'Pregnancy Has Its Advantages': The Voices of Street Connected Children and Youth in Eldoret, Kenya

"If they had a place to live, they would be taking medication": a qualitative study identifying strategies for engaging street-connected young people in the HIV prevention-care continuum in Kenya

INTRODUCTION

Street-connected young people (SCY) experience structural and social barriers to engaging in the HIV prevention-care continuum. We sought to elicit recommendations for interventions that may improve SCY's engagement along the HIV prevention-care continuum from healthcare providers, policymakers, community members and SCY in Kenya.

METHODS

This qualitative study was conducted in Uasin Gishu, Trans Nzoia, Bungoma, Nakuru and Kitale counties in Kenya between May 2017 and September 2018 to explore and describe the public perceptions of, and proposed and existing responses to, the phenomenon of SCY. This secondary analysis focuses on a subset of data interviews that investigated SCY's healthcare needs in relation to HIV prevention and care. We conducted 41 in-depth interviews and seven focus group discussions with 100 participants, of which 43 were SCY. In total, 48 participants were women and 52 men.

RESULTS

Our analysis resulted in four major themes corresponding to stages in the HIV prevention-care continuum for key populations. We identified the need for an array of strategies to engage SCY in HIV prevention and testing services that are patient-centred and responsive to the diversity of their circumstances. The use of pre-exposure prophylaxis was a biomedical prevention strategy that SCY and healthcare providers alike stressed the need to raise awareness around and access to for SCY. Several healthcare providers suggested peer-based approaches for engaging SCY throughout the continuum. However, SCY heavily debated the appropriateness of using peer-based methods. Structural interventions, such as the provision of food and housing, were suggested as strategies to improve antiretroviral therapy adherence.

CONCLUSIONS

This study identified contextually relevant interventions that should be adapted and piloted for use with SCY. Education and sensitization of SCY and healthcare providers alike were identified as possible strategies, along with affordable housing and anti-poverty strategies as cash transfers and provision of food. Peer-based interventions are a clear option but require SCY-specific adaptation to be implemented effectively.

Intersectional Stigma and Implementation of HIV Prevention and Treatment Services for Adolescents Living with and at Risk for HIV: Opportunities for Improvement in the HIV Continuum in Sub-Saharan Africa

Adolescents in sub-Saharan Africa, specifically adolescent girls and young women, young men who have sex with men, transgender persons, persons who use substances, and adolescents experiencing homelessness experience intersectional stigma, have a high incidence of HIV and are less likely to be engaged in HIV prevention and care. We conducted a thematic analysis informed by the Health and Discrimination Framework using a multiple case study design with five case studies in 3 sub-Saharan African countries. Our analysis found commonalities in adolescents' intersectional stigma experiences across cases, despite different contexts. We characterize how intersectional stigma impacts the uptake and implementation of HIV prevention and treatment services along the continuum for adolescents. Findings reveal how intersectional stigma operates across social-ecological levels and worsens HIV-related outcomes for adolescents. We identify opportunities for implementation science research to address stigma-related barriers to the uptake and delivery of HIV services for adolescents in sub-Saharan Africa.

Prevalence, incidence and chronicity of child abuse among orphaned, separated, and street-connected children and adolescents in western Kenya: What is the impact of care environment?

BACKGROUND

The effect of different types of care environment on orphaned and separated children and adolescents' (OSCA) experiences of abuse in sub-Saharan Africa is uncertain.

OBJECTIVE

Our two primary objectives were 1) to compare recent child abuse (physical, emotional, and sexual) between OSCA living in institutional environments and those in family-based care; and 2) to understand how recent child abuse among street-connected children and youth compared to these other vulnerable youth populations.

PARTICIPANTS AND SETTING

This project followed a cohort of OSCA in Uasin Gishu County, Kenya (2009-2019). This analysis includes 2393 participants aged 18 years and below, 1017 from institutional environments, 1227 from family-based care, and 95 street-connected participants.

METHODS

The primary outcome of interest was recent abuse. Multiple logistic regression was used to estimate the odds of recent abuse at baseline, follow-up, and chronically for each abuse domain and adjusted odds ratios (AOR) between care environments, controlling for multiple factors.

