'I feel that I should decide on my own….': who should be involved in the decision-making process for adolescent involvement in HIV research?

INTRODUCTION

Efforts to improve health outcomes among adolescents and young adults living with HIV (ALHs) are hampered by limited adolescent engagement in HIV-related research. We sought to understand the views of adolescents, caregivers and healthcare workers (HCWs) about who should make decisions regarding ALHs' research participation.

METHODS

We conducted focus group discussions (FGDs) and in-depth interviews (IDIs) with ALHs (aged 14-24 years), caregivers of ALHs and HCWs from six HIV care clinics in Western Kenya. We used semi-structured guides to explore ALHs' involvement in research decisions. Transcripts were analysed using thematic analysis; perspectives were triangulated between groups.

RESULTS

We conducted 24 FGDs and 44 IDIs: 12 FGDs with ALHs, 12 with caregivers, and 44 IDIs with HCWs, involving 216 participants. HCWs often suggested that HIV research decision-making should involve caregivers and ALHs deciding together. In contrast, ALHs and parents generally thought decisions should be made individually, whether by HCWs/research teams (although this is likely ethically problematic), adolescents or caregivers. Caregiver and ALH preferences depended on ALHs' age, with younger ALHs requiring more support. A few caregivers felt that ALHs should consult with the research team/HCWs due to their greater knowledge of clinical care. ALHs emphasised that they should independently decide because they thought they had the right to do so and the capacity to consent. Poor communication and parental non-disclosure of HIV status influenced ALHs' views to exclude caregivers from decision-making. Regarding influences on research decision-making, ALHs were more willing to participate based on perceived contribution to science and less interested in participating in studies with potential risks, including loss of confidentiality.

DISCUSSION

While research teams and HCWs felt that adolescents and caregivers should jointly make research decisions, ALHs and caregivers generally felt individuals should make decisions. As ALHs sometimes find caregiver support lacking, improving family dynamics might enhance research engagement.

Higher rates of mental health screening of adolescents recorded after provider training using simulated patients in a Kenyan HIV clinic: results of a pilot study

Background

Kenyan adolescent girls and young women (AGYW) experience a dual burden of HIV and common mental disorders (CMD). HIV clinics are a key entry point for AGYW in need of integrated CMD and HIV care; however, rates of screening and referral for CMDs are low. Our objective was to test an evidence-based provider training strategy, simulated patient encounters (SPEs), on CMD service delivery for AGYW in a Kenyan HIV clinic.

Methods

This pilot study was conducted in a public HIV clinic in Thika, Kenya from January to November 2021. The simulated patient encounter (SPE) implementation strategy included case script development from prior qualitative work, patient actor training, and a three-day SPE training including four standardized mock clinical encounters followed by quantitative surveys assessing provider competencies for each encounter. We abstracted medical record data related to HIV and CMDs such as HIV status, reason for visit, CMD screening test performed, and counselling or referral information. We conducted an interrupted time series analysis using abstracted HIV and CMD screening rates from AGYW ages 16-25 years visiting the clinic 7 months before and 3 months after SPE training. We used generalized linear models to assess changes in CMD screening rates after training.

Results

A total of 10 providers participated in the training. Competency ratings improved across four mock encounters (mean score from 8.1 to 13.7) between first and fourth encounters. We abstracted all medical records (n = 1,154) including from 888 (76%) AGYW seeking HIV treatment, 243 (21%) seeking prevention services, and 34 (3%) seeking other services. CMD screening rates increased immediately following training from 8 to 21% [relative risk (RR) = 2.57, 95% confidence interval (CI) = 1.34-4.90, p < 0.01]. The 3 months following the SPE training resulted in an 11% relative increase in CMD screening proportion compared to the 7 months pre-SPE (RR: 1.11, 95% CI: 1.04-1.17, p < 0.01). Finally, 1% of all pre-SPE screens resulted in referral versus 5% of post-SPE screens (p = 0.07).

Conclusion

The SPE model is a promising implementation strategy for improving HIV provider competencies and CMD service delivery for adolescents in HIV clinics. Future research is needed to explore effects on adolescent clinical outcomes in larger trials.

Implementation determinants and strategies in integration of PrEP into maternal and child health and family planning services: experiences of frontline healthcare workers in Kenya

Background

Delivery of PrEP to adolescent girls and young women (AGYW) and to pregnant women through maternal and child health (MCH) and family planning (FP) clinics is scaling up in Kenya. Evaluation of implementation challenges and strategies is critical to optimize delivery.

Methods

We conducted focus group discussions (FGDs) with healthcare workers (HCWs) in MCH and FP clinics offering PrEP in a large implementation project in Kisumu, Kenya. Discussion guides were based on the Consolidated Framework for Implementation Research (CFIR). FGDs were audio recorded and transcribed. Directed content analysis was used to identify implementation challenges and strategies to overcome them.

Results

Fifty HCWs from 26 facilities participated in 8 FGDs. HCWs believed PrEP integration was appropriate because it met the needs of AGYW and pregnant women by providing a female-controlled prevention strategy and aligned with policy priorities of elimination of vertical HIV transmission. They were universally accepting of PrEP provision, especially through MCH clinics, noting the relative advantage of this approach because it: (1) enabled high coverage, (2) harmonized PrEP and MCH visits, and (3) minimized stigma compared to PrEP offered through HIV care clinics. However, HCWs noted implementation challenges affecting feasibility and adoption including: (1) increased workload and documentation burden amid workforce shortages, (2) insufficient health care worker knowledge (3) multiple implementing partners with competing priorities (4) drug and documentation form stockouts. HCWs employed various implementation strategies to overcome challenges, including task shifting from nurses to HIV testing providers, patient flow modifications (e.g., fast-tracking PrEP clients to reduce wait times), PrEP demand generation and myth clarification during health talks, provider education, dedicated PrEP delivery rooms, and coordination with adolescent-friendly services. Additional suggested strategies to improve PrEP integration included community education to increase broader PrEP awareness and enable shorter counseling sessions, and task-shifting data entry and client risk assessments.

Conclusions

HCWs were enthusiastic about the appropriateness and acceptability of integrating PrEP services into MCH and FP clinics but noted challenges to adoption and feasibility. Strategies to address challenges focused on improving provider time and space constraints, and increasing provider and client knowledge.

The Fidelity of a Pharmacy-Based Oral HIV Pre-Exposure Prophylaxis Delivery Model in Kenya

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) delivery at private pharmacies is a promising new differentiated service delivery model that may address barriers to PrEP delivery at public health care facilities. We measured the fidelity of this model (ie, delivery as intended) in a pilot study in Kenya.

SETTING

Five private, retail pharmacies in Kisumu and Thika Counties.

METHODS

Trained pharmacy providers delivered PrEP services, including identifying eligible clients, counseling on HIV risk, assessing PrEP safety, testing for HIV, and dispensing PrEP. Pharmacy clients completed surveys that assessed the fidelity of the services received after each visit. Standardized client actors (ie, mystery shoppers) were trained on 4 different case scripts, then made unannounced pharmacy visits, and then completed a 40-item checklist that assessed the fidelity and quality of service delivery components.

RESULTS

From November 2020 to December 2021, 287 clients initiated and 159 (55%) refilled PrEP. At initiation, most clients were counseled on PrEP adherence (99%, 284 of 287) and potential side effects (97%, 279 of 287) and all received provider-assisted HIV self-testing before PrEP dispensing (findings consistent across refill visits). Nine standardized client actors completed 15 pharmacy visits. At each visit, most actors were asked about their behaviors associated with HIV risk (80%, 12/15) and all were counseled on PrEP safety and side effects. All actors reported that pharmacy providers treated them with respect.

CONCLUSIONS

In this first pilot study of pharmacy-delivered PrEP services in Africa, the fidelity of service delivery was high, suggesting that trained providers at private pharmacies can deliver quality PrEP services.

Development and validation of a prediction tool to support engagement in HIV care among young people ages 10-24 years in Kenya

INTRODUCTION

Loss to follow-up (LTFU) among adolescents and young adults living with HIV (AYALWH) is a barrier to optimal health and HIV services. We developed and validated a clinical prediction tool to identify AYALWH at risk of LTFU.

