Pima CD4 instruments, and monitored user errors. Aggregate data review for plausibility further confirmed the high quality of testing.

CONCLUSIONS

Ongoing engagement of laboratory personnel to oversee processes at all levels of the surveys is critical for successful national surveys. High-quality population-based HIV impact assessments laboratory data ensured reliable results and demonstrated the impact of HIV programs in 13 countries.

Characterisation of tuberculosis mortality in informal settlements in Nairobi, Kenya: analysis of data between 2002 and 2016

BACKGROUND

Tuberculosis (TB) remains one of the key public health problems in Africa. Due to multifaceted challenges, its burden is poorly described in informal settlements. We describe tuberculosis mortality in two informal settlements in Nairobi, Kenya.

METHODS

This is a secondary analysis of 2002-2016 verbal autopsy data from informal settlements in the Nairobi Urban Health Demographic Surveillance System (NUHDSS). A descriptive analysis of deaths assigned as caused by TB was done. Pearson chi-square tests were used to determine differences between socio-demographic factors. Logistic regression was carried out to examine the risk of death from TB within the characteristics.

RESULTS

There were 6218 deaths in the NUHDSS within the period of analysis, of which 930 (14.96%) were deaths from TB. The average number of TB deaths per year was 62(SD 23.9). There was a reduction in TB deaths from 21.2% in 2005 to 1.7% in 2016. Males had 1.39 higher odds of dying from TB than females (AOR 1.39; 95% CI 1.18-1.64; p-value < 0.001). Compared to those aged 30-39 years, the ≥50-year-olds had a 42% lower chance of dying from TB (AOR 0.57; 95% CI 0.47-0.73; p-value < 0.001). Those dying at home had 1.39 odds of dying from TB as compared to those who died in a health facility(AOR 1.93; 95% CI 1.17-1.64; p value< 0.001).

CONCLUSION

There was a reduction in TB deaths over the study period. Males had the highest risk of death. There is a need to strengthen TB surveillance and access to TB diagnosis and treatment within informal settlements to enhance early diagnosis and treatment.

Large age shifts in HIV-1 incidence patterns in KwaZulu-Natal, South Africa

HIV incidence has recently been in decline across some of the most intense epidemics in sub-Saharan Africa due to the scale-up of prevention and transmission-blocking treatments. Understanding whether declines in incidence are being felt equally across age and gender can help prioritize demographic groups where more effort is needed to lower transmission. We found that HIV incidence has declined disproportionately in the youngest men and women in a population with the highest HIV prevalence in the world. Shifts in the age distribution of risk may be the consequence of aging prevalence, prioritized prevention to younger individuals, and delays in age at infection from reduced overall force of infection. Our results highlight the need to expand age targets for HIV prevention.

Recent declines in adult HIV-1 incidence have followed the large-scale expansion of antiretroviral therapy and primary HIV prevention across high-burden communities of sub-Saharan Africa. Mathematical modeling suggests that HIV risk will decline disproportionately in younger adult age-groups as interventions scale, concentrating new HIV infections in those >age 25 over time. Yet, no empirical data exist to support these projections. We conducted a population-based cohort study over a 16-y period (2004 to 2019), spanning the early scale-up of antiretroviral therapy and voluntary medical male circumcision, to estimate changes in the age distribution of HIV incidence in a hyperepidemic region of KwaZulu-Natal, South Africa, where adult HIV incidence has recently declined. Median age of HIV seroconversion increased by 5.5 y in men and 3.0 y in women, and the age of peak HIV incidence increased by 5.0 y in men and 2.0 y in women. Incidence declined disproportionately among young men (64% in men 15 to 19, 68% in men 20 to 24, and 46% in men 25 to 29) and young women (44% in women 15 to 19, 24% in women 20 to 24) comparing periods pre- versus post-universal test and treat. Incidence was stable (<20% change) in women aged 30 to 39 and men aged 30 to 34. Age shifts in incidence occurred after 2012 and were observed earlier in men than in women. These results provide direct epidemiological evidence of the changing demographics of HIV risk in sub-Saharan Africa in the era of large-scale treatment and prevention. More attention is needed to address lagging incidence decline among older individuals.

High HIV prevalence among decedents received by two high-volume mortuaries in Kisumu, western Kenya, 2019

Background

Accurate data on HIV-related mortality are necessary to evaluate the impact of HIV interventions. In low- and middle-income countries (LMIC), mortality data obtained through civil registration are often of poor quality. Though not commonly conducted, mortuary surveillance is a potential complementary source of data on HIV-associated mortality.

Methods

During April-July 2019, we assessed HIV prevalence, the attributable fraction among the exposed, and the population attributable fraction among decedents received by two high-volume mortuaries in Kisumu County, Kenya, where HIV prevalence in the adult population was estimated at 18% in 2019 with high ART coverage (76%). Stillbirths were excluded. The two mortuaries receive 70% of deaths notified to the Kisumu East civil death registry; this registry captures 45% of deaths notified in Kisumu County. We conducted hospital chart reviews to determine the HIV status of decedents. Decedents without documented HIV status, including those dead on arrival, were tested using HIV antibody tests or polymerase chain reaction (PCR) consistent with national HIV testing guidelines. Decedents aged less than 15 years were defined as children. We estimated annual county deaths by applying weights that incorporated the study period, coverage of deaths, and mortality rates observed in the study.

Results

The two mortuaries received a total of 1,004 decedents during the study period, of which 95.1% (955/1004) were available for study; 89.1% (851/955) of available decedents were enrolled of whom 99.4% (846/851) had their HIV status available from medical records and post-mortem testing. The overall population-based, age- and sex-adjusted mortality rate was 12.4 per 1,000 population. The unadjusted HIV prevalence among decedents was 28.5% (95% confidence interval (CI): 25.5–31.6). The age- and sex-adjusted mortality rate in the HIV-infected population (40.7/1000 population) was four times higher than in the HIV-uninfected population (10.2/1000 population). Overall, the attributable fraction among the HIV-exposed was 0.71 (95% CI: 0.66–0.76) while the HIV population attributable fraction was 0.17 (95% CI: 0.14–0.20). In children the attributable fraction among the exposed and population attributable fraction were 0.92 (95% CI: 0.89–0.94) and 0.11 (95% CI: 0.08–0.15), respectively.

Conclusions

Over one quarter (28.5%) of decedents received by high-volume mortuaries in western Kenya were HIV-positive; overall, HIV was considered the cause of death in 17% of the population (19% of adults and 11% of children). Despite substantial scale-up of HIV services, HIV disease remains a leading cause of death in western Kenya. Despite progress, increased efforts remain necessary to prevent and treat HIV infection and disease.

A decade and beyond: learnings from HIV programming with underserved and marginalized key populations in Kenya

INTRODUCTION

Key populations (KP) continue to account for high HIV incidence globally. Still, prioritization of KP in the national HIV prevention response remains insufficient, leading to their suboptimal access to HIV programmes. This commentary aims to share Kenya's challenges and successes in achieving 2020 global HIV targets and scaling up the KP programme in the last decade.