RESULTS

In total, 47 % of OSCA reported ever experiencing any kind of recent abuse at baseline and 54 % in follow-up. Compared to those in family-based care, street-connected participants had a much higher reported prevalence of all types of recent abuse at baseline (AOR: 5.01, 95 % CI: 2.89, 9.35), in follow-up (AOR: 5.22, 95 % CI: 2.41, 13.98), and over time (AOR: 3.44, 95 % CI: 1.93, 6.45). OSCA in institutional care were no more likely than those in family-based care of reporting any recent abuse at baseline (AOR: 0.85 95 % CI: 0.59-1.17) or incident abuse at follow-up (AOR: 0.91, 95 % CI: 0.61-1.47).

CONCLUSION

OSCA, irrespective of care environment, reported high levels of recent physical, emotional, and sexual abuse. Street-connected participants had the highest prevalence of all kinds of abuse. OSCA living in institutional care did not experience more child abuse than those living in family-based care.

Factors associated with pregnancy and induced abortion among street-involved female adolescents in two Nigerian urban cities: a mixed-method study

OBJECTIVES

This study determined the correlates of unwanted pregnancy and induced abortion among sexually active female street-involved adolescents (SIAs) aged 10-19 years in two urban cities in South-west, Nigeria.

METHODS

The data for this study were extracted from a larger mixed-method survey dataset on the sexual and reproductive health (SRH) of 1505 street-involved young people aged 10 to 24 years. For the quantitative data, the explanatory variables were age, history of school attendance, employment status, religion, living arrangement and city of residence. The study outcomes were a history of pregnancy and a history of induced abortion of last pregnancy. Binomial regression analysis was performed to determine the association between the explanatory and outcome variables. For the qualitative data generated through focus group discussions and in-depth-interviews, inductive and deductive approaches were used in conducting a thematic analysis to explore the perspectives and experiences of SIA on pregnancy and induced abortion.

RESULTS

Of the 424 female SIAs, 270 (63.7%) reported having had sex. Sixty-four (23.7%) respondents had a history of pregnancy, of which 38 (59.4%) gave a history of induced abortion of the last pregnancy. A history of school attendance significantly reduced the likelihood of being pregnant (AOR: 0.42, 95% C.I: 0.19-0.91), while 15-19-years-old SIAs who were pregnant were significantly less likely to abort (AOR: 0.13, 95% C.I: 0.02-0.77). Qualitative reports indicated that unintended pregnancy and induced abortion was a common experience among the sexually active SIAs. Many participants were aware of the methods of, and places to induce abortion.

CONCLUSION

A large proportion of SIAs are sexually active with a high incidence of unintended pregnancy and a high rate of unsafe abortion. Access of female SIAs to education can reduce the risk of unintended pregnancy. Attention needs to be paid to how SIAs can have access to contraception.

Barriers to and facilitators of accessing HIV services for street-involved youth in Canada and Kenya

Introduction

UNICEF estimates that there are as many as 100 million street-involved youth (SIY) globally. Marginalized conditions put SIY at higher risk of HIV and adverse outcomes once HIV-positive. The objective of this analysis was to describe barriers and facilitators of accessing HIV prevention, testing, and treatment services as Phase I of an implementation study evaluating the use of peer navigators to increase access to HIV services.

Methods

Semi-structured interviews, focus group discussions (FGD), and theatre testing were conducted with individuals who identify as SIY, health care providers, and community stakeholders living in Canada (Toronto, Montreal, London) and Kenya (Eldoret, Huruma, Kitale). Data were analyzed using a directed content approach, guided by the socio-ecological model (SEM).

Results

Across the six sites were 195 participants: 64 SIY, 42 healthcare providers, and 97 community-based stakeholders. Barriers were identified at the societal (e.g. intersectional stigma and discrimination), public policy (e.g., inadequate access to basic needs, legal documentation, lack of health insurance, and limited community-based funding), institutional (e.g. lack of inclusive education and training, inadequate HIV educational outreach, and restrictive service provision), interpersonal (e.g., ineffective communication from healthcare providers), and intrapersonal levels (e.g. lack of trust and associated fear, low perception for healthcare, and lack of self-esteem). These contributed to limited HIV services utilization among SIY. Conversely, numerous facilitators were also identified at the public policy (e.g. affordable HIV services and treatment), institutional (e.g. available and accessible HIV prevention tools, HIV education and awareness programs, and holistic models of care), interpersonal level (e.g., systems navigation support, peer support, and personal relationships), and intrapersonal levels (e.g. self-efficacy) as positively supporting SIY access to HIV services.