METHODS

We used electronic medical records (EMR) of AYALWH ages 10 to 24 in HIV care at 6 facilities in Kenya and surveys from a subset of participants. Early LTFU was defined as >30 days late for a scheduled visit in the last 6 months, which accounts for clients with multi-month refills. We developed a tool combining surveys with EMR ('survey-plus-EMR tool'), and an 'EMR-alone' tool to predict high, medium, and low risk of LTFU. The survey-plus-EMR tool included candidate sociodemographics, partnership status, mental health, peer support, any unmet clinic needs, WHO stage, and time in care variables for tool development, while the EMR-alone included clinical and time in care variables only. Tools were developed in a 50% random sample of the data and internally validated using 10-fold cross-validation of the full sample. Tool performance was evaluated using Hazard Ratios (HR), 95% Confidence Intervals (CI), and area under the curve (AUC) ≥ 0.7 for good performance and ≥0.60 for modest performance.

RESULTS

Data from 865 AYALWH were included in the survey-plus-EMR tool and early LTFU was (19.2%, 166/865). The survey-plus-EMR tool ranged from 0 to 4, including PHQ-9 ≥5, lack of peer support group attendance, and any unmet clinical need. High (3 or 4) and medium (2) prediction scores were associated with greater risk of LTFU (high, 29.0%, HR 2.16, 95%CI: 1.25-3.73; medium, 21.4%, HR 1.52, 95%CI: 0.93-2.49, global p-value = 0.02) in the validation dataset. The 10-fold cross validation AUC was 0.66 (95%CI: 0.63-0.72). Data from 2,696 AYALWH were included in the EMR-alone tool and early LTFU was 28.6% (770/2,696). In the validation dataset, high (score = 2, LTFU = 38.5%, HR 2.40, 95%CI: 1.17-4.96) and medium scores (1, 29.6%, HR 1.65, 95%CI: 1.00-2.72) predicted significantly higher LTFU than low-risk scores (0, 22.0%, global p-value = 0.03). Ten-fold cross-validation AUC was 0.61 (95%CI: 0.59-0.64).

CONCLUSIONS

Clinical prediction of LTFU was modest using the surveys-plus-EMR tool and the EMR-alone tool, suggesting limited use in routine care. However, findings may inform future prediction tools and intervention targets to reduce LTFU among AYALWH.

Effect of HIV stigma on depressive symptoms, treatment adherence, and viral suppression among youth with HIV

OBJECTIVE

We estimated the effects of HIV stigma on mental health and treatment outcomes for youth with HIV (YWH).

DESIGN

Secondary analysis of data for YWH ages 15-24 years in Western Kenya.

METHODS

Participants completed a longitudinal survey (baseline, months 6 and 12) assessing socio-demographics, antiretroviral therapy (ART) adherence, depressive symptoms (PHQ-9), and HIV stigma (10-item Wright scale). First viral load (VL) after enrollment was abstracted from records. We estimated risk of depressive symptoms (score > 4), nonadherence (missing ≥2 days of ART in a month), and detectable VL (≥50 copies/ml) for each standard deviation (SD) increase in HIV stigma score, adjusted for age and sex (and regimen in VL model). The generalizing estimating equation models included measures for the three visits.

RESULTS

Median age for the 1011 YWH was 18 years. At baseline, frequency of nonadherence, depressive symptoms and detectable VL was 21%, 21%, and 46%, respectively. Mean stigma score was 25 (SD = 7.0). Each SD stigma score increment was associated with higher risk of depressive symptoms {adjusted relative risk [aRR] 1.31 [95% confidence interval (CI): 1.20-1.44]}, nonadherence [aRR 1.16 (CI: 1.05-1.27)] and detectable VL [aRR 1.20 (CI: 1.08-1.32)]. Experienced and anticipated stigma were associated with detectable VL [aRR 1.16 (CI: 1.10-1.22) and aRR 1.23 (CI: 1.12-1.35), respectively]. Internalized and perceived community stigma were associated with depressive symptoms [aRR 1.31 (CI: 1.21-1.40) and aRR 1.24 (CI: 1.13-1.36), respectively].

CONCLUSIONS

Stigma was associated with depressive symptoms, nonadherence and detectable VL. Interventions to decrease stigma may improve virologic and mental health outcomes in YWH.

Nursing Workforce Optimization Study: A Multi-method Evaluation and Process Improvement Intervention for HIV Service Delivery in Tanzania and Zambia

ABSTRACT

Nurses are often suboptimally used in HIV care, due to misalignment of training and practice, workflow inefficiencies, and management challenges. We sought to understand nursing workforce capacity and support implementation of process improvement strategies to improve efficiency of HIV service delivery in Tanzania and Zambia. We conducted time and motion observations and task analyses at 16 facilities followed by process improvement workshops. On average, each nurse cared for 45 clients per day in Tanzania and 29 in Zambia. Administrative tasks and documentation occupied large proportions of nurse time. Self-reported competency was low at baseline and higher at follow-up for identifying and managing treatment failure and prescribing antiretroviral therapy. After workshops, facilities changed care processes, provided additional training and mentorship, and changed staffing and supervision. Efficiency outcomes were stable despite staffing increases. Collaborative approaches to use workforce data to engage providers in improvement strategies can support roll-out of nurse-managed HIV treatment.

Individual-, Interpersonal- and Institutional-Level Factors Associated with HIV Stigma Among Youth in Kenya

HIV stigma remains a barrier in achieving optimal HIV treatment. We studied the prevalence and predictors of HIV stigma among adolescents and youth with HIV (AYWHIV) ages 15-24 years in Western Kenya. Of 1011 AYWHIV, 69% were female with a median age of 18 years. Most (59%) attended adolescent clinic days, and 40% attended support groups. One-quarter (27%) had experienced physical, 18% emotional, and 7% sexual violence. The majority of AYWHIV (88%) reported disclosure concerns, 48% reported perceived community stigma, 36% experienced, and 24% internalized stigma. Compared to AYWHIV attending adolescent clinics, those in general/adult clinics had higher internalized stigma. Similarly, having dropped out of school was associated with higher internalized stigma. AYWHIV in sexual relationships had higher experienced stigma and disclosure concerns. Lastly, exposure to violence was associated with higher experienced, internalized, perceived community stigma and disclosure concerns. These risk factors can be targeted when developing stigma-prevention interventions.

"[T]he laws need to change to reflect current society": Insights from stakeholders involved in development, review or implementation of policies about adolescent consent for HIV testing, care and research in Kenya

INTRODUCTION

Engaging adolescents in HIV care and research promotes the development of interventions tailored to their unique needs. Guidelines generally require parental permission for adolescents to receive HIV care/testing or participate in research, with exceptions. Nevertheless, parental permission requirements can restrict adolescent involvement in care and research. To better appreciate prospects for policy reform, we sought to understand the perspectives of stakeholders involved in the development, review and implementation of policies related to adolescents living with HIV.

METHODS

Semi-structured individual interviews (IDIs) were conducted from October 2019 to March 2020 with 18 stakeholders with expertise in the (1) development of policy through membership in the Law Society of Kenya or work as a health policy official; (2) review of policy through ethics review committee service; or (3) implementation of policy through involvement in adolescent education. IDIs were conducted in English by Kenyan social scientists, audio-recorded and transcribed verbatim. We used thematic analysis to identify themes around how policies can be reformed to improve adolescent engagement in HIV care and research.

RESULTS

Our analysis identified three major themes. First, policies should be flexible rather than setting an age of consent. Stakeholders noted that adolescents' capacity for engagement in HIV care and research depended on context, perceived risks and benefits, and "maturity"-and that age was a poor proxy for the ability to understand. Second, policies should evolve with changing societal views about adolescent autonomy. Participants recognized a generational shift in how adolescents learn and mature, suggesting the need for a more frequent review of HIV care and research guidelines. Third, adults should empower adolescent decision-making. Stakeholders felt that caregivers can gradually involve adolescents in decision-making to equip them to gain ownership over their health and lives, improving their confidence and capacity.