DISCUSSION

The KP programme in Kenya has scaled up in the last decade with the inclusion of female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), transgender people and people in prisons as priority populations in the national HIV response. KP coverage based on official size estimates for FSW is 73%, for MSM is 82%, for PWID through needle syringe programme (NSP) is 71%, and through opioid substitution therapy (OST) is 26% and for transgender people is 5%. The service outcomes for KP have been relatively strong in prevention with high condom use at last paid sex for FSW (92%) and use of sterile equipment among PWID (88%), though condom use at last sex with a non-regular partner among MSM (78%) is still low. The KP programme has not met care continuum targets for all subpopulations with low case findings. The national KP programme led by the Ministry of Health has scaled up the programme through (a) strategic partnerships with KP-led and competent organizations, researchers and donors; (b) development of policy guidance and programme standards; (c) continuous sensitization and advocacy to garner support; (d) development of national reporting systems, among others. However, the programme is still struggling with uncertain size estimates; lack of updated bio-behavioural survey data; inadequate scale-up of interventions among transgender people and people in prison settings; gaps in reaching adolescent and young KP, and effectively addressing structural barriers like violence and stigma.

CONCLUSIONS

To reach the ambitious global HIV targets, sufficient coverage of KP with quality HIV programmes is critical. Despite scaling up the KP programme, Kenya has not yet achieved the 2020 global HIV targets and needs more efforts to scale-up quality programmes for KP who are underserved in the HIV response.

Experiences and lessons learned from the real-world implementation of an HIV recent infection testing algorithm in three routine service-delivery settings in Kenya and Zimbabwe

INTRODUCTION

Testing for recent HIV infection can distinguish recently acquired infection from long-standing infections. Given current interest in the implementation of recent infection testing algorithms (RITA), we report our experiences in implementing a RITA in three pilot studies and highlight important issues to consider when conducting recency testing in routine settings.

METHODS

We applied a RITA, incorporating a limited antigen (LAg) avidity assay, in different routine HIV service-delivery settings in 2018: antenatal care clinics in Siaya County, Kenya, HIV testing and counselling facilities in Nairobi, Kenya, and female sex workers clinics in Zimbabwe. Discussions were conducted with study coordinators, laboratory leads, and facility-based stakeholders to evaluate experiences and lessons learned in relation to implementing recency testing.

RESULTS

In Siaya County 10/426 (2.3%) of women testing HIV positive were classified as recent, compared to 46/530 (8.7%) of women and men in Nairobi and 33/313 (10.5%) of female sex workers in Zimbabwe. Across the study setting, we observed differences in acceptance, transport and storage of dried blood spot (DBS) or venous blood samples. For example, the acceptance rate when testing venous blood was 11% lower than when using DBS. Integrating our study into existing services ensured a quick start of the study and kept the amount of additional resources required low. From a laboratory perspective, the LAg avidity assay was initially difficult to operationalise, but developing a network of laboratories and experts to work together helped to improve this. A challenge that was not overcome was the returning of RITA test results to clients. This was due to delays in laboratory testing, the need for multiple test results to satisfy the RITA, difficulties in aligning clinic visits, and participants opting not to return for test results.

CONCLUSION

We completed three pilot studies using HIV recency testing based on a RITA in Kenya and Zimbabwe. The main lessons we learned were related to sample collection and handling, LAg avidity assay performance, integration into existing services and returning of test results to participants. Our real-world experience could provide helpful guidance to people currently working on the implementation of HIV recency testing in sub-Saharan Africa.

What has comprehensive HIV/AIDS knowledge got to do with HIV testing among men in Kenya and Mozambique? Evidence from Demographic and Health Surveys

People living with undiagnosed HIV are big contributors to the transmission of the virus. Although measures have been made to scale up HIV prevention and voluntary counselling and testing in sub-Saharan Africa, testing coverage remains low in many sub-Saharan African countries, including Mozambique and Kenya, where most people live with HIV/AIDS. Studies have shown that, in most countries in sub-Saharan Africa, men are less likely to test for HIV compared with women. This study examined the relationship between comprehensive HIV/AIDS knowledge and HIV testing among men in Kenya and Mozambique. Data were from the men's re-code file of the Demographic and Health Surveys of Mozambique and Kenya. Binary logistic regression models were generated and the results presented as crude odds ratios (cOR) and adjusted odds ratios (aOR). The prevalences of HIV testing in Kenya and Mozambique were 80.1% and 46.7%, respectively. Men in Mozambique who had comprehensive HIV/AIDS knowledge (aOR=1.26, CI: 1.07-1.47) were more likely to test for HIV compared with their counterparts who had no comprehensive HIV/AIDS knowledge. In Kenya, men who had comprehensive HIV/AIDS knowledge (aOR=1.23, CI: 1.09-1.39) were more likely to test for HIV compared with their counterparts who had no comprehensive HIV/AIDS knowledge. This study found a statistically strong significant association between comprehensive HIV/AIDS knowledge and HIV testing among men in Kenya and Mozambique. To improve HIV testing rate among men, it is important that interventions are geared towards improving men's comprehensive HIV/AIDS knowledge, perhaps by expanding HIV/AIDS education programmes and campaigns. This could improve HIV testing rates and ensure the realization of the global HIV/AIDS target of 95-95-95 by the year 2030.

Prevalence and Covariates of Food Insecurity Across the First 1000 Days Among Women of Mixed HIV Status in Western Kenya: A Longitudinal Perspective

BACKGROUND

Food insecurity (FI) is common globally and can have lifelong consequences. However, few studies have longitudinally examined how FI varies across gestation and the postpartum period ("the first 1000 days"); none have explored this in sub-Saharan Africa or in the context of HIV.

OBJECTIVE

To assess the prevalence and covariates of FI in the first 1000 days among Kenyan women.

METHODS

All pregnant women attending 7 clinics in western Kenya (n = 1247) were screened for HIV and FI (Individual Food Insecurity Access Scale) between September 2014 and June 2015. A subset of women (n = 371) was recruited into an observational cohort study and surveyed 11 times through 2 years postpartum (NCT02974972, NCT02979418). Data on FI, sociodemographics, and health were repeatedly collected. Severe FI was modeled using multilevel, mixed-effects logistic regressions (n = 346).

RESULTS

Of the 1247 pregnant women screened, 76.5% were severely food insecure in the prior month. Further, the prevalence of severe FI was higher among women living with HIV than those without (82.6% vs 74.6%, P < .05). In the cohort, the odds of being severely food insecure decreased monotonically after delivery. Each point higher on the Center for Epidemiologic Studies-Depression scale was associated with 1.08 times greater odds of being severely food insecure (95% CI: 1.05-1.10); each point higher on the Duke/UNC Functional Social Support Scale was associated with 0.97 lower odds of severe FI (95% CI: 0.94-0.99).

CONCLUSIONS

Severe FI is prevalent during the first 1000 days in western Kenya. Services to mitigate the far-reaching consequences of this modifiable risk should be considered.