Conclusion

Intersectional stigma was a critical barrier in all sites, and policies and programs that foster welcoming environments for youth from diverse backgrounds and living circumstances may be better able to respond to the HIV service needs of this high risk population. Social support and navigation services were reported to facilitate access to HIV services in all sites.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14290-7.

Pregnancy and parenting support for youth experiencing homelessness

This study explored the perceptions and experiences related to pregnancy and parenting support among youth while homeless. This study employed a qualitative descriptive design using data collected from focus group discussions. We assessed the experiences and perceptions of youth related to pregnancy and parenting support. Eighty-one youth participated in eight focus group discussions and were recruited from shelters, drop-in centers, and organizations that serve youth in a large metropolitan areas in the southern United States. Thematic content analyses were used to generate results from the qualitative data. Four main themes emerged: youth encountered barriers to accessing healthcare services at the individual and system levels; pregnancy and parenting are stressful, especially during homelessness; support can help overcome the stresses of parenting; and embracing responsibility or "stepping up" is a positive influence of pregnancy and parenting during homelessness. Youth experiencing homelessness (YEH) face significant challenges to accessing healthcare services and adjusting to the parental role. Interventions for pregnant and parenting youth should be co-designed with and tailored for youth and address the existing health inequities within the healthcare and social service systems.

Risky Sexual Practice among Street Dwelling People in Southern Ethiopia: A mixed-Method Study

Background

The number of street dwellers in major cities in Ethiopia is rapidly increasing. However, their sexual health needs are not that much studied. Hence, this study assessed risky sexual practice and associated factors among street dwelling people in southern Ethiopia.

Methods

A cross-sectional study employing a mixed method was conducted. For the quantitative part, a snowball sampling technique was made to conduct face-to-face interviews among 842 respondents. In-depth interviews among street dwellers and key informant interviews among stakeholders were conducted to collect qualitative data.A pre-tested and structured interviewer-administered questionnaire was used to collect data. The collected data were entered using Epidata and exported to SPSS for analysis, and qualitative data analyzed by thematic analysis approach.

Results

About one third, 266(31.6%), of the participants had risky sexual practices within the last year of the study period. Sexual violence such as gang rape and same-sex practice were reported qualitatively. Male respondents (AOR: 3.24, 95%CI: 2.09-5.02) had a more likelihood of risky sexual practice than females. Living in Dilla (AOR: 9.62, 95%CI: 4.49-20.58) and Wolaita Soddo towns (AOR: 14.35, 95%CI: 6.29-32.69) had also a more likelihood of risky sexual practice than living in Hawassa. Moreover, the daily average income of 21-50 Birr (AOR: 0.52, 95%CI: 0.29-0.92) had a less likelihood of risky sexual practice compared to those with a daily average income of 5-20 Birr.

Conclusion

Risky sexual practice among street dwelling people is found high. The Federal Ministry of Health and other stakeholders should work to cut risky sexual practices among street dwelling people.

"From Analog to Digital": The Feasibility, Acceptability, and Preliminary Outcomes of a Positive Parenting Program for Street-Connected Mothers in Kenya

BACKGROUND

Children of street-connected women in Kenya are at risk of child maltreatment. There have been increasing calls for positive parenting programs for parents experiencing homelessness, however never has one been implemented with this population. We therefore adapted the evidence-based Parenting for Lifelong Health for Young Children program using participatory methods, and piloted the adapted program with street-connected mothers in Kenya.

OBJECTIVES

To (a) determine if the adapted program was feasible and acceptable with street-connected mothers, and (b) assess indicative effects on child maltreatment, positive parenting, and parental stress.

PARTICIPANTS AND SETTING

Two groups of 15 mothers (ages 19+, and 20- ) participated between June-July 2018 in Eldoret, Kenya. Participants were eligible if they (a) were the mother of at least one child and (b) self-identified as street-connected.

METHODS

Feasibility was measured via enrollment, attendance, drop-out rates, and engagement in take-away activities. Focus groups explored program acceptability and program outcomes. Self-report surveys assessed pre-post changes in child maltreatment, parental stress, parental sense of inefficacy, and positive parenting practices.