CONCLUSIONS

Revising relevant laws to consider context, alternative measures of maturity, and evolving societal views about adolescence, along with supporting caregivers to assist in developing adolescent autonomy may promote more equitable and representative participation of adolescents in HIV care and research. Additional research should explore how to support caregivers and other adults to empower adolescents and improve stakeholder engagement in a more routine process of policy reform.

Condom Use Behaviors, Risk Perception, and Partner Communication Following Oral HIV Self-testing Among Adolescents and Young Adults in Kenya: A Cohort Study

HIV self-testing (HIVST) can improve testing completion among adolescents and young adults (AYA), although its influence on sexual behaviors is unclear. We evaluated whether HIVST was associated with changes in talking with sexual partners about HIVST, condom use, and HIV risk perception among AYA ages 15-24 years in a study of HIVST distribution through homes, pharmacies, and nightclubs in Nairobi, Kenya. All participants had negative HIVST results. Regression models were used to evaluate changes between pre-HIVST and 4 months post-HIVST. Overall, there was a significant increase in talking with sexual partners about HIVST. There was a significant reduction in number of condomless sex acts among AYA recruited through pharmacies and homes. Unexpectedly, among females, there was a significant decrease in consistent condom use with casual partners. HIVST services for AYA may benefit from including strategies to support condom use and partner communication about self-testing adapted to specific populations and partnerships.

Data-informed stepped care to improve youth engagement in HIV care in Kenya: a protocol for a cluster randomised trial of a health service intervention

INTRODUCTION

Adolescents and youth living with HIV (AYLHIV) have lower retention in care, adherence to treatment, and viral suppression compared with adults. Stepped care is a process by which clients are assigned to increasingly intensive services or 'steps' according to level of need. Differentiated care, in which stable clients access less frequent services, can be combined with stepped care to align needs and preferences of youth to promote optimal engagement in care.

METHODS AND ANALYSIS

This hybrid type I effectiveness implementation cluster randomised trial aims to evaluate a data-informed stepped care (DiSC) intervention for AYLHIV. AYLHIV ages 10-24 receiving care at 24 HIV treatment facilities in Kisumu, Homabay and Migori counties in Kenya will be enrolled. Twelve facilities will be randomised to the DiSC intervention, and 12 will provide standard care. A clinical assignment tool developed by the study team will be used at intervention sites to assign AYLHIV to one of four steps based on risk for loss to follow-up: differentiated care, standard care, counselling services or intensive support services. The primary clinical outcome is retention in care, specifically missed visits (failure to return within 30 days for any visit) and 12-month loss to follow-up. Implementation outcomes are based on the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. Proportions of missed visits will be compared using mixed effect models clustered by facility and participant.

ETHICS AND DISSEMINATION

This study has been approved by the University of Washington Institutional Review Board (STUDY00011096), Maseno University Ethical Review Committee (MUERC/00917/20) and the Kenya National Commission for Science, Technology and Innovation (444824). AYLHIV provide written informed consent when legally permitted, or assent with caregiver permission for minors. Study staff will work with a Community Advisory Board, including youth members, to disseminate results via discussions, presentations, journal publications and local or international conferences.

TRIAL REGISTRATION NUMBER

NCT05007717.

Key influences on the decision to initiate PrEP among adolescent girls and young women within routine maternal child health and family planning clinics in Western Kenya

We sought to understand influences on PrEP uptake among Kenyan adolescent girls and young women (AGYW) whose decision on PrEP use was misaligned with their risk for HIV acquisition. In-depth interviews were conducted with 47 Kenyan HIV-negative AGYW aged 15-24 years who were offered PrEP during routine maternal and child health and family planning services. AGYW were sampled from two groups (1) declined PrEP and had ≥1 sexual partner(s) of unknown HIV status and (2) initiated PrEP and reported having one HIV-negative partner. AGYW with HIV-negative partners initiated PrEP due to known or suspected infidelity. AGYW with partners of unknown HIV status recognized PrEP as a helpful HIV prevention tool, yet worried about partner reactions and prioritized avoiding uncomfortable or unsafe situations over PrEP. Among pregnant AGYW, the responsibility of motherhood and providing a future for one's family, through staying healthy and remaining HIV-free, was a strong PrEP use motivator. Among AGYW who desired future motherhood, fears that PrEP could negatively impact fertility or reduce contraceptive effectiveness led to declining PrEP. Peers positively influenced PrEP decision-making, especially personally knowing a PrEP user. Strategies are needed to enhance messaging and delivery approaches that are tailored to AGYW, including peer-led strategies.

Improving Quality of PrEP Counseling for Adolescent Girls and Young Women in Kenya With Standardized Patient Actors: A Dose-Response Analysis

BACKGROUND

Health care worker (HCW) training using standardized patient actors (SPs) is an evidence-based approach for improving patient-provider interactions. We evaluated whether SP training among HCWs in Western Kenya improved the quality of pre-exposure prophylaxis (PrEP) counseling for adolescent girls and young women (AGYW).

METHODS

We conducted a 2-day SP training intervention among HCWs providing PrEP counseling for AGYW. Six trained SPs role played one encounter each with HCWs following scripts depicting common PrEP-seeking scenarios. SPs used checklists to report and discuss domains of adherence to national PrEP guidelines, communication, and interpersonal skills using validated scales after each encounter. HCWs presented to each case in a random order. Overall and domain-specific mean score percentages were compared between the first and subsequent case encounters using generalized linear models, clustering by HCWs.

RESULTS

During 564 training cases among 94 HCWs, the overall mean quality of PrEP counseling score was 83.1 (SD: 10.1); scores improved over the course of the 6 encounters (P < 0.001). Compared with the first case encounter, the mean scores for the fourth were significantly higher (79.1 vs. 85.9, P < 0.001). The mean scores plateaued from the fourth to the sixth case (85.2). Although HCWs demonstrated high baseline communication (95.3) and interpersonal skills (83.7), adherence to PrEP guidelines at baseline was suboptimal (57.6). By the fourth case, scores increased significantly (P < 0.001) for all domains.

CONCLUSIONS

SP training improved PrEP counseling overall and in domains of interpersonal skills, use of guidelines, and communication with AGYW and could be useful in efforts to improve the quality of PrEP counseling for AGYW.

Kenyan HIV Clinics With Youth-Friendly Services and Trained Providers Have a Higher Prevalence of Viral Suppression Among Adolescents and Young Adults: Results From an Observational Study

ABSTRACT

Sustained viral suppression in adolescents and young adults living with HIV (AYALWH) is necessary for epidemic control. We evaluated facility and individual correlates of viral suppression using programmatic data from AYALWH between ages 10 and 24 years at 24 HIV clinics in Kenya. Binomial regression was used to evaluate correlates of viral load (VL) suppression (<1,000 copies/ml). Of 5,316 AYALWH on antiretroviral therapy ≥6 months, 2,081 (39%) had VLs available in the medical record, of which 76% were virally suppressed. In multivariable analyses, antiretroviral therapy initiation among AYALWH older than 10 years was associated with higher viral suppression than initiation younger than 10 years (adjusted risk ratio [aRR] 10-14 = 1.03, 95% confidence interval [CI] 0.97-1.10; aRR 15-19 = 1.30, 95% CI 1.19-1.41; aRR 20-24 = 1.43, 95% CI 1.24-1.63). Facilities with both youth-friendly services (YFS) and trained providers had significantly higher VL suppression compared with facilities without YFS or trained providers (adjusted odds ratio: 2.07, 95% CI: 1.71-2.52). Viral suppression remains suboptimal among AYALWH. YFS and trained providers plus greater use of VL data may help increase viral suppression among AYALWH.

Brief Report: "What Is This PrEP?"-Sources and Accuracy of HIV Pre-Exposure Prophylaxis (PrEP) Awareness Among Adolescent Girls and Young Women Attending Family Planning and Maternal Child Health Clinics in Western Kenya

BACKGROUND

Pre-exposure prophylaxis (PrEP) delivery to adolescent girls and young women (AGYW) is scaling up in sub-Saharan African countries. Understanding how AGYW learn about PrEP is needed to inform programs seeking to reach AGYW with HIV prevention tools.