Development and Validation of a Sociodemographic and Behavioral Characteristics-Based Risk-Score Algorithm for Targeting HIV Testing Among Adults in Kenya

To inform targeted HIV testing, we developed and externally validated a risk-score algorithm that incorporated behavioral characteristics. Outpatient data from five health facilities in western Kenya, comprising 19,458 adults ≥ 15 years tested for HIV from September 2017 to May 2018, were included in univariable and multivariable analyses used for algorithm development. Data for 11,330 adults attending one high-volume facility were used for validation. Using the final algorithm, patients were grouped into four risk-score categories: ≤ 9, 10-15, 16-29 and ≥ 30, with increasing HIV prevalence of 0.6% [95% confidence interval (CI) 0.46-0.75], 1.35% (95% CI 0.85-1.84), 2.65% (95% CI 1.8-3.51), and 15.15% (95% CI 9.03-21.27), respectively. The algorithm's discrimination performance was modest, with an area under the receiver-operating-curve of 0.69 (95% CI 0.53-0.84). In settings where universal testing is not feasible, a risk-score algorithm can identify sub-populations with higher HIV-risk to be prioritized for HIV testing.

High level of HIV false positives using EIA-based algorithm in survey: Importance of confirmatory testing

The Mozambique Indicators of Immunization, Malaria and HIV/AIDS (IMASIDA) survey was conducted in 2015 and used a two Enzyme Immunoassay (EIA) (Vironostika HIV-1/2 and Murex HIV-1/2) based algorithm to determine the HIV status of the consented participants. The Mozambique Ministry of Health, with support from the US Centers for Disease Control and Prevention (US CDC), added Bio-Rad Geenius™ HIV-1/2 Supplemental Assay to the IMASIDA HIV testing algorithm to confirm all specimens that were found to be reactive on one or both EIAs. In total 11690 specimens were collected to estimate the proportion of HIV positive samples. Results indicate that the proportion of HIV positive samples based on the concordant positive results of two EIA assays was 21.5% (2518/11690). The addition of the Geenius assay to the IMASIDA HIV testing algorithm demonstrated that 792 (31.5%) of 2518 specimens were false-positive and reduced the proportion of HIV positive samples to 14.7% (1722/11690), demonstrating the importance of including a highly specific HIV test to confirm HIV diagnosis. HIV surveys exclusively based on EIA testing algorithm may result in misleading high prevalence results. Our results demonstrate that more specific confirmatory testing should be added to the EIA-based algorithms to ensure accurate HIV diagnosis and correct HIV prevalence estimate in cross-sectional surveys.

Successes and gaps in the HIV cascade of care of a high HIV prevalence setting in Zimbabwe: a population-based survey

INTRODUCTION

Gutu, a rural district in Zimbabwe, has been implementing comprehensive HIV care with the support of Médecins Sans Frontières (MSF) since 2011, decentralizing testing and treatment services to all rural healthcare facilities. We evaluated HIV prevalence, incidence and the cascade of care, in Gutu District five years after MSF began its activities.

METHODS

A cross-sectional study was implemented between September and December 2016. Using multistage cluster sampling, individuals aged ≥15 years living in the selected households were eligible. Individuals who agreed to participate were interviewed and tested for HIV at home. All participants who tested HIV-positive had their HIV-RNA viral load (VL) measured, regardless of their antiretroviral therapy (ART) status, and those not on ART with HIV-RNA VL ≥ 1000 copies/mL had Limiting-Antigen-Avidity EIA Assay for cross-sectional estimation of population-level HIV incidence.

RESULTS

Among 5439 eligible adults ≥15 years old, 89.0% of adults were included in the study and accepted an HIV test. The overall prevalence was 13.6% (95%: Confidence Interval (CI): 12.6 to 14.5). Overall HIV-positive status awareness was 87.4% (95% CI: 84.7 to 89.8), linkage to care 85.5% (95% CI: 82.5 to 88.0) and participants in care 83.8% (95% CI: 80.7 to 86.4). ART coverage among HIV-positive participants was 83.0% (95% CI: 80.0 to 85.7). Overall, 71.6% (95% CI 68.0 to 75.0) of HIV-infected participants had a HIV-RNA VL < 1000 copies/mL. Women achieved higher outcomes than men in the five stages of the cascade of care. Viral Load Suppression (VLS) among participants on ART was 83.2% (95% CI: 79.7 to 86.2) and was not statistically different between women and men (p = 0.98). The overall HIV incidence was estimated at 0.35% (95% CI 0.00 to 0.70) equivalent to 35 new cases/10,000 person-years.

CONCLUSIONS

Our study provides population-level evidence that achievement of HIV cascade of care coverage overall and among women is feasible in a context with broad access to services and implementation of a decentralized model of care. However, the VLS was relatively low even among participants on ART. Quality care remains the most critical gap in the cascade of care to further reduce mortality and HIV transmission.

Pathways for HIV Prevention Behaviors Following a Home-Based Couples Intervention for Pregnant Women and Male Partners in Kenya

Pregnancy is a time of heightened HIV risk, but also a phase when a couple can prioritize family health. We conducted secondary analysis of a home-based intervention in rural Kenya to explore couple-level adherence to HIV prevention behaviors. The intervention included health education, relationship-building skills, and Couples HIV Testing and Counseling. Pregnant women were randomized to the intervention (n = 64) or standard care (n = 63) along with male partners. Of 96 couples, 82 (85.0%) were followed to 3 months postpartum, when 31.0% of couples reported perfect adherence to HIV prevention. In logistic regression, intervention condition couples had three-fold higher odds of perfect adherence (AOR = 3.07, 95% CI = 1.01-9.32). A structural equation model found the intervention had moderate effects on couple communication, large effects on couple efficacy to take action around HIV, which in turn improved HIV prevention behaviors (CFI = 0.969; TLI = 0.955; RMSEA = 0.049). Strengthening couple communication and efficacy may help prevent the spread of HIV to infants or partners around the time of pregnancy.

Agricultural and Finance Intervention Increased Dietary Intake and Weight of Children Living in HIV-Affected Households in Western Kenya

We tested whether a multisectoral household agricultural and finance intervention increased the dietary intake and improved the nutritional status of HIV-affected children. Two hospitals in rural Kenya were randomly assigned to be either the intervention or the control arm. The intervention comprised a human-powered water pump, microfinance loan for farm commodities, and training in sustainable farming practices and financial management. In each arm, 100 children (0-59 mo of age) were enrolled from households with HIV-infected adults 18-49 y old. Children were assessed beginning in April 2012 and every 3 mo for 1 y for dietary intake and anthropometry. Children in the intervention arm had a larger increase in weight (β: 0.025 kg/mo, P = 0.030), overall frequency of food consumption (β: 0.610 times · wk-1 · mo-1, P = 0.048), and intakes of staples (β: 0.222, P = 0.024), fruits and vegetables (β: 0.425, P = 0.005), meat (β: 0.074, P < 0.001), and fat (β: 0.057, P = 0.041). Livelihood interventions have potential to improve the nutrition of HIV-affected children. This trial was registered at clinicaltrials.gov as NCT01548599.