RESULTS

70% of participants attended ≥3/4 of sessions, 10% dropped out, and >50% of take-away activities were completed. Participants reported high acceptability and requested its continuation for themselves and other parents. There was an increase in supporting good behaviour (t(21)=8.15, p < .000) and setting limits (t(18) = 10.03, p < .000); a reduction in physical abuse (t(23) = -2.15, p = .042) and parental stress (t(22) = -7.08, p < .000); results for parental inefficacy were not statistically significant (t(22) = 0.15, p = .882).

CONCLUSIONS

The adapted program is feasible and acceptable to street-connected mothers, and may reduce child maltreatment and parental stress, and increase positive parenting. Further research should test program effectiveness.

Exploring patient-provider interactions and the health system's responsiveness to street-connected children and youth in Kenya: a qualitative study

Background

In Kenya, street-connected children and youth (SCY) have poor health outcomes and die prematurely due to preventable causes. This suggests they are not accessing or receiving adequately responsive healthcare to prevent morbidity and mortality. We sought to gain insight into the health systems responsiveness to SCY in Kenya through an in-depth exploration of SCY’s and healthcare provider’s reflections on their interactions with each other.

Methods

This qualitative study was conducted across 5 counties in western Kenya between May 2017 and September 2018 using multiple methods to explore and describe the public perceptions of, and proposed and existing responses to, the phenomenon of SCY in Kenya. The present analysis focuses on a subset of data from focus group discussions and in-depth interviews concerning the delivery of healthcare to SCY, interactions between SCY and providers, and SCY’s experiences in the health system. We conducted a thematic analysis situated in a conceptual framework for health systems responsiveness.

Results

Through three themes, context, negative patient-provider interactions, and positive patient-provider interactions, we identified factors that shape health systems responsiveness to SCY in Kenya. Economic factors influenced and limited SCY’s interactions with the health system and shaped their experiences of dignity, quality of basic amenities, choice of provider, and prompt attention. The stigmatization and discrimination of SCY, a sociological process shaped by the social-cultural context in Kenya, resulted in experiences of indignity and a lack of prompt attention when interacting with the health system. Patient-provider interactions were highly influenced by healthcare providers’ adverse personal emotions and attitudes towards SCY, resulting in negative interactions and a lack of health systems responsiveness.

Conclusions

This study suggests that the health system in Kenya is inadequately responsive to SCY. Increasing public health expenditures and expanding universal health coverage may begin to address economic factors, such as the inability to pay for care, which influence SCY’s experiences of choice of provider, prompt attention, and dignity. The deeply embedded adverse emotional responses expressed by providers about SCY, associated with the socially constructed stigmatization of this population, need to be addressed to improve patient-provider interactions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06376-6.

Lost in freedom: ambivalence on sexual freedom among Burundian adolescents living in the Nakivale refugee settlement, Uganda

This paper explores how Burundian adolescents in the Nakivale refugee settlement, Uganda, experience umwidegemvyo, loosely translated as "freedom", with regard to their sexuality. We draw on ethnographic research conducted between August and November 2017 with adolescents aged 13-19 years. Our research included in-depth individual interviews, focus group discussions, and participant observation. We present a context-sensitive appreciation of "freedom" and its social implications for adolescents' sexual and love relationships. We show how adolescents attribute their sexual experiences and practices, including experimental sex, stress-relief sex and transactional sex, to the freedom experienced in the refugee context. Yet they also view this freedom with ambivalence: while some degree of freedom is desirable, too much is referred to in terms of kutitabwaho n'ababyeyi, loosely translated as "parental neglect", implying a lack of parental involvement, care and provisioning.

Exploring media framing of abortion content on Kenyan television: a qualitative study protocol

Background

Media framing of abortion messages is an emerging field of research. However, little is known about how the news media frames abortion messages aimed at influencing adolescents’ reproductive health choices. This study therefore seeks to investigate the framing of abortion in TV news items on three leading Kenyan TV outlets over a period of 3 years, understand Kenyan journalists’ perceptions and experiences with abortion coverage, and to examine adolescents’ perceptions and experiences with abortion coverage on Kenyan televised news media.