METHODS

AGYW (ages 15-24), attending routine family planning and maternal child health clinics in Kisumu, Kenya, participated in in-depth interviews. AGYW were recruited if they either declined or accepted PrEP when offered that day in clinic or were currently or previously on PrEP. Thematic analysis was used to identify key themes related to the type and quality of knowledge sources from which AGYW first became aware of PrEP.

RESULTS

Overall, 140 in-depth interviews were conducted with AGYW. The median age was 21.5 years (interquartile range: 20.0-23.0), 65% of participants were married, and almost half (45.7%) were currently taking PrEP. Participants reported learning about PrEP from 3 primary sources: (1) clinic-based education; (2) friends, family, or other PrEP users; and (3) media and community outreach. Participants who reported learning about PrEP from friends or family were highly enthusiastic about PrEP. The accuracy and completeness of knowledge varied with most inaccuracies around the cost, dosing, and who benefits from PrEP. Community outreach campaigns provided fewer details, resulting in more inaccurate information and distrust of information received.

CONCLUSION

PrEP information reaches AGYW through many sources with variable accuracy and completeness. Training providers and peer leaders to disseminate thorough and accurate PrEP information when counseling AGYW could positively impact acceptance and proper use.

Healthcare-associated infections and antibiotic use in long-term care residents from two geographical regions in Switzerland

BACKGROUND

The burden of healthcare-associated infections (HAIs) and antimicrobial use in Swiss long-term care facilities (LTCFs) is currently unknown. This study assessed the prevalence of HAIs and antibiotic use among LTCF residents in Switzerland.

METHODS

A point-prevalence study was undertaken in LTCFs in eastern and western Switzerland from August to October 2019 according to the 'Healthcare-associated infections in long-term care facilities' (HALT) protocol. Characteristics of residents (age, sex, wounds, dementia, indwelling catheters) and institutions (specific factors, geographic region) were assessed. LTCF residents were screened for HAIs and current antibiotic treatment. Personal and institutional factors associated with HAIs were assessed.

RESULTS

In total, 1185 residents from 16 LTCFs (eight per geographic region) were screened for HAIs and antibiotic treatment. Median age was 87 years (interquartile range 79-91) and 71% were female. The prevalence of HAIs was 4.2% (west 4.3% vs east 4.2%; P=0.93), with mucocutaneous skin infections (36%) and respiratory tract infections (30%) being the most common. Independent risk factors for the presence of HAIs were presence of a chronic wound [odds ratio (OR) 2.4, 95% confidence interval (CI) 1.1-5.0; P=0.02] and being immobile (OR 1.8, 95% CI 1.0-3.3; P=0.04). Antibiotics were given to 2.9% of residents (west 3.9% vs east 1.8%; P=0.05) on the day of the survey. The most commonly prescribed antibiotics were amoxicillin-clavulanic acid and quinolones.

CONCLUSIONS

The prevalence of HAIs in Swiss LTCFs is similar to that in other European countries, whereas antibiotic consumption is lower. Further point-prevalence surveys on a broader scale are recommended to improve understanding of the burden of HAIs and antibiotic consumption in this setting.

Contraceptive counseling experiences among women attending HIV care and treatment centers: A national survey in Kenya

OBJECTIVES

To characterize contraceptive counseling experiences among women living with HIV (WLWH) receiving HIV care in Kenya.

STUDY DESIGN

Sexually active, WLWH aged 15 to 49 years were purposively sampled from 109 high-volume HIV Care and Treatment Centers in Kenya between June and September 2016. Cross-sectional surveys were administered to enroll women on a tablet using Open Data Kit. Poisson generalized linear regression models adjusted for facility-level clustering were used to examine cofactors for receiving family planning (FP) counseling with a provider.

RESULTS

Overall, 4805 WLWH were enrolled, 60% reported they received FP counseling during the last year, 72% of whom reported they were counseled about benefits of birth spacing and limiting. Most women who received FP counseling were married (64%) and discussed FP with their partner (78%). Use of FP in the last month (adjusted Prevalence Ratio [aPR] = 1.74, 95% confidence interval [CI]: 1.41-2.15, p < 0.001), desire for children in >2 years (aPR = 1.18, 95% CI: 1.09-1.28, p < 0.001), and concern about contraceptive side-effects (aPR = 1.13, 95% CI 1.02-1.25, p < 0.05) were significantly higher among WLWH who received FP counseling compared to those that did not.

CONCLUSIONS

Over one-third of WLWH did not receiving FP counseling with an HIV care provider during the last year, and counseling was more commonly reported among women who were using FP or desired children in >2 years.

IMPLICATIONS

There are missed opportunities for FP counseling in HIV care. FP integration in HIV care could improve FP access and birth spacing or limiting among WLWH.

Contraceptive Method Mix and HIV Risk Behaviors Among Kenyan Adolescent Girls and Young Women Seeking Family Planning Services: Implications for Integrating HIV Prevention

Background: Understanding HIV risk behaviors among adolescent girls and young women (AGYW) seeking contraception could help inform integrating HIV prevention services within family planning (FP) clinics. Methods: From 10/2018 to 04/2019, we conducted a survey at 4 FP clinics in Kisumu, Kenya to evaluate risk behaviors among AGYW without HIV infection seeking contraception. All AGYW aged 15-24 were invited to participate following receipt of FP services. Adolescent girls and young women initiating or refilling contraception were included in this analysis. Long-acting reversible contraceptives (LARC) included intrauterine devices, implants, or injectables. Non-LARC methods included oral contraceptive pills (OCP) or condoms. We used an empiric risk score to assess HIV risk behaviors; HIV risk scores of ≥5 (corresponding to 5-15% HIV incidence) defined "high" HIV risk. Results: Overall, 555 AGYW seeking FP were included. Median age was 22 years [interquartile range (IQR) 20-23], median completed education was 12 years (IQR 10-12); 23% of AGYW had HIV risk scores of ≥5. The most frequent form of contraception was injectables (43%), followed by implants (39%). After adjustment for education, prior pregnancy, and marital status, LARC users more frequently engaged in transactional sex than non-LARC users [6 vs. 0%, adjusted prevalence ratio (PR) = 1.17, 95% CI 1.09-1.29, p < 0.001]; LARC use was not associated with HIV risk scores ≥5. Among LARC users, AGYW using injectables more frequently had condomless sex compared to AGYW using other LARC methods (85 vs. 75%, adjusted PR = 1.52, 95% CI 1.09-2.10, p = 0.012); injectable use was not associated with HIV risk scores ≥5. Conclusions: Adolescent girls and young women seeking contraception frequently had high HIV risk, emphasizing the importance of integrating HIV prevention within FP. Multipurpose technologies for contraception and HIV prevention could particularly benefit AGYW.

“They Just Tell Me to Abstain:” Variable Access to and Uptake of Sexual and Reproductive Health Services Among Adolescents Living With HIV in Kenya

Background: To improve holistic care for adolescents living with HIV (ALHIV), including integration of sexual and reproductive health services (SRHS), the Kenya Ministry of Health implemented an adolescent package of care (APOC). To inform optimized SRH service delivery, we sought to understand the experiences with SRHS for ALHIV, their primary caregivers, and health care workers (HCWs) following APOC implementation.

Methods: We completed a mixed methods evaluation to characterize SRHS provided and personal experiences with access and uptake using surveys conducted with facility managers from 102 randomly selected large HIV treatment facilities throughout Kenya. Among a subset of 4 APOC-trained facilities in a high burden county, we conducted in-depth interviews (IDIs) with 40 ALHIV and 40 caregivers of ALHIV, and 4 focus group discussions (FGDs) with HCWs. Qualitative data was analyzed using thematic analysis. Facility survey data was analyzed using descriptive statistics.

Results: Of 102 surveyed facilities, only 56% reported training in APOC and 12% reported receiving additional adolescent-related SRHS training outside of APOC. Frequency of condom provision to ALHIV varied, with 65% of facilities providing condoms daily and 11% never providing condoms to ALHIV. Family planning (FP) was provided to ALHIV daily in 60% of facilities, whereas 14% of facilities reported not providing any FP services to ALHIV. Screening and treatment for STIs for adolescents were provided at all clinics, with 67% providing STI services daily. Three key themes emerged characterizing experiences with adolescent SRHS access and uptake: (1) HCWs were the preferred source for SRH information, (2) greater adolescent autonomy was a facilitator of SRH discussions with HCWs, and (3) ALHIV had variable access to and limited uptake of SRHS within APOC-trained health facilities. The primary SRHS reported available to ALHIV were abstinence and condom use education. There was variable access to FP, condoms, pregnancy and STI testing, and partner services. Adolescents reported limited utilization of SRHS beyond education.