Trends in Hospitalisation for Human Immunodeficiency Virus in a Tertiary Hospital in Dar es Salaam, Tanzania: A Case study

Background:

Reports on systematic evaluation of the impact of antiretroviral therapy(ART) on patients' hospitalisation in Sub Saharan Africa (SSA) and Tanzania in particular are scarce. We aimed at documenting the trends of hospital admissions at Muhimbili National Hospital (MNH) following scale up of free access to ART in Tanzania.

Methods:

Records for all admissions at MNH from June 2005 to June 2015 were reviewed. We extracted data from Hospital Information Management System as well as from patients' charts. Data extracted included diagnosis at discharge, reason for admission and thereafter assessed admission trends over the decade. We summarised the data as frequency and percentages. We compared proportions using Chi squared test, P<0.05 was deemed significant.

Results:

Overall there were 209,101 admissions during the study period (June 2005 to June 2015) and 7864/209,101 (3.8%) were due to HIV infection. Whereas 598/4,519 (13.2%) of all admissions in 2005 were due to HIV, only 345/13,119 (2.6%) of admissions in 2015 were HIV-related; showing a significant drop over time (P value for trend < .001). Generally, females 3887/6679 (58.2%) were more likely to be admitted than males (41.8%). Median CD4 count for admitted HIV patients was 143 cells/µl. Majority of admissions occured in the medical wards 3643/5310 (68.6%). Discharge diagnoses were Tuberculosis 1396/6482 (21.5%), anaemias 1016/6482 (15.6 %), malignancies 789/6482(12.2%), CNS infections 541/6482 (8.3%) and chronic kidney disease 308/6482 (4.8%). Three leading AIDS defining malignancies among hospitalised patients included Kaposi's sarcoma 380/789 (48.2%), carcinoma of the cervix 77/789 (9.8%), and Non-Hodgkin's lymphoma 44/789 (5.6%).

Conclusion:

Despite drastic drop of HIV related admissions at Muhimbili National Hospital over the years, the infection remains a problem of the adults, largely females suffering from medical conditions and presenting with severe immunosuppression. Tuberculosis remained the most common opportunistic infection among hospitalized HIV infected patients. Anaemia and cancers became more important causes of admission than was diarrhoea which had been the most common among HIV infected patients in pre- ART era.

Uptake and utilization of institutional voluntary HIV testing and counseling services among students aged 18-24 in Kenya's public Universities

BACKGROUND

Kenya is home to an estimated 1.7 million people living with HIV/AIDS. According to the Kenya AIDS Indicator survey KAIS 2012, HIV prevalence in the age group 15-24 stood at 2.2%. Globally, young people aged 15-24 are a highly vulnerable population with respect to HIV/AIDS infection and transmission. HIV testing and counseling services play a critical role as an entry point to care and treatment. However, uptake of HIV testing and counseling services among the youth in Kenya has been reportedly low. Youths at Universities are among the priority populations in HIV/AIDS programs.

OBJECTIVES

This study aimed to determine the barriers to uptake and utilization of institution-based voluntary counseling and testing VCT services among students aged 18-24 in selected public universities in Kenya. The specific objectives were to determine the factors associated with uptake and utilization and the association between various socio-demographic factors and service uptake in institutional VCT facilities.

METHODS

This research utilized a descriptive cross-sectional study design where primarily, data was collected using semi-structured questionnaires and through focus group discussions held with the students in the sampled Universities. Data available at Jomo Kenyatta University of Agriculture and Technology JKUAT Hospital VCT were reviewed for the period 2010 and 2016 to give an insight into service utilization rates among students. Multi-stage sampling technique was utilized to reach a student sample size of 305 from the selected public Universities in Kenya.

RESULTS

Uptake of institutional VCT services among University students sampled stood at 45% from a population where 84.4% were aware of the presence of these services on their campuses. More males than females utilized the services. Emerging themes from the study indicated that participants utilized the services for different reasons. Accessibility to test site, testing hours, fear to be seen at site and fear of test result were also identified as factors affecting service uptake. These factors also were also reported when students were asked about their desired characteristics of a VCT facility on campus.

CONCLUSION

This study has unraveled the factors that are associated with testing and counseling in institutional facilities. University students seem to seek and utilize VCT services for different reasons. It is also clear that patterns of services utilization vary from group to another as observed in the case of year of study, gender and age category.

RECOMMENDATIONS

It is necessary for policy makers in institutions of higher learning together with those tasked with managing healthcare services in these institutions to adopt approaches that will overcome the barriers to utilization of VCT services among students. With knowledge of the factors associated with uptake and utilization of VCT services in institutional facilities, efforts to tackle the barriers and maximize on enhancers should be utilized fully in order to improve uptake and utilization of services. More research should also focus on the persisting risky sexual behaviors among University students despite the high knowledge they have on HIV/AIDS.

Cancer in Kenya: types and infection-attributable. Data from the adult population of two National referral hospitals (2008-2012)

Background: Cancer in Africa is an emerging health problem. In Kenya it ranks third as a cause of death after infectious and cardiovascular diseases. Nearly 31% of the total cancer burden in sub-Saharan Africa is attributable to infectious agents. Information on cancer burden is scanty in Kenya and this study aimed to provide comprehensive hospital based data to inform policies. Method: A cross-sectional retrospective survey was conducted at Kenyatta National Hospital (KNH) and Moi Teaching and Referral Hospital (MTRH) from January 2008 to December 2012.  Data was obtained from the patients files and the study was approved by the KNH/University of Nairobi and MTRH Ethics and Research Committees.   Results: In KNH, the top five cancers were: cervical (62, 12.4%), breast (59, 11.8%), colorectal (31, 6.2%), chronic leukemia (27, 5.4%) and stomach cancer (26, 5.2%). Some 154 (30.8%) of these cancers were associated with infectious agents, while an estimated 138 (27.6%) were attributable to infections. Cancers of the cervix (62, 12.4%), stomach (26, 5.2%) and nasopharynx (17, 3.4%) were the commonest infection-associated cancers. In MTRH, the five common types of cancers were Kaposi's sarcoma (93, 18.6%), breast (77, 15.4%), cervical (41, 8.2%), non-Hodgkin's lymphoma (37, 7.4%) and colorectal, chronic leukemia and esophageal cancer all with 27 (5.4%). Some 241 (48.2%) of these cancers were associated with infectious agents, while an estimated 222 (44.4%) were attributable to infections. Kaposi's sarcoma (93, 18.6%), cancer of the cervix (41, 8.2%) and non-Hodgkin's lymphoma (37, 7.4%) were the commonest infection-associated cancers. Conclusion: Our results suggest that 30.8% and 48.2% of the total cancer cases sampled in KNH and MTRH respectively were associated with infectious agents, while 27.6% and 44.4% were attributable to infections in the two hospitals respectively. Reducing the burden of infection-attributable cancers can translate to a reduction of the overall cancer burden.