Methods

This qualitative study which will be conducted in two sites-Nairobi and Uasin Gishu counties-in Kenya will purposively sample abortion news items from three leading media outlets aired between January 2016 to December 2019, for content analysis. Additionally, 12 journalists (9 reporters, 3 news editors) will be purposively sampled for Key Informant Interviews (KIIs) on journalist framing of abortion messages. Finally, convenience sampling will be used to select approximately 48 university-going adolescents for four Focus Group Discussions (FGDs)-2 female, 2 male- aimed at examining adolescents’ perceptions and experiences with abortion coverage in the broadcast news media. The KIIs and FGDs will be audio-recorded, transcribed and translated. These data will be analyzed thematically.

Discussion

This study moves beyond interrogating only media items to further exploring framing from the perspectives of media consumers and investigations in the process behind production of abortion messages. The study interrogates abortion messages aimed at younger demographics such as adolescents as well as the gendered differences of the effects of these abortion messages, an area barely explored. The study findings will be informative to those who wish to develop media that could be used to promote safe abortion as well as advocate for sexual reproductive health rights, especially among adolescents.

Improving livelihoods and gender equitable attitudes of street-connected young people in Eldoret, Kenya: Results from a pilot evidence-based intervention

Street-connected young people (SCY) in Eldoret, Kenya, experience substantial gender inequities, economic marginalization and are highly vulnerable to acquiring HIV. This study sought to explain and explore how participation in a pilot-adapted evidence-based intervention, Stepping Stones and Creating Futures, integrated with matched savings, changed SCY's economic resources, livelihoods and gender equitable attitudes. We piloted our adapted intervention using a convergent mixed-methods design measuring outcomes pre- and post-intervention with 80 SCY in four age- and gender-stratified groups of 20 participants per group (young women aged 16-19 years and 20-24 years, young men aged 16-19 years and 20-24 years). The pilot occurred at MTRH-Rafiki Centre for Excellence in Adolescent Health in Eldoret, Kenya, from September 2017 to January 2018. Through street outreach, Peer Facilitators created four age- and gender-stratified sampling lists of SCY whom met the eligibility criteria and whom indicated their interest in participating in the intervention during outreach sessions. Simple random sampling was used to select eligible participants who indicated their interest in participating in the intervention. The adapted intervention, Stepping Stones ya Mshefa na Kujijenga Kimaisha, included 24 sessions that occurred over 14 weeks, focused on sexual and reproductive health, gender norms in society, livelihoods and included a matched-savings programme conditional on attendance. The primary outcome of interest was gender equitable attitudes measured using the Gender Equitable Men scale and secondary outcomes included economic resources and livelihoods. Participants had a significant change in gender equitable attitudes from pre- to post-intervention from 43 (IQR 38-48) to 47 (IQR 42-51) (p < .001). Quantitatively and qualitatively participants reported increases in daily earnings, changes in street involvement, housing and livelihood activities. Overall, this study demonstrated that the adapted programme might be effective at changing gender equitable attitudes and improving livelihood circumstances for SCY in Kenya.

Characterizing street-connected children and youths' social and health inequities in Kenya: a qualitative study

BACKGROUND

Street-connected children and youth (SCY) in Kenya disproportionately experience preventable morbidities and premature mortality. We theorize these health inequities are socially produced and result from systemic discrimination and a lack of human rights attainment. Therefore, we sought to identify and understand how SCY's social and health inequities in Kenya are produced, maintained, and shaped by structural and social determinants of health using the WHO conceptual framework on social determinants of health (SDH) and the Convention on the Rights of the Child (CRC) General Comment no. 17.

METHODS

This qualitative study was conducted from May 2017 to September 2018 using multiple methods including focus group discussions, in-depth interviews, archival review of newspaper articles, and analysis of a government policy document. We purposively sampled 100 participants including community leaders, government officials, vendors, police officers, general community residents, parents of SCY, and stakeholders in 5 counties across Kenya to participate in focus group discussions and in-depth interviews. We conducted a thematic analysis situated in the conceptual framework on SDH and the CRC.

RESULTS

Our findings indicate that SCY's social and health disparities arise as a result of structural and social determinants stemming from a socioeconomic and political environment that produces systemic discrimination, breaches human rights, and influences their unequal socioeconomic position in society. These social determinants influence SCY's intermediary determinants of health resulting in a lack of basic material needs, being precariously housed or homeless, engaging in substance use and misuse, and experiencing several psychosocial stressors, all of which shape health outcomes and equity for this population.