Conclusions: Our results indicate a gap in SRHS offered within APOC trained facilities and highlight the importance of adolescent autonomy when providing SRHS and further HCW training to improve SRHS integration within HIV care for ALHIV.

Influences on Early Discontinuation and Persistence of Daily Oral PrEP Use Among Kenyan Adolescent Girls and Young Women: A Qualitative Evaluation From a PrEP Implementation Program

BACKGROUND

Discontinuation of daily oral pre-exposure prophylaxis (PrEP) is frequent among adolescent girls and young women (AGYW) in African settings. We explored factors influencing early PrEP discontinuation and persistence among Kenyan AGYW who accepted PrEP within a programmatic setting.

METHODS

We conducted in-depth interviews with AGYW (aged 15-24 years) who accepted PrEP from 4 maternal child health (MCH) and family planning (FP) clinics. AGYW were identified by nurses at routine clinic visits and purposively sampled based on 4 categories: (1) accepted PrEP pills, but never initiated PrEP use (eg, never swallowed PrEP pills), (2) discontinued PrEP <1 month after initiation, (3) discontinued PrEP within 1-3 months, and (4) persisted with PrEP use >3 months. Informed by the Stages of Change Model, thematic analysis characterized key influences on PrEP discontinuation/persistence.

RESULTS

We conducted 93 in-depth interviews with AGYW who accepted pills. Median age was 22 years, 71% were married; 89% were from MCH, and 11% were from FP clinics. Early PrEP use was positively influenced by encouragement from close confidants and effective concealment of PrEP pill-taking when necessary to avoid stigma or negative reactions from partners. Pregnancy helped conceal PrEP use because pill-taking is normalized during pregnancy, but concealment became more difficult postpartum. AGYW found keeping up with daily PrEP pill-taking challenging, and many noted only episodic periods of the HIV risk. Frequently testing HIV-negative reassured AGYW that PrEP was working and motivated persistence.

DISCUSSION

As PrEP programs scale-up in MCH/FP, it is increasingly important to enhance protection-effective PrEP use through approaches tailored to AGYW, with special considerations during pregnancy and postpartum.

Evaluation of a New Field Epidemiology Training Program Intermediate Course to Strengthen Public Health Workforce Capacity in Tanzania

OBJECTIVES

Sub-Saharan Africa faces a shortage of skilled epidemiologists to prevent, detect, and respond to health threats. Tanzania has implemented one of the first Centers for Disease Control and Prevention Field Epidemiology Training Program (FETP) Intermediate courses in Africa. This course aims to strengthen health workforce capacity in surveillance system assessment, outbreak investigation, and evaluation, prioritizing HIV control. We conducted an outcome evaluation of this new course.

METHODS

We used a pre/post evaluation design using data from 4 cohorts of trainees who took the FETP Intermediate course from 2017 to 2020. We conducted knowledge assessments before and after each cohort and combined those results. Outcomes included knowledge and self-rated competency and trends in integrated disease surveillance and response (IDSR) data. We collected data through tests, field assignments, exit interviews, and data audits. We compared the mean change in pre-/posttest scores using linear regression and 95% CIs. We used content analysis to summarize exit interviews.

RESULTS

Fifty-three FETP trainees from 10 regions enrolled in the FETP Intermediate course, and 52 (99.0%) completed the course. We found substantial increases in mean knowledge (44.0 to 68.0 points) and self-rated competency (4.14 to 4.43) scores before and after the course. Trainees evaluated 52 surveillance systems and 52 district HIV care programs, and 39 (75.0%) trainees participated in outbreak investigations. From before to after cohort 1, timeliness and completeness of IDSR reports increased from 4.2% to 52.1% and from 27.4% to 76.5%, respectively. Course strengths were quality of instruction, individualized mentoring, and practical skills gained. Challenges were mentor availability, limited time for data analysis practice, and balancing work and field assignments.

CONCLUSIONS

The Tanzania FETP Intermediate course substantially improved trainee knowledge and helped to improve local data quality and reporting. This course is a promising model to strengthen subnational capacity to prevent, detect, and respond to public health threats in Africa.

The Psychosocial Effects of the COVID-19 Pandemic on Youth Living with HIV in Western Kenya

The objective of this study was to assess psychosocial effects of COVID-19 among adolescents living with HIV (ALHIV) in Kenya and to assess the feasibility of conducting behavioral surveys by phone. We adapted our protocol to administer telephone rather than in-person follow-up surveys and included questions about COVID-19. The majority of participants (99%) reported having heard of COVID-19; 23% reported no longer being able to go outside, 17% reported that they could no longer go to their regular clinic for medical care, and 3% reported that they could no longer get medication refills. PHQ-9 screening identified 9% (n = 45) with mild depression symptoms, and 1% (n = 3) with moderate-to-severe depression symptoms. Young adults 20–24 years old had more mild to severe depressive symptoms than the younger age groups (p < 0.001). Offering remote peer-support or mental health care, continuing to offer differentiated care services, and considering financial support will support the health and well-being of ALHIV.

Adolescent participation in HIV research: consortium experience in low and middle-income countries and scoping review

Adolescents in low and middle-income countries (LMICs) have a high prevalence of HIV, therefore, it is important that they are included in HIV research. However, ethical challenges regarding consent can hinder adolescent research participation. We examined examples from the Prevention and Treatment Through a Comprehensive Care Continuum for HIV-affected Adolescents in Resource Constrained Settings (PATC3H) research consortium, which investigates adolescent HIV prevention and treatment in seven LMICs: Brazil, Kenya, Mozambique, Nigeria, South Africa, Uganda, and Zambia. PATC3H researchers were asked to identify ethical and practical challenges of adolescent consent to research participation in these countries. We also did a scoping review of strategies that could improve adolescent participation in LMIC HIV studies. Examples from PATC3H research highlighted many ethical challenges that affect adolescent participation, including inconsistent or absent consent guidance, guidelines that fail to account for the full array of adolescents' lives, and variation in how ethical review committees assess adolescent studies. Our scoping review identified three consent-related strategies to expand adolescent inclusion: waiving parental consent requirements, allowing adolescents to independently consent, and implementing surrogate decision making. Our analyses suggest that these strategies should be further explored and incorporated into ethical and legal research guidance to increase adolescent inclusion in LMIC HIV research.

First marine litter survey on beaches in Solomon Islands and Vanuatu, South Pacific: Using OSPAR protocol to inform the development of national action plans to tackle land-based solid waste pollution

The increasing abundance of marine litter is impacting the environment, human health and economies in the South Pacific. Small Islands Developing States are particularly affected by marine litter, primarily due to insufficient waste management systems. For the first time, marine litter was quantified and characterised on 13 beaches in Solomon Islands and Vanuatu in the South Pacific region using the OSPAR beach litter monitoring guidelines. A total of 1053 (±1017) and 974 (±745) items of litter per 100 m beach were recorded in Solomon Islands and Vanuatu respectively. Litter composition and distribution show that the majority of the litter comes from local land-based sources and large quantities of fragments and single use plastics were found by cities and river mouths. Actions to reduce single use plastic, improve collection, reuse and recycling, together with outreach campaigns would reduce marine litter significantly in these countries. Furthermore, there is great potential to develop a more circular economy to manage the substantial quantities of recyclable items that were found stranded on the beaches.