Prevalence of parental bereavement among female sex workers (FSW) in Kibra, Kenya

Female sex workers (FSW) residing in Kibra, Kenya experience elevated exposure to adverse events, yet the prevalence of parental bereavement is not well characterized. This cross-sectional pilot study on 301 FSWs residing in Kibra, Kenya found that 67.7% of these women were parentally bereaved. Significantly fewer parentally bereaved women reported historical use of condoms and emergency contraception compared to non-bereaved women, and older age of paternal bereavement was significantly associated with current contraceptive use. Prevalence rates of bereavement among this cohort are well over the national Kenyan average, and further research on the specific impact of bereavement is warranted.

Cancer in Kenya: types and infection-attributable. Data from the adult population of two National referral hospitals (2008-2012)

Background: Cancer in Africa is an emerging health problem. In Kenya it ranks third as a cause of death after infectious and cardiovascular diseases. Nearly 31% of the total cancer burden in sub-Saharan Africa is attributable to infectious agents. Information on cancer burden is scanty in Kenya and this study aimed to provide comprehensive hospital based data to inform policies. Method: A cross-sectional retrospective survey was conducted at Kenyatta National Hospital (KNH) and Moi Teaching and Referral Hospital (MTRH) from January 2008 to December 2012.  Data was obtained from the patients files and the study was approved by the KNH/University of Nairobi and MTRH Ethics and Research Committees.   Results: In KNH, the top five cancers were: cervical (62, 12.4%), breast (59, 11.8%), colorectal (31, 6.2%), chronic leukemia (27, 5.4%) and stomach cancer 26 (5.2%). Some 154 (30.8%) of these cancers were associated with infectious agents, while an estimated 138 (27.6%) were attributable to infections. Cancers of the cervix (62, 12.4%), stomach (26, 5.2%) and nasopharynx (17, 3.4%) were the commonest infection-associated cancers. In MTRH, the five common types of cancers were Kaposi's sarcoma (93, 18.6%), breast (77, 15.4%), cervical (41, 8.2%), non-Hodgkin's lymphoma (37, 7.4%) and colorectal, chronic leukemia and esophageal cancer all with 27 (5.4%). Some 241 (48.2%) of these cancers were associated with infectious agents, while an estimated 222 (44.4%) were attributable to infections. Kaposi's sarcoma (93, 18.6%), cancer of the cervix (41, 8.2%) and non-Hodgkin's lymphoma (37, 7.4%) were the commonest infection-associated cancers. Conclusion: Our results suggest that 30.8% and 48.2% of the total cancer cases sampled in KNH and MTRH respectively were associated with infectious agents, while 27.6% and 44.4% were attributable to infections in the two hospitals respectively. Reducing the burden of infection-attributable cancers can translate to a reduction of the overall cancer burden.

Text messaging for maternal and infant retention in prevention of mother-to-child HIV transmission services: A pragmatic stepped-wedge cluster-randomized trial in Kenya

BACKGROUND

Timely diagnosis of infant HIV infection is essential for antiretroviral therapy (ART) initiation. In a randomized controlled trial, we found the Texting Improves Testing (TextIT) intervention (a theory-based text messaging system) to be efficacious for improving infant HIV testing rates and maternal retention in prevention of mother-to-child HIV transmission (PMTCT) programs. Using an implementation science approach, we aimed to evaluate real-world effectiveness of the intervention.

METHODS AND FINDINGS

In a pragmatic, cluster-randomized, stepped-wedge trial with 2 time periods of observation, we randomly allocated 10 clinics to begin implementing the intervention immediately and 10 clinics to begin implementing 6 months later. To approximate real-world conditions, inclusion criteria were broad. Women at clinics implementing the intervention received up to 14 text messages during pregnancy and after delivery and had the option to respond to text messages, call, or send inquiry text messages to a designated clinic phone. The primary outcomes were infant HIV testing and maternal retention in care during the first 8 weeks after delivery. We used modified Poisson regression with robust variance estimation to estimate the relative risk and 95% confidence intervals (CIs). Generalized estimating equations were applied on individual-level data to account for clustering by site. Between February 2015 and December 2016, 4,681 women were assessed for study participation, and 2,515 were included. Participant characteristics at enrollment did not differ by study arm. Overall median age was 27 years (interquartile range [IQR] 23-30), median gestational age was 30 weeks (IQR 28-34), 99% were receiving ART, and 87% who enrolled during intervention phases owned a phone. Of 2,326 infants analyzed, 1,466 of 1,613 (90.9%) in the intervention group and 609 of 713 (85.4%) in the control group met the primary outcome of HIV virologic testing performed before 8 weeks after birth (adjusted relative risk [aRR] 1.03; 95% CI 0.97-1.10; P = 0.3). Of 2,472 women analyzed, 1,548 of 1,725 (90%) in the intervention group and 571 of 747 (76%) in the control group met the primary outcome of retention in care during the first 8 weeks after delivery (aRR 1.12; 95% CI 0.97-1.30; P = 0.1). This study had two main limitations. Staff at all facilities were aware of ongoing observation, which may have contributed to increased rates of infant HIV testing and maternal retention in care at both intervention and control facilities, and programmatic initiatives to improve maternal and infant retention in care were ongoing at all facilities at the time of this study, which likely limited the ability to demonstrate effectiveness of the trial intervention.

CONCLUSIONS

In this study, a larger proportion of infants in the intervention group received HIV testing compared with the control group, but the difference was small and not statistically significant. There was also a nonsignificant increase in maternal postpartum retention in the intervention periods. Despite the lack of a significant effect of the intervention, key lessons emerged, both for strengthening PMTCT and for implementation research in general. Perhaps most important, improving the implementation of usual care may have been sufficient to substantially improve infant HIV testing rates.

TRIAL REGISTRATION

ClinicalTrials.gov Trial Number NCT02350140.

Water, Sanitation, and Hygiene Characteristics among HIV-Positive Households Participating in the Global Enteric Multicenter Study in Rural Western Kenya, 2008-2012

Diarrheal illness, a common occurrence among people living with human immunodeficiency virus (PLHIV), is largely preventable through access to safe drinking water quality, sanitation, and hygiene (WASH) facilities. We examined WASH characteristics among households with and without HIV-positive residents enrolled in the Global Enteric Multicenter Study (GEMS) in rural Western Kenya. Using univariable logistic regression, we examined differences between HIV-positive and HIV-negative households in regard to WASH practices. Among HIV-positive households, we explored the relationship between the length of time knowing their HIV status and GEMS enrollment. No statistically significant differences were apparent in the WASH characteristics among HIV-positive and HIV-negative households. However, we found differences in the WASH characteristics among HIV-positive households who were aware of their HIV status ≥ 30 days before enrollment compared with HIV-positive households who found out their status < 30 days before enrollment or thereafter. Significantly more households aware of their HIV-positive status before enrollment reported treating their drinking water (odds ratio [OR] confidence interval [CI]: 2.34 [1.12, 4.86]) and using effective water treatment methods (OR [CI]: 9.6 [3.09, 29.86]), and had better drinking water storage practices. This suggests that within this region of Kenya, HIV programs are effective in promoting the importance of practicing positive WASH-related behaviors among PLHIV.

Correlates of HIV infection in adolescent girls and young women in Lesotho: results from a population-based survey

BACKGROUND

HIV acquisition remains high among adolescent girls and young women (AGYW, aged 15-24 years) in sub-Saharan Africa. We aimed to estimate prevalence and incidence of HIV in AGYW and to identify correlates of HIV infection by using data from the Lesotho Population-based HIV Impact Assessment (LePHIA).

