Correlates of HIV-status awareness among adults in Nairobi slum areas

"Something Like That": Awareness and Acceptability of HIV PrEP and PEP Among Kenyan Adolescents

BACKGROUND

Adolescents account for 15% of new HIV cases in Kenya. HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) are highly effective prevention tools, but uptake is low among adolescents, particularly in resource-limited settings. We assessed awareness and acceptability of PrEP and PEP among Kenyan adolescents.

METHOD

Focus group discussions were conducted with 120 adolescent boys and girls ages 15 to 19 in Kisumu. Data were analyzed using the Framework Approach.

RESULTS

Adolescent participants often had not heard of or could not differentiate between PrEP and PEP. They also confused these HIV prevention tools with emergency contraceptives. Taking a daily pill to prevent HIV was perceived as analogous to taking a pill to treat HIV. Boys were aware of and willing to consider using PrEP and PEP due to their dislike for using condoms. Adolescents identified insufficient information, cost, and uncomfortableness speaking with healthcare workers about their HIV prevention needs due to sexuality stigma as barriers to using PrEP and PEP.

CONCLUSION

Low awareness and poor understanding of PrEP and PEP among adolescents reveal the need for increased education and sensitization about these HIV prevention options. Expanding access to sexual and reproductive health services that are tailored to the needs of adolescents and staffed with non-judgmental providers could help reduce sexuality stigma as a barrier to accessing care. New HIV prevention approaches such as long-acting injectables or implants, on-demand regimens, and multipurpose prevention technologies may encourage increased uptake of PrEP and PEP by adolescents.

Predictors of First-Time and Repeat HIV Testing Among HIV-Positive Individuals in Kenya

BACKGROUND

Despite a doubling of HIV testing coverage in Kenya over the past decade, approximately 2 in 10 people with HIV remained unaware of their infection in 2018. HIV testing is most effective in identifying people with undiagnosed HIV through frequent and strategic testing in populations at high risk. An assessment of testing frequency and predictors of first-time and repeat testing is critical for monitoring effectiveness of testing strategies.

METHODS

We conducted a cross-sectional analysis of adults aged ≥18 years who tested HIV-positive at 4 HIV testing and counseling clinics in Kenya from February 2015 to February 2016. We categorized individuals based on testing history, used Wilcoxon rank-sum tests to assess differences in intervals between the most recent and current HIV test, and used log-binomial regression to determine characteristics associated with first-time and repeat testing.

RESULTS

Among 1136 people testing HIV-positive, 336 (30%) had never tested before and 800 (70%) had, of whom 208 (26%) had previously tested positive. Among previously negative repeat testers, the median intertest interval was 414 days in key/priority populations (interquartile range = 179-1072) vs. 538 in the general population (interquartile range = 228-1299) (P = 0.09). Compared with previously negative repeat testers, being a first-time tester was associated with being age ≥40 years [vs. 18-24; adjusted risk ratio = 1.67, 95% confidence interval (CI): 1.23 to 2.26], men (vs. women; adjusted risk ratio = 1.45, 95% CI: 1.21 to 1.71), and testing through provider-initiated testing and counseling (vs. client initiated; 1.19, 95% CI: 1.00 to 1.40).

CONCLUSIONS

There is a need to increase HIV testing among older individuals and men, increase testing frequency in key/priority populations, and maintain provider-initiated and facility-based testing to reach first-time testers.

Lessons learned from using respondent-driven sampling (RDS) to assess sexual risk behaviors among Kenyan young adults living in urban slum settlements: A process evaluation

Background

Respondent-driven sampling (RDS) is a peer-referral sampling methodology used to estimate characteristics of underserved groups that cannot be randomly sampled. RDS has been implemented in several settings to identify hidden populations at risk for HIV, but few studies have reported the methodological lessons learned on RDS design and implementation for assessing sexual risk behaviors in marginalized youth.

Methods

We used RDS to recruit N = 350 young adults, aged 18 to 22, who were living in urban slum settlements in Nairobi, Kenya. A structured survey was used to assess sexual risk behaviors. Twenty seeds were selected and asked to recruit up to three eligible peers. We used small monetary incentives and a three-day recruitment coupon with sequential numbers linking recruiters to their recruits.

Results

Data collection was completed in 8 days with a maximum chain length of 6 waves. Each seed yielded 16 to 21 eligible recruits. Three (15%) seeds were unproductive and were replaced. RDS benefits were high identification rates (90% coupons returned per coupons given), high eligibility rates (100% eligible recruits per coupons returned), and high efficiency (~39 eligible recruits per day). 44% of the sample was female. Most recruits (74%) reported being “friends” for 7+ years with their recruiter. RDS overcame feasibility concerns of household-, clinic-, and school-based sampling methodologies in that underserved youth who were unemployed (68%), out of school (48%), ethnic minorities (26%), and having prior residential instability (≥2 moves in the past year) (20%) were successfully recruited, based on weighted analyses. Youth reporting HIV risk behaviors, including unprotected sex (38%), sex while high/drunk (35%), and sex exchange for pay (14%), were also enrolled. However, 28% were not sexually active within the last 6 months. Challenges included managing wait times during peaks and participant referral expectations. Community engagement, use of study-stamped coupons, broad inclusion criteria, incentives, and study sites within walking distances all contributed to the successful implementation of the sampling methodology.

Conclusion

RDS is an important tool in reaching a diverse sample of underserved and at-risk young adults for study participation. Implications for optimizing RDS for behavioral studies in this population are discussed.