Depression and HIV risk behaviors among adolescent girls and young women seeking family planning services in Western Kenya

We assessed prevalence of human immunodeficiency virus (HIV) risk behaviors and depressive symptoms among adolescent girls and young women (AGYW) aged 15-24 years attending four public family planning clinics in Western Kenya from January to June 2019. Moderate-to-severe depression (MSD) was defined as a Center for Epidemiologic Studies Depression Scale (CESD-10) score ≥10. Among 487 AGYW, the median age was 22 years (interquartile range 20-23), and 59 (12%) AGYW reported MSD. MSD was more prevalent among AGYW without a current partner (p = 0.001) and associated with HIV risk factors including partner ≥10 years older, recent transactional sex, forced sex, intimate partner violence, and alcohol use (each p ≤ 0.005). Thirty-four percent of AGYW with MSD had a high HIV risk score corresponding to 5 to 15 incident HIV cases per 100 person-years. Overlapping high prevalence of depression and HIV risk among AGYW underscores the need for integrated mental health and HIV services in family planning clinics.

Standardised patient encounters to improve quality of counselling for pre-exposure prophylaxis (PrEP) in adolescent girls and young women (AGYW) in Kenya: study protocol of a cluster randomised controlled trial

INTRODUCTION

Adolescent girls and young women (AGYW) in sub-Saharan Africa are at high risk of HIV acquisition. Pre-exposure prophylaxis (PrEP) demonstration projects observe that AGYW uptake and adherence to PrEP during risk periods is suboptimal. Judgemental interactions with healthcare workers (HCW) and inadequate counselling can be barriers to PrEP use among AGYW. Improving HCW competency and communication to support PrEP delivery to AGYW requires new strategies.

METHODS AND ANALYSIS

PrEP Implementation for Young Women and Adolescents Program-standardised patient (PrIYA-SP) is a cluster randomised trial of a standardised patient actor (SP) training intervention designed to improve HCW adherence to PrEP guidelines and communication skills. We purposively selected 24 clinics offering PrEP services under fully programmatic conditions in Kisumu County, Kenya. At baseline, unannounced SP 'mystery shoppers' present to clinics portraying AGYW in common PrEP scenarios for a cross-sectional assessment of PrEP delivery. Twelve facilities will be randomised to receive a 2-day training intervention, consisting of lectures, role-playing with SPs and group debriefing. Unannounced SPs will repeat the assessment in all 24 sites following the intervention. The primary outcome is quality of PrEP counselling, including adherence to national guidelines and communication skills, scored on a checklist by SPs blinded to intervention assignment. An intention-to-treat (ITT) analysis will evaluate whether the intervention resulted in higher scores within intervention compared with control facilities, adjusted for baseline SP scores and accounting for clustering by facility. We hypothesise that the intervention will improve quality of PrEP counselling compared with standard of care. Results from this study will inform guidelines for PrEP delivery to AGYW in low-resource settings and offer a potentially scalable strategy to improve service delivery for this high-risk group.

ETHICS AND DISSEMINATION

The protocol was approved by institutional review boards at Kenyatta National Hospital and University of Washington. An external advisory committee monitors social harms. Results will be disseminated through peer-reviewed journals and presentations.

TRIAL REGISTRATION NUMBER

NCT03875950.

Sources of viral respiratory infections in Canadian acute care hospital healthcare personnel

BACKGROUND

Viral respiratory illnesses are common causes of outbreaks and can be fatal to some patients.

AIM

To investigate the association between laboratory-confirmed viral respiratory infections and potential sources of exposure during the previous 7 days.

METHODS

In this nested case-control analysis, healthcare personnel from nine Canadian hospitals who developed acute respiratory illnesses during the winters of 2010/11-2013/14 submitted swabs that were tested for viral pathogens. Associated illness diaries and the weekly diaries of non-ill participants provided information on contact with people displaying symptoms of acute respiratory illness in the previous week. Conditional logistic regression assessed the association between cases, who were matched by study week and site with controls with no respiratory symptoms.

FINDINGS

There were 814 laboratory-confirmed viral respiratory illnesses. The adjusted odds ratio (aOR) of a viral illness was higher for healthcare personnel reporting exposures to ill household members [7.0, 95% confidence interval (CI) 5.4-9.1], co-workers (3.4, 95% CI 2.4-4.7) or other social contacts (5.1, 95% CI 3.6-7.1). Exposures to patients with respiratory illness were not associated with infection (aOR 0.9, 95% CI 0.7-1.2); however, healthcare personnel with direct patient contact did have higher odds (aOR 1.3, 95% CI 1.1-1.6). The aORs for exposure and for direct patient contact were similar for illnesses caused by influenza.

CONCLUSION

Community and co-worker contacts are important sources of viral respiratory illness in healthcare personnel, while exposure to patients with recognized respiratory infections is not associated. The comparatively low risk associated with direct patient contact may reflect transmission related to asymptomatic patients or unrecognized infections.

A systematic review and meta-analysis of postpartum contraceptive use among women in low- and middle-income countries

BACKGROUND

Short birth intervals increase risk for adverse maternal and infant outcomes including preterm birth, low birth weight (LBW), and infant mortality. Although postpartum family planning (PPFP) is an increasingly high priority for many countries, uptake and need for PPFP varies in low- and middle-income countries (LMIC). We performed a systematic review and meta-analysis to characterize postpartum contraceptive use, and predictors and barriers to use, among postpartum women in LMIC.

METHODS

PubMed, EMBASE, CINAHL, PsycINFO, Scopus, Web of Science, and Global Health databases were searched for articles and abstracts published between January 1997 and May 2018. Studies with data on contraceptive uptake through 12 months postpartum in low- and middle-income countries were included. We used random-effects models to compute pooled estimates and confidence intervals of modern contraceptive prevalence rates (mCPR), fertility intentions (birth spacing and birth limiting), and unmet need for contraception in the postpartum period.

RESULTS

Among 669 studies identified, 90 were selected for full-text review, and 35 met inclusion criteria. The majority of studies were from East Africa, West Africa, and South Asia/South East Asia. The overall pooled mCPR during the postpartum period across all regions was 41.2% (95% CI: 15.7-69.1%), with lower pooled mCPR in West Africa (36.3%; 95% CI: 27.0-45.5%). The pooled prevalence of unmet need was 48.5% (95% CI: 19.1-78.0%) across all regions, and highest in South Asia/South East Asia (59.4, 95% CI: 53.4-65.4%). Perceptions of low pregnancy risk due to breastfeeding and postpartum amenorrhea were commonly associated with lack of contraceptive use and use of male condoms, withdrawal, and abstinence. Women who were not using contraception were also less likely to utilize maternal and child health (MCH) services and reside in urban settings, and be more likely to have a fear of method side effects and receive inadequate FP counseling. In contrast, women who received FP counseling in antenatal and/or postnatal care were more likely to use PPFP.

CONCLUSIONS

PPFP use is low and unmet need for contraception following pregnancy in LMIC is high. Tailored counseling approaches may help overcome misconceptions and meet heterogeneous needs for PPFP.

Acceptability, feasibility and utility of a Mobile health family planning decision aid for postpartum women in Kenya

BACKGROUND

Unmet need for contraception is high during the postpartum period, increasing the risk of unintended subsequent pregnancy. We developed a client facing mobile phone-based family planning (FP) decision aid and assessed acceptability, feasibility, and utility of the tool among health care providers and postpartum women.

METHODS

Semi-structured in-depth interviews (IDIs) were conducted among postpartum women (n = 25) and FP providers (n = 17) at 4 Kenyan maternal and child health clinics, 2 in the Nyanza region (Kisumu and Siaya Counties) and 2 in Nairobi. Stratified purposive sampling was used to enroll postpartum women and FP providers. Data were analyzed using an inductive content analysis approach by 3 independent coders, with consensual validation.

RESULTS

FP providers stated that the Interactive Mobile Application for Contraceptive Choice (iMACC) tool contained the necessary information about contraceptive methods for postpartum women and believed that it would be a useful tool to help women make informed, voluntary decisions. Most women valued the decision aid content, and described it as being useful in helping to dispel myths and misconceptions, setting realistic expectations about potential side effects and maintaining confidentiality. Both women and providers expressed concerns about literacy and lack of familiarity with smart phones or tablets and suggested inclusion of interactive multimedia such as audio or videos to optimize the effectiveness of the tool.

CONCLUSIONS

The iMACC decision aid was perceived to be an acceptable tool to deliver client-centered FP counseling by both women and providers. Counseling tools that can support FP providers to help postpartum women make informed and individualized FP decisions in resource-limited settings may help improve FP counseling and contraceptive use in the postpartum period.