METHODS

LePHIA was a nationally representative survey of adults and children based on a multistage cluster sampling method with random selection of enumeration areas and households. All adults aged 15 years and older who had slept in the household the night before were eligible for participation; participants completed an interview and HIV testing. We estimated incidence with the HIV-1 limiting antigen avidity enzyme immunoassay combined with viral load and examined the association between demographic and behavioural variables (including characteristics of cohabitating mothers and sexual partners, when available) and prevalence and incidence among AGYW using logistic regression, incorporating survey weights.

FINDINGS

We interviewed 8824 households, including 2358 AGYW who were tested for HIV infection. Weighted HIV prevalence was 11·1% (95% CI 9·7-12·5) in the overall population (273 of 2358 AGYW), 5·7% (4·1-7·2) in adolescent girls aged 15-19 years (64 of 1156), and 16·7% (14·4-19·0) in women aged 20-24 years (209 of 1212). Annualised HIV incidence was 1·8% (0·8-2·8). Correlates of prevalent infection include reporting a history of anal sex (adjusted odds ratio [aOR] 3·08, 1·11-8·57), having lived outside Lesotho in the past year (1·86, 1·01-3·42), having a partner suspected or known to be HIV positive (11·7, 6·0-22·5), and having two or more lifetime sexual partners (1·84, 1·21-2·78, for 2-3 lifetime sexual partners; 2·44, 1·45-4·08, for ≥4 lifetime sexual partners). For the 570 AGYW living with their mothers, maternal education was negatively associated with HIV prevalence in their daughters (aOR 0·36, 0·15-0·82, per increase in level attended). For AGYW with a cohabitating partner, the factors associated with AGYW infection were partner age (OR 4·54, 1·30-15·80, for partners aged 35-49 years, although the OR was no longer significant when adjusted for HIV status of partner), HIV status (aOR 11·22, 4·05-31·05), lack of viral load suppression (OR 0·16, 0·04-0·66), and partner employment in the past year (aOR 3·41, 1·12-10·42).

INTERPRETATION

The findings confirm the importance of improving the treatment cascade in male partners and targeting preventive interventions to AGYW who are at increased risk. A regional approach to prevention could mitigate the effect of migration on transnational spread of HIV.

FUNDING

President's Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention.

Peripheral neuropathy in patients with human immunodeficiency viral infection at a tertiary hospital in Ghana

Peripheral neuropathy (PN) is the most frequent neurological complication in people living with HIV/AIDS. Neurological damage was identified to not only be caused by the viral infection itself but also through neurotoxic antiretroviral therapy (ART). PN is associated with a variety of risk factors; however, detailed knowledge is scarce for sub-Saharan African populations, bearing among the highest HIV/AIDS infection burden.In a cross-sectional study, we assessed the prevalence of PN in 525 adult outpatients suffering from HIV/AIDS and admitted to the largest tertiary hospital in Ghana. Through a detailed questionnaire and clinical examination including neurologic assessment and laboratory blood sample testing, this study investigated associations of PN with demographic and health determinants and identified risk factors associated with sensory neuropathy.The prevalence of PN in the Ghanaian cohort was 17.7% and increased odd ratios (OR) when patients were taller (> 1.57 m; OR = 3.84; 95% CI 1.38-10.66) or reached the age > 34 years (p = 0.124). Respondents with longer education duration had significantly less PN (≥ 9 years of education; OR = 0.49; 95% CI 0.26-0.92). The study also identified significant association of PN to both waist and hip girth and neutrophil counts. Curiously, higher adjusted odd ratios (aOR) of PN of patients under ART treatment were observed when CD4 lymphocytes were elevated (aOR = 0.81; 95% CI 0.36-1.83 and aOR = 2.17; 95% CI 0.93-5.05, for 300 and 600 counts, respectively). For patients on ART, an increase of 10 CD4 cell count units increased their chance of developing PN by 1% (aOR = 1.01; 95% CI 1.00 to 1.03).Despite current drug application regulations, prevalence of PN is still unacceptably high in sub-Saharan African populations. Reduction in chronic morbidity through a health system with routine monitoring, early diagnosis and prompt intervention, and effective case management can improve people living with HIV/AIDS' quality of life.

Community perspectives of second-generation alcohol misuse and HIV risk in rural Kenya: A gendered syndemic lens

Sub-Saharan Africa is at the intersection of the HIV epidemic and the highest burden of alcohol-related disease and injury. Alcohol consumption is associated with an increased likelihood of HIV infection, high rates of intimate partner violence and is considered both a cause and a contributor of economic stress and poverty. Our study integrates the syndemic and socio-ecological system theoretical frameworks to qualitatively explore the effect of second-generation alcohol consumption on sexual risk behaviours, alcohol misuse, violence and economic stress (SAVE) factors and HIV infection risk. We recruited 80 people from rural Kenya to participate in 12 focus groups. Consistent with the literature, we found evidence of syndemic associations of second-generation alcohol consumption with SAVE factors, including HIV infection risk. Structural-level factors including availability of cheap second-generation alcohol and widespread unemployment are the biggest risk factors for alcohol misuse. Because of the psychological effect of women's increasing economic independence on men, gendered syndemic programming - that includes both men and women - and addresses the complex web of risk factors for second-generation alcohol misuse can interrupt the vicious cycle of poverty, violence, sexual risk behaviours and mitigate HIV infection risk in rural Kenya.

Index participant characteristics and HIV assisted partner services efficacy in Kenya: results of a cluster randomized trial

INTRODUCTION

We have previously demonstrated that assisted partner services (aPS) increases HIV testing and case finding among partners of persons living with HIV (PLHIV) in a cluster randomized trial in Kenya. However, the efficacy of aPS may vary across populations. In this analysis, we explore differences in aPS efficacy by characteristics of index participants.

METHODS

Eighteen HIV testing sites were randomized to immediate versus 6-week delayed aPS. Participants were PLHIV (or index participants) and their sexual partners. Partners of index participants were contacted for HIV testing and linked to care if HIV positive. Primary outcomes were the number of partners per index participant who: 1) tested for HIV, 2) tested HIV positive and 3) enrolled in HIV care. We used generalized estimating equations to assess differences in aPS efficacy by region, testing location, gender, age and knowledge of HIV status.