CONCLUSIONS

SCY in Kenya experience social and health inequities that are avoidable and unjust. These social and health disparities arise as a result of structural and social determinants of health inequities stemming from the socioeconomic and political context in Kenya that produces systemic discrimination and influences SCYs' unequal socioeconomic position in society. Remedial action to reverse human rights contraventions and to advance health equity through action on SDH for SCY in Kenya is urgently needed.

Piloting an evidence-based intervention for HIV prevention among street youth in Eldoret, Kenya

OBJECTIVES

This study presents findings from piloting an adapted evidence-based intervention, Stepping Stones and Creating Futures, to change street-connected young people's HIV knowledge, condom-use self-efficacy, and sexual practices.

METHODS

Eighty street-connected young people participated in a pre- and post-test mixed methods design in Eldoret, Kenya. The primary outcome of interest was HIV knowledge. Secondary outcomes included condom-use self-efficacy and sexual practices. Multiple linear regression models for change scores with adjustment for socio-demographic variables were fitted. Qualitative and quantitative findings are presented together, where integration confirms, expands on, or uncovers discordant findings.

RESULTS

Participants had a significant increase in HIV knowledge from pre- to post-intervention. The median HIV knowledge score pre-intervention was 11 (IQR 8-13) and post-intervention 14 (IQR 12-16). Attendance was significantly associated with HIV knowledge change scores. Qualitatively participants reported increased HIV and condom-use knowledge and improved condom-use self-efficacy and health-seeking practices.

CONCLUSIONS

Our findings support the potential for further testing with a rigorous study design to investigate how best to tailor the intervention, particularly by gender, and increase the overall effectiveness of the program.

Sexually transmitted disease among street dwellers in southern Ethiopia: a mixed methods study design

Background

Lack of knowledge about sexual violence, its consequences, substance use and homelessness are major problems that make street dwellers susceptible to sexually transmitted diseases. Hence, this study assessed knowledge, attitudes and treatment-seeking behaviors related to sexually transmitted diseases among street dwellers in southern Ethiopia.

Methods

An explanatory sequential mixed-methods study design was conducted among 842 respondents. A simple random sampling technique was used to select seven cities among fourteen major cities of the region. The sample was allocated proportionally to each selected city. In order to identify and fill in the required sample size, a snowball sampling technique was used. A pre-tested and structured interviewer-administered questionnaire was used to collect quantitative data. The collected data were entered using Epidata and exported to SPSS version 23.0 for further analysis. Unstructured questionnaires were also used to collect 21 in-depth interviews and 10 key informants’ interviews. Respondents for in-depth interviews were selected purposively during quantitative data collection.

Results

Most street dwellers were aware of (86.7%) and had a favourable attitude towards (84.4%) prevention and management of sexually transmitted diseases. A portion of respondents experienced bad-smelling genital discharge (13.8%), genital ulcers (11.2%) and a burning sensation (14.5%) during urination, in the previous year. Among those who experienced symptoms of sexually transmitted disease, only 15.3% of them received treatment from a health care provider. Fear of questions raised by providers was one of the reasons for not seeking care according to our qualitative findings.

Conclusions

In this study, a significant number of street dwellers reported experiencing symptoms of a sexually transmitted disease. Despite having awareness about sexually transmitted diseases, seeking treatment from a health center was found to be low based on both quantitative and qualitative findings. We recommend that health care providers should undergo special training to address the sexual and reproductive health problems of street dwellers.

Adapting an evidence-based gender, livelihoods, and HIV prevention intervention with street-connected young people in Eldoret, Kenya

Despite being highly vulnerable to acquiring HIV, no effective evidence-based interventions (EBI) exist for street-connected young people (SCY) in low- and middle-income countries (LMICs). Therefore, this paper describes the research process of adapting an existing EBI in Eldoret, Kenya using a modified ADAPT-ITT model with a young key population. From May to August 2018 we adapted the combined Stepping Stones and Creating Futures interventions. We used community-based participatory methods, focus group discussions, and working groups with four Peer Facilitators and 24 SCY aged 16-24 years. At the inception of this project, a matched-savings programme was integrated into the intervention to further address structural drivers of HIV. Numerous adaptations came forth through the participatory process. Engaging SCY in the adaptation process ensured the programme was responsive to their needs, relevant to the street context, and respected their right to participate in the research process.