Pilot evaluation of a standardized patient actor training intervention to improve HIV care for adolescents and young adults in Kenya

Poor retention in HIV care remains a major problem for Adolescents and Young Adults (AYA). A Standardized Patient (SP) clinical training intervention was developed to improve healthcare worker (HCW) "adolescent-friendly" competencies in Kenya. Professional actors were trained to portray HIV-infected AYA according to standardized scripts. HCWs completed a 2-day SP training that included didactic sessions, 7 video-recorded SP encounters, and group debriefing. AYA health experts rated HCWs by reviewing the video recordings. All HCWs (10/10) reported high satisfaction with the intervention and overall improvement in self-rated competency in caring for HIV-infected AYA. Cases were reported to be realistic and relevant by between 7 and 10 of 10 HCWs. The case on disclosure and adherence was rated as most challenging in communication and making medical decisions by HCWs. Areas identified by SPs for improvement by HCWs included allowing patients time to ask questions, and enabling SP to share sensitive information. The overall ICC by experts was low 0.27 (95% CI: -0.79 to 0.95), however, ICCs in assessment of HIV disclosure 0.78 (95% CI: 0.17-0.98), and sexual behavior 0.97 (95% CI: 0.89-0.99) were high. This intervention was acceptable for Kenyan HCWs and improved self-rated competency in caring for HIV-infected AYA.

First clinical case of KPC-3-producing Klebsiella michiganensis in Europe

Klebsiella michiganensis is a newly emerging human pathogen. We describe a case of bloodstream infection in an immunocompromised patient. The pathogen was repeatedly isolated from blood and one rectal swab, and was identified using routine standard procedures. Further investigations revealed that the K. michiganensis was multidrug resistant, carrying a plasmid harbouring a Klebsiella pneumoniae carbapenemase (KPC)-3 carbapenemase gene. This plasmid has been frequently encountered in K. pneumoniae isolates in Europe but has never been described in K. michiganensis.

A Risk Assessment Tool for Identifying Pregnant and Postpartum Women Who May Benefit From Preexposure Prophylaxis

Background

A human immunodeficiency virus (HIV) risk assessment tool for pregnant women could identify women who would most benefit from preexposure prophylaxis (PrEP) while minimizing unnecessary PrEP exposure.

Methods

Data from a prospective study of incident HIV among pregnant/postpartum women in Kenya were randomly divided into derivation (n = 654) and validation (n = 650) cohorts. A risk score was derived using multivariate Cox proportional hazards models and standard clinical prediction rules. Ability of the tool to predict maternal HIV acquisition was assessed using the area under the curve (AUC) and Brier score.

Results

The final risk score included the following predictors: having a male partner with unknown HIV status, number of lifetime sexual partners, syphilis, bacterial vaginosis (BV), and vaginal candidiasis. In the derivation cohort, AUC was 0.84 (95% confidence interval [CI], .72-.95) and each point increment in score was associated with a 52% (hazard ratio [HR], 1.52 [95% CI, 1.32-1.76]; P < .001) increase in HIV risk; the Brier score was 0.11. In the validation cohort, the score had similar AUC, Brier score, and estimated HRs. A simplified score that excluded BV and candidiasis yielded an AUC of 0.76 (95% CI, .67-.85); HIV incidence was higher among women with risk scores >6 than with scores ≤6 (7.3 vs 1.1 per 100 person-years, respectively; P < .001). Women with simplified scores >6 accounted for 16% of the population but 56% of HIV acquisitions.

Conclusions

A combination of indicators routinely assessed in antenatal clinics was predictive of HIV risk and could be used to prioritize pregnant women for PrEP.

Cost-effectiveness analysis of universal screening for carbapenemase-producing Enterobacteriaceae in hospital inpatients

The purpose of this study was to assess the cost-effectiveness of screening all hospital inpatients for carbapenemase-producing Enterobacteriaceae (CPE) at the time of hospital admission, compared to not screening, from a US hospital perspective. We used a linked transmission/Markov model to compare outcomes for a typical hospitalized medical patient, from a community with a colonization prevalence of 0.05%. Outcomes were number of colonized patients, CPE-related clinical infections and deaths, expected quality-adjusted life years (QALYs), cost, and the incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed to assess the effect of parameter uncertainty, using a willingness-to-pay threshold of $100,000 per QALY gained. Screening prevented six CPE colonization cases per 1000 patients (1/1000 colonized with screening, 7/1000 without screening), over half of all symptomatic CPE infections (2/10,000 symptomatic with screening, 5/10,000 symptomatic without screening), and nearly half of all CPE-related deaths (8/100,000 deaths with screening, 15/100,000 deaths without screening). Screening accrued 0.0009 additional QALYs and cost an additional $24.68, compared to not screening, and was cost-effective (ICER $26,283 per QALY gained). Our results were sensitive to uncertainty in prevalence and the number of secondary colonizations per colonized patient. Screening was not cost-effective at a prevalence below 0.015% or if transmission to fewer than 0.9 new patients occurred for each colonized patient. At prevalence levels above 0.3%, screening was cost-saving compared to not screening. Screening inpatients for CPE carriage is likely cost-effective, and may be cost-saving, depending on the local prevalence of carriage.

Creating academic structures to promote nursing's role in global health policy

AIM

We highlight key components of emerging academic structures in global health nursing and explain how this investment can expand nursing's broader engagement in global health policy development.

BACKGROUND

Engaging nursing in global health policy development is vital to ensure the scale-up of effective health programmes. Globally, nurses promote development of interprofessional healthcare teams who are responsible for translating sound global health policy and evidence-based programming into practice. However, the role of nurses within policy forums and on influential decision-making bodies within the global health space remains limited, which reinforces suboptimal global health policy implementation.

INTRODUCTION

Investment in globally engaged academic structures is an important way to expand participation of nursing in global health policy development.

SOURCES OF EVIDENCE

A review of the current knowledge and substantive findings related to academic structures promoting global health nursing was conducted, and included a directed search of institutional websites, related grey and peer-reviewed literature, and communication with top-tier schools of nursing in the United States, to identify specific developments in global health nursing academic structures.

DISCUSSION/CONCLUSION

Effective academic structures promoting global health nursing include a framework of four critical components - Research, Education, Policy and Partnership. Academic structure type and core activities vary depending on institutional priorities.

IMPLICATIONS FOR NURSING, HEALTH AND SOCIAL POLICY

Increasingly, global health research, driven by individual nursing investigators, is expanding; however, in order to translate these advances into expanded involvement in global health policy development, academic structures within schools of nursing need to systematically expand educational opportunities, bolster research capacity and promote partnership with policymakers.

A single prolonged milking interval of 24h compromises the well-being and health of dairy Holstein cows

Cows are often shown at dairy shows with overfilled udders to achieve a better show placing. However, it is unclear to what degree "over-bagging" affects the health and well-being of show cows. The goal of this study was to assess the effect of a single prolonged milking interval (PMI) of 24h on the measurable signs of health and well-being in dairy cows in early and mid-lactation and to assess the effect of a nonsteroidal anti-inflammatory drug (NSAID) on well-being during a PMI. Fifteen Holstein cows were studied in early lactation (89.5±2.7d in milk) and were given an NSAID or physiological saline in a crossover design. Ten cows were studied again in mid-lactation (151.6±4.0d in milk). Data on clinical signs of cows' health, behavior, and well-being were collected at 1 or 2h intervals before and during a PMI of 24h. Data from the last 6h of a 12h milking interval were compared with the last 6h of the PMI. Compared with that of a cow in the last 6h of a 12-h milking interval, the behavior of cows in early lactation (saline group) changed during the last 6h of the PMI: we observed decreased eating time (22.4 vs. 16.2min/h), increased ruminating time (13.3 vs. 25.0min/h), and increased hind limb abduction while walking (score 41.7 vs. 62.6) and standing (31.2 vs. 38.9cm). Udder firmness was increased (2.9 vs. 4.5kg) during this period and more weight was placed on the hind limbs (46.4 vs. 47.0%). We also found pathological signs at the end of the PMI: all cows showed milk leaking, and 10 of 15 cows developed edema in the subcutaneous udder tissue. Somatic cell count was significantly increased from 12h to 72h after the PMI. Administration of an NSAID had no influence on measured variables, except that the occurrence of edema was not significantly increased during PMI in the flunixin group (10 of 15 and 6 of 15 cows for the saline and flunixin groups, respectively). In the cows in mid-lactation, different variables were not significantly changed in the PMI compared with baseline values (e.g., eating and ruminating time, occurrence of edema, and abduction). We conclude that the cows' health and well-being were compromised by a single PMI of 24h, because their behavior changed and pathological signs were recorded. Administration of an NSAID had a slight effect on cows' well-being during a PMI. The stage of lactation had more effect on the cows' health and well-being, because fewer variables were changed in mid-lactation.