RESULTS

From 2013 to 2015, the study enrolled 1119 index participants, 625 of whom were in the immediate group. These index participants named 1286 sexual partners. Immediate aPS was more efficacious than delayed aPS in promoting HIV testing among partners in high compared to low HIV prevalence regions (Nyanza incidence rate ratio (IRR) 7.2; 95% confidence interval (CI) 5.4, 9.6 vs. Nairobi/Central IRR 3.4 95% CI 2.3, 4.8). Higher rates of partner HIV testing were also observed for index participants in rural/peri-urban compared to urban sites (IRR 6.6; 95% CI 4.5, 9.6 vs. IRR 3.5 95% CI 2.5, 5.0 respectively), for female versus male index participants (IRR 5.8 95% CI 4.2, 7.9 vs. IRR 3.7; 95% CI 2.4, 5.8 respectively) and for newly diagnosed versus known HIV-positive index participants (IRR 6.0 95% CI 4.2, 8.7 vs. IRR 3.3; 95% CI 2.0, 7.7 respectively). Providing aPS to female versus male index participants also had a significantly higher HIV case finding rate (IRR 9.1; 95% CI 4.0, 20.9 vs. IRR 3.2 95% CI 1.7, 6.0 respectively.) CONCLUSIONS: While it is known that aPS promotes increases in HIV testing and case finding, this is the first study to demonstrate significant differences in aPS efficacy across characteristics of the index participant. Understanding these differences and their drivers will be critical as aPS is brought to scale in order to ensure all PLHIV have access to these services.

Selected genes of Human herpesvirus-8 associated Kaposi's sarcoma among patients with Human Immunodeficiency Virus-1 and Acquired Immunodeficiency Disease Syndrome

INTRODUCTION

Kaposi's sarcoma (KS) is a kind of cancer that causes flat or raised lesions containing Human herpes virus 8 (HHV8). The KS lesions are common among immunosuppressed HIV patients. Highly Active Antiretroviral (HHART) treats and prevents the development of KS. The objective of this study was to determine the presence of K1 and K15 (predominant alleles) genes in Kaposi's sarcoma-associated herpes virus (KSHV) among immunosuppressed patients due to HIV-1.

METHODS

This was a cross-sectional descriptive study where consecutive sampling technique was adopted to pick archived tissue blocks from the Thematic Unit of Anatomic Pathology, Department of Human Pathology, College of Health Sciences, University of Nairobi and Department of Laboratory Medicine, Histology Section, Kenyatta National Hospital.

RESULTS

Upon staining 81 tissue blocks with H & E, 84% (68/81) were diagnosed as KS and 16% (13/81) as KS-like. The K1 and K15 (P) genes were both detected at 88.9% (72/81) in the tissue blocks, with 95.8% (69/72) detection from KS and 4.2% (3/72) from the KS-like.

CONCLUSION

The K1 and K15 (P) genes of KSHV were present among the immunosuppressed patients with Human Immunodeficiency Virus (HIV)-1. It is important to carry out K1 and K15 (P) genes detection on tissues that are diagnosed as KS or KS-like by histology technique.

Cancer in Kenya: types and infection-attributable. Data from two National referral hospitals

Background: Cancer in Africa is an emerging health problem. In Kenya it ranks third as a cause of death after infectious and cardiovascular diseases. Nearly 31% of the total cancer burden in sub-Saharan Africa is attributable to infectious agents. Information on cancer burden is scanty in Kenya and this study aimed to provide comprehensive hospital based data to inform policies. Method: A cross-sectional retrospective survey was conducted at Kenyatta National Hospital (KNH) and Moi Teaching and Referral Hospital (MTRH) from 2008 to 2012.  Data was obtained from the patients files and the study was approved by the KNH/University of Nairobi and MTRH Ethics and Research Committees.   Results: In KNH, the top five cancers were: cervical (62, 12.4%), breast (59, 11.8%), colorectal (31, 6.2%), chronic leukemia (27, 5.4%) and stomach cancer 26 (5.2%). Some 154 (30.8%) of these cancers were associated with infectious agents, while an estimated 138 (27.6%) were attributable to infections. Cancers of the cervix (62, 12.4%), stomach (26, 5.2%) and nasopharynx (17, 3.4%) were the commonest infection-associated cancers. In MTRH, the five common types of cancers were Kaposi's sarcoma (93, 18.6%), breast (77, 15.4%), cervical (41, 8.2%), non-Hodgkin's lymphoma (37, 7.4%) and colorectal, chronic leukemia and esophageal cancer all with 27 (5.4%). Some 241 (48.2%) of these cancers were associated with infectious agents, while an estimated 222 (44.4%) were attributable to infections. Kaposi's sarcoma (93, 18.6%), cancer of the cervix (41, 8.2%) and non-Hodgkin's lymphoma (37, 7.4%) were the commonest infection-associated cancers. Conclusion: Our results suggest that 30.8% and 48.2% of the total cancer cases sampled in KNH and MTRH respectively were associated with infectious agents, while 27.6% and 44.4% were attributable to infections in the two hospitals respectively. Reducing the burden of infection-attributable cancers can translate to a reduction of the overall cancer burden.

HIV risk behaviours among women who inject drugs in coastal Kenya: findings from secondary analysis of qualitative data

Background

Injecting drug users are at high risk of HIV infection globally. Research related to female drug users is rare in Kenya, yet it is required to inform the development of gender-sensitive HIV prevention and harm reduction services in East Africa, where injecting drug use is on the rise.

Methods

This study aimed to document the nature of HIV risks encountered by women who inject drugs in the Mombasa and Kilifi, Kenya. Secondary data analysis was conducted on an existing dataset from a 2015 primary qualitative study involving 24 interviews and 3 focus group discussions with 45 women who inject drugs. These were complemented with five interviews with key stakeholders involved in the provision of services to women who inject drugs. Guided by the social ecology theory, a thematic analysis was conducted to identify the nature of HIV risks and their underlying determinants.

Results

HIV risk behaviours fell into two broad categories: unsafe injecting and unprotected sex. These risks occurred in the form of sharing of needles, unprotected oral, anal, and vaginal sex, sexual assaults, injecting drug use during sex, sex work, and other types of transactional sex. The primary determinants underlying these risks were a low-risk perception, inequitable gender power, economic pressures, and poor availability of needles and condoms. These social-ecological determinants did not exist in isolation, but intersected with each other to create powerful influences which exposed women to HIV. Social-ecological determinants exerted constant influence and created a persistent ‘HIV risk environment’ that was involuntarily experienced by women.

Conclusion

Individual, interpersonal, and societal-structural factors intersect to produce HIV risk behaviours. As a minimum, these risks will require a combination of multifaceted micro-level interventions including self-efficacy training, risk assessment skills, couple counselling, and universal access to the recommended harm reduction package. In addition, the current focus on micro-level interventions in Kenya needs to shift to incorporate macro-level interventions, including livelihood, employability, and gender norms-transforming interventions, to mitigate economic and gender-related drivers of HIV risks. In the Kenyan context, injecting drug use during sex work is emerging as an increasingly important HIV risk behaviour needing to be addressed.

Disclosure and Clinical Outcomes Among Young Adolescents Living With HIV in Kenya

PURPOSE

Informing adolescents of their own HIV infection is critical as the number of adolescents living with HIV increases. We assessed the association between HIV disclosure and retention in care and mortality among adolescents aged 10-14 years in Kenya's national program.

METHODS

We abstracted routinely collected patient-level data for adolescents enrolled into HIV care in 50 health facilities from November 1, 2004, through March 31, 2010. We defined disclosure as any documentation that the adolescent had been fully or partially made aware of his or her HIV status. We compared weighted proportions for categorical variables using χ2 and weighted logistic regression to identify predictors of HIV disclosure; we estimated the probability of LTFU using Kaplan-Meier methods and dying using Cox regression-based test for equality of survival curves.