Understanding HIV risks among adolescent girls and young women in informal settlements of Nairobi, Kenya: Lessons for DREAMS

INTRODUCTION

High incidence of HIV infection among adolescent girls and young women (AGYW) has been attributed to the numerous and often layered vulnerabilities that they encounter including violence against women, unfavourable power relations that are worsened by age-disparate sexual relations, and limited access to sexual and reproductive health information and services. For AGYW living in urban informal settlements (slums), these vulnerabilities are compounded by pervasive poverty, fragmented social networks, and limited access to social services including health and education. In this paper, we assess sexual risk behaviours and their correlates among AGYW in two slum settlements in Nairobi, Kenya, prior to the implementation of interventions under the Determined Resilient Empowered AIDS-free Mentored and Safe (DREAMS) Partnership.

METHODS

We drew on secondary data from the Transition to Adulthood study, the most recent representative study on adolescent sexual behaviour in the two settlements. The study was nested within the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). Data were collected in 2009 from 1,390 AGYW aged 12-23 years. We estimated the proportions of AGYW reporting ever tested for HIV, condom use, multiple sexual partners and age-disparate sex by socio-demographic characteristics. "High risk" sexual behaviour was defined as a composite of these four variables and age at first sex. Multivariable regression analyses were performed to identify factors associated with risk behaviours.

RESULTS

Fifty-one percent of AGYW reported that they had ever tested for HIV and received results of their last test, with the proportion rising steeply by age (from 15% to 84% among those <15 years and 20-23 years, respectively). Of 578 AGYW who were sexually active in the 12 months preceding the survey, 26% reported using a condom at last sex, 4% had more than one sexual partner, and 26% had sex with men who were at least 5 years older or younger. All girls aged below 15 years who had sex (n = 9) had not used condoms at last sex. The likelihood of engaging in "high risk" sexual risk behaviour was higher among older AGYW (19-23 years), those in marital unions, of Luo ethnicity, out of school, living alone or with a friend (versus parents), living with spouse (versus parents), and those whose friends engaged in risky/anti-social behaviours. In contrast, Muslim faith, co-residence with both parents, and belonging to an organised social group were associated with lower odds of risky sexual behaviours.

CONCLUSION

Our study findings suggest that multifaceted approaches addressing the educational and social mediators of AGYW's vulnerability and that also reach the people with whom AGYW live and interact, are needed to reduce the rapid onset of sexual risk during the adolescent years. There is a particular need to reach the youngest adolescent girls in poor urban settings, among whom condom use and awareness of HIV status is rare.

Higher risk sexual behaviour is associated with unawareness of HIV-positivity and lack of viral suppression - implications for Treatment as Prevention

Efficacy of Treatment as Prevention Strategy depends on a variety of factors including individuals’ likelihood to test and initiate treatment, viral load and sexual behaviour. We tested the hypothesis that people with higher risk sexual behaviour are less likely to know their HIV-positive status and be virologically suppressed. A cross-sectional population-based survey of individuals aged 15–59 years old was conducted in 2013 in KwaZulu-Natal, South Africa. A two-stage cluster probability sampling was used. After adjustment for age and sex, lack of awareness of HIV-positivity was strongly associated with having more than one sexual partner in the preceding year (aOR: 2.1, 95%CI: 1.5–3.1). Inconsistent condom use was more common in individuals with more than one sexual partner (aOR: 16.6, 95%CI: 7.6–36.7) and those unaware (aOR: 3.7, 95%CI: 2.6–5.4). Among people aware of their HIV-positivity, higher risk sexual behaviour was associated with lack of viral suppression (aOR: 2.2, 95%CI: 1.1–4.5). Risky sexual behaviour seems associated with factors linked to poor health-seeking behaviour which may have negative implications for HIV testing and Treatment as Prevention. Innovative strategies, driven by improved epidemiological and anthropological understanding, are needed to enable comprehensive approaches to HIV prevention.

Who Needs to Be Targeted for HIV Testing and Treatment in KwaZulu-Natal? Results From a Population-Based Survey

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Introduction:

Identifying gaps in HIV testing and treatment is essential to design specific strategies targeting those not accessing HIV services. We assessed the prevalence and factors associated with being HIV untested, unaware, untreated, and virally unsuppressed in KwaZulu-Natal, South Africa.

Methods:

Cross-sectional population-based survey. People aged 15–59 years were eligible. Interviews, HIV testing, and blood collection for antiretroviral drug presence test, CD4, and viral load were done at the participants' home.

Results:

Of the 5649 individuals included, 81.4% (95% CI: 79.8 to 82.9) had previously been tested. HIV prevalence was 25.2%. HIV-positivity awareness rate was 75.2% (95% CI: 72.9 to 77.4). Of all unaware, 73.3% of people were aged <35 years and 68.7% were women. Antiretroviral therapy coverage was 75.0% (95% CI: 72.0 to 77.8) among those eligible for treatment (CD4 < 350, PMTCT-B) and 53.1% (95% CI: 50.4 to 55.7) among all HIV-positive individuals. Viral load was <1000 copies per milliliter in 57.1% of all HIV-positive individuals. Although 66.3% and 71.7% of people with viral load ≥1000 copies per milliliter were people aged <35 years and women respectively, men had 4.4, 1.8, 1.6, and 1.7 times the odds of being untested, unaware, untreated, and virally unsuppressed. In addition, people with more than 1 sexual partner had 1.3, 2.2, and 1.9 times the odds of being untested, unaware, and untreated.

Conclusions:

The majority of HIV-positive people unaware of their status, untreated, and virally unsuppressed were individuals aged <35 years and women. However, men were disproportionately untested, unaware HIV positivity, untreated, and virally unsuppressed. In this context, HIV testing and treatment should be prioritized to target young people and women, whereas novel strategies are necessary to reach men.