A Pilot Study of "Peer Navigators" to Promote Uptake of HIV Testing, Care and Treatment Among Street-Connected Children and Youth in Eldoret, Kenya

Research suggests a burden of HIV among street-connected youth (SCY) in Kenya. We piloted the use of peer navigators (PNs), individuals of mixed HIV serostatus and with direct experience of being street-connected, to link SCY to HIV testing and care. From January 2015 to October 2017, PNs engaged 781 SCY (585 male, 196 female), median age 16 (IQR 13-20). At initial encounter, 52 (6.6%) were known HIV-positive and 647 (88.8%) agreed to HIV testing. Overall, 63/781 (8.1%) SCY engaged in this program were HIV-positive; 4.6% males and 18.4% females (p < 0.001). Of those HIV-positive, 48 (82.8%) initiated ART. As of October 2017, 35 (60.3%) of the HIV-positive SCY were alive and in care. The pilot suggests that PNs were successful in promoting HIV testing, linkage to care and ART initiation. More research is needed to evaluate how to improve ART adherence, viral suppression and retention in care in this population.

HIV prevalence in young people and children living on the streets, Kenya

OBJECTIVE

To obtain an estimate of the size of, and human immunodeficiency (HIV) prevalence among, young people and children living on the streets of Eldoret, Kenya.

METHODS

We counted young people and children using a point-in-time approach, ensuring we reached our target population by engaging relevant community leaders during the planning of the study. We acquired point-in-time count data over a period of 1 week between the hours of 08:00 and 23:00, from both a stationary site and by mobile teams. Participants provided demographic data and a fingerprint (to avoid double-counting) and were encouraged to speak with an HIV counsellor and undergo HIV testing. We used a logistic regression model to test for an association between age or sex and uptake of HIV testing and seropositivity.

FINDINGS

Of the 1419 eligible participants counted, 1049 (73.9%) were male with a median age of 18 years. Of the 1029 who spoke with a counsellor, 1004 individuals accepted HIV counselling and 947 agreed to undergo an HIV test. Combining those who were already aware of their HIV-positive status with those who were tested during our study resulted in an overall HIV seroprevalence of 4.1%. The seroprevalence was 2.7% (19/698) for males and 8.9% (23/259) for females. We observed an increase in seroprevalence with increasing age for both sexes, but of much greater magnitude for females.

CONCLUSION

By counting young people and children living on the streets and offering them HIV counselling and testing, we could obtain population-based estimates of HIV prevalence.

Pathways to increased coverage: an analysis of time trends in contraceptive need and use among adolescents and young women in Kenya, Rwanda, Tanzania, and Uganda

BACKGROUND

Despite efforts to make contraceptive services more "youth friendly," unmet need for contraception among young women in sub-Saharan Africa remains high. For health systems to effectively respond to the reproductive health needs of a growing youth population, it is imperative to understand their contraceptive needs and service seeking practices. This paper describes changes over time in contraceptive need, use, and sources of care among young women in four East African countries.

METHODS

We used three rounds of DHS data from Kenya, Rwanda, Tanzania, and Uganda to examine time trends from 1999 to 2015 in met need for modern contraception, method mix, and source of care by sector (public or private) and type of provider among young women aged 15-24 years. We assessed disparities in contraceptive coverage improvements over time between younger (15-24 years) and older women (25-49 years) using a difference-in-differences approach.

RESULTS

Met need for contraception among women aged 15-24 years increased over time, ranging from a 20% increase in Tanzania to more than a 5-fold increase in Rwanda. Improvements in met need were greater among older women compared to younger women in Rwanda and Uganda, and higher among younger women in Kenya. Injectables have become the most popular contraceptive choice among young women, with more than 50% of modern contraceptive users aged 15-24 years currently using the method in all countries except for Tanzania, where condoms and injectables are used by 38% and 35% of young users, respectively. More than half of young women in Tanzania and Uganda receive contraceptives from the private sector; however, while the private sector played an important role in meeting the growing contraceptive needs among young women in Tanzania, increased use of public sector services drove expanded access in Kenya, Rwanda, and Uganda.

CONCLUSIONS

Our study shows that contraceptive use increased among young East African women, yet, unmet need remains high. As youth populations continue to grow, governments must develop more targeted strategies for expanding access to reproductive health services for young women. Engaging the private sector and task-shifting to lower-level providers offer promising approaches; however, additional research is needed to identify the key facilitators and barriers to the success of these strategies in different contexts.