RESULTS

Of the 710 adolescents aged 10-14 years analyzed; 51.3% had severe immunosuppression, 60.3% were in WHO stage 3 or 4, and 36.6% were aware of their HIV status. Adolescents with HIV-infected parents, histories of opportunistic infections (OIs), and enrolled in support groups were more likely to be disclosed to. At 36 months, disclosure was associated with lower mortality [1.5% (95% CI .6%-4.1%) versus 5.4% (95% CI 3.6.6%-8.0%, p < .001)] and lower LTFU [6.2% (95% CI 3.0%-12.6%) versus 33.9% (95% CI 27.3%-41.1%) p < .001].

CONCLUSIONS

Only one third of HIV-infected Kenyan adolescents in treatment programs had been told they were infected, and knowing their HIV status was associated with reduced LTFU and mortality. The disclosure process should be systematically encouraged and organized for HIV-infected adolescents.

Field evaluation of near point of care Cepheid GeneXpert HIV-1 Qual for early infant diagnosis

Background

Access to point-of-care HIV testing shortens turn-around times, time to diagnosis and reduces loss to follow-up hence minimizing barriers to early linkage to care and treatment among HIV infected infants. Currently samples for early infant HIV diagnosis are sent to centralized testing facilities which are few and located only at specific regions in Kenya. However, there are Point of Care (POC) early infant diagnosis [EID] technologies elsewhere such as SAMBA and ALERE-Q that are yet to be evaluated in Kenya despite the urgent need for data to inform policy formulation regarding EID. The Cepheid GeneXpert HIV-1 Qual (GeneXpert) technology for POC EID offers a great opportunity to minimize HIV associated morbidity, mortality and loss to follow-up through decentralization of early infant HIV testing to the clinics. This technology also allows for same-day results thus facilitating prompt linkage to care.

Methods

We evaluated the GeneXpert HIV Qual EID POC in Homabay County against the standard of care platform, Roche CAP/CTM HIV-1 qualitative PCR, using dried blood spots (DBS). Between February—July 2016, DBS samples were collected from HIV exposed children <18 months of age enrolled in a cross-sectional study. Samples were collected by qualified nurse counselors, and were tested by trained technicians using field based GeneXpert and conventional laboratory based Roche CAP/CTM HIV-1 qualitative PCR. Sensitivity and specificity were determined.

Results

Overall, 3,814 mother/infant pairs were included in the study, out of which 921 infants were HIV exposed as per the mothers’ HIV status and based on the infant’s HIV rapid test. A total of 969 PCR tests were performed, out of which 30 (3.3%) infants were concordantly positive using both platforms. GeneXpert HIV-1 Qual yielded a sensitivity of 94.1% and specificity of 99.8% with an overall error rate of 0.7%.

Conclusion

Our findings show that GeneXpert HIV-1 Qual performs well compared to CAP/CTM using DBS samples, suggesting that this technology may be adopted in decentralized laboratories as a near POC device. It may contribute to prompt diagnosis of HIV exposed infants hence enabling early linkage to care, thus advancing further gains in EID.

HIV-1 subtype diversity, transmission networks and transmitted drug resistance amongst acute and early infected MSM populations from Coastal Kenya

Background

HIV-1 molecular epidemiology amongst men who have sex with men (MSM) in sub-Saharan Africa remains not well characterized. We aimed to determine HIV-1 subtype distribution, transmission clusters and transmitted drug resistance (TDR) in acute and early infected MSM from Coastal Kenya.

Methods

Analysis of HIV-1 partial pol sequences from MSM recruited 2005–2017 and sampled within six months of the estimated date of infection. Volunteers were classified as men who have sex with men exclusively (MSME) or with both men and women (MSMW). HIV-1 subtype and transmission clusters were determined by maximum-likelihood phylogenetics. TDR mutations were determined using the Stanford HIV drug resistance database.

Results

Of the 97 volunteers, majority (69%) were MSMW; 74%, 16%, 9% and 1% had HIV-1 subtypes A1, D, C or G, respectively. Overall, 65% formed transmission clusters, with substantial mixing between MSME and MSMW. Majority of volunteer sequences were either not linked to any reference sequence (56%) or clustered exclusively with sequences of Kenyan origin (19%). Eight (8% [95% CI: 4–16]) had at least one TDR mutation against nucleoside (n = 2 [2%]) and/or non-nucleoside (n = 7 [7%]) reverse transcriptase inhibitors. The most prevalent TDR mutation was K103N (n = 5), with sequences forming transmission clusters of two and three taxa each. There were no significant differences in HIV-1 subtype distribution and TDR between MSME and MSMW.

Conclusions

This HIV-1 MSM epidemic was predominantly sub-subtype A1, of Kenyan origin, with many transmission clusters and having intermediate level of TDR. Targeted HIV-1 prevention, early identification and care interventions are warranted to break the transmission cycle amongst MSM from Coastal Kenya.

Burden of cancer in Kenya: types, infection-attributable and trends. A national referral hospital retrospective survey

Background: Cancer in Africa is an emerging health problem. In Kenya it ranks third as a cause of death after infectious and cardiovascular diseases. Nearly 31% of the total cancer burden in sub-Saharan Africa is attributable to infectious agents. Information on cancer burden is scanty in Kenya and this study aimed to provide comprehensive hospital based data to inform policies. Method: A cross-sectional retrospective survey was conducted at Kenyatta National Hospital (KNH) and Moi Teaching and Referral Hospital (MTRH) from 2008 to 2012.  Data was obtained from the patients files and the study was approved by the KNH/University of Nairobi and MTRH Ethics and Research Committees.   Results: In KNH, the top five cancers were: cervical (62, 12.4%), breast (59, 11.8%), colorectal (31, 6.2%), chronic leukemia (27, 5.4%) and stomach cancer 26 (5.2%). Some 154 (30.8%) of these cancers were associated with infectious agents, while an estimated 138 (27.6%) were attributable to infections. Cancers of the cervix (62, 12.4%), stomach (26, 5.2%) and nasopharynx (17, 3.4%) were the commonest infection-associated cancers. In MTRH, the five common types of cancers were Kaposi's sarcoma (93, 18.6%), breast (77, 15.4%), cervical (41, 8.2%), non-Hodgkin's lymphoma (37, 7.4%) and colorectal, chronic leukemia and esophageal cancer all with 27 (5.4%). Some 241 (48.2%) of these cancers were associated with infectious agents, while an estimated 222 (44.4%) were attributable to infections. Kaposi's sarcoma (93, 18.6%), cancer of the cervix (41, 8.2%) and non-Hodgkin's lymphoma (37, 7.4%) were the commonest infection-associated cancers. Conclusion: Our results suggest that 30.8% and 48.2% of the total cancer cases sampled in KNH and MTRH respectively were associated with infectious agents, while 27.6% and 44.4% were attributable to infections in the two hospitals respectively. Reducing the burden of infection-attributable cancers can translate to a reduction of the overall cancer burden.