Forensic ancestry analysis with two capillary electrophoresis ancestry informative marker (AIM) panels: Results of a collaborative EDNAP exercise

There is increasing interest in forensic ancestry tests, which are part of a growing number of DNA analyses that can enhance routine profiling by obtaining additional genetic information about unidentified DNA donors. Nearly all ancestry tests use single nucleotide polymorphisms (SNPs), but these currently rely on SNaPshot single base extension chemistry that can fail to detect mixed DNA. Insertion-deletion polymorphism (Indel) tests have been developed using dye-labeled primers that allow direct capillary electrophoresis detection of PCR products (PCR-to-CE). PCR-to-CE maintains the direct relationship between input DNA and signal strength as each marker is detected with a single dye, so mixed DNA is more reliably detected. We report the results of a collaborative inter-laboratory exercise of 19 participants (15 from the EDNAP European DNA Profiling group) that assessed a 34-plex SNP test using SNaPshot and a 46-plex Indel test using PCR-to-CE. Laboratories were asked to type five samples with different ancestries and detect an additional mixed DNA sample. Statistical inference of ancestry was made by participants using the Snipper online Bayes analysis portal plus an optional PCA module that analyzes the genotype data alongside calculation of Bayes likelihood ratios. Exercise results indicated consistent genotyping performance from both tests, reaching a particularly high level of reliability for the Indel test. SNP genotyping gave 93.5% concordance (compared to the organizing laboratory's data) that rose to 97.3% excluding one laboratory with a large number of miscalled genotypes. Indel genotyping gave a higher concordance rate of 99.8% and a reduced no-call rate compared to SNP analysis. All participants detected the mixture from their Indel peak height data and successfully assigned the correct ancestry to the other samples using Snipper, with the exception of one laboratory with SNP miscalls that incorrectly assigned ancestry of two samples and did not obtain informative likelihood ratios for a third. Therefore, successful ancestry assignments were achieved by participants in 92 of 95 Snipper analyses. This exercise demonstrates that ancestry inference tests based on binary marker sets can be readily adopted by laboratories that already have well-established CE regimes in place. The Indel test proved to be easy to use and allowed all exercise participants to detect the DNA mixture as well as achieving complete and concordant profiles in nearly all cases. Lastly, two participants successfully ran parallel next-generation sequencing analyses (each using different systems) and achieved high levels of genotyping concordance using the exercise PCR primer mixes unmodified.

Factors associated with methicillin-resistant coagulase-negative staphylococci as causing organisms in deep sternal wound infections after cardiac surgery

Established preoperative antibiotic prophylaxis in cardiac surgery is ineffective against methicillin-resistant coagulase-negative staphylococci (CoNS). This case-control study aimed to determine factors predicting deep sternal wound infections due to methicillin-resistant CoNS. All cardiac surgery patients undergoing sternotomy between June 2009 and March 2013 prospectively documented in a Swiss tertiary care center were included. Among 1999 patients, 82 (4.1%) developed deep sternal wound infection. CoNS were causal in 36 (44%) patients, with 25/36 (69%) being methicillin resistant. Early reintervention for noninfectious causes (odds ratio (OR) 4.3; 95% confidence interval (CI) 1.9-9.5) was associated with methicillin-resistant CoNS deep sternal wound infection. Among CoNS deep sternal wound infection, perioperative antimicrobial therapy (p 0.002), early reintervention for noninfectious causes (OR 7.9; 95% CI 0.9-71.1) and time between surgery and diagnosis of infection over 21 days (OR 10.8; 95% CI 1.2-97.8) were associated with methicillin resistance. These findings may help to better tailor preoperative antimicrobial prophylaxis.

A community-based assessment of correlates of facility delivery among HIV-infected women in western Kenya

BACKGROUND

Childbirth at health facilities is an important strategy to reduce maternal morbidity and mortality, improve fetal outcomes, and reduce mother-to-child transmission of HIV. Although access to antenatal care in Kenya is high (>90%), less than half of births occur at health facilities. This analysis aims to assess correlates of facility delivery among recently pregnant HIV-infected women participating in a community-based survey, and to determine whether these correlates were unique when compared to HIV-uninfected women from the same region.

METHODS

Women residing in the Kenya Medical Research Institute/Centers for Disease Control and Prevention Health and Demographic Surveillance System, and who had delivered an infant in the previous year were visited at home in 2011. Consenting mothers answered a questionnaire assessing demographics, place of delivery, utilization of prevention of mother-to-child HIV transmission (PMTCT) services, and stigma indicators. Known HIV-positive women were purposively oversampled. Chi-square tests of proportions and multivariate logistic regression, stratified by HIV status, were performed to assess correlates of facility delivery.

RESULTS

Overall, 101 (46.8%) HIV-infected and 127 (39.9%) HIV-uninfected women delivered at health facilities. Among HIV-infected women, cost (42.8%), distance (18.8%) and fear of harsh treatment (15.2%) were primary disincentives for facility delivery; 2.9% noted fear of HIV testing was a disincentive. HIV-infected women who delivered at facilities had higher education (p = 0.04) and socioeconomic status (p < 0.005), initiated antenatal care (ANC) earlier (4.9 vs. 5.4 months, p = 0.016), were more likely to know partner's HIV status (p = 0.016), report satisfaction with delivery care (p = 0.001) and use antiretrovirals (87.1% vs. 77.4%, p = 0.063) compared to those with non-facility delivery. Stigma indicators were not associated with delivery location. Similar cofactors of facility delivery were noted among uninfected women.

CONCLUSIONS

Utilization of facility delivery remains low in Kenya and poses a challenge to elimination of infant HIV and reduction of peripartum mortality. Cost, distance, and harsh treatment were cited as barriers and these need to be addressed programmatically. HIV-infected women with lower socioeconomic status and those who present late to ANC should be prioritized for interventions to increase facility delivery. Partner involvement may increase use of maternity services and could be enhanced by couples counseling.

First documented outbreak of KPC-2-producing Klebsiella pneumoniae in Switzerland: infection control measures and clinical management

We report the epidemiological and clinical features of the first outbreak of Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-KP) type 2 in Switzerland. The outbreak took place in the medical intensive care unit (MICU) of our tertiary care hospital and affected three severely ill patients. After the implementation of strict infection control measures, no further patients colonised with KPC-KP could be detected by the screening of exposed patients. Successful treatment of patients infected with KPC-KP consisted of a combination therapy of meropenem, colistin and tigecycline.

Male, mobile, and moneyed: loss to follow-up vs. transfer of care in an urban African antiretroviral treatment clinic

OBJECTIVES

The purpose of this study was to analyze characteristics, reasons for transferring, and reasons for discontinuing care among patients defined as lost to follow-up (LTFU) from an antiretroviral therapy (ART) clinic in Nairobi, Kenya.

DESIGN

The study used a prospective cohort of patients who participated in a randomized, controlled ART adherence trial between 2006 and 2008.

METHODS

Participants were followed from pre-ART clinic enrollment to 18 months after ART initiation, and were defined as LTFU if they failed to return to clinic 4 weeks after their last scheduled visit. Reasons for loss were captured through phone call or home visit. Characteristics of LTFU who transferred care and LTFU who did not transfer were compared to those who remained in clinic using log-binomial regression to estimate risk ratios.

RESULTS

Of 393 enrolled participants, total attrition was 83 (21%), of whom 75 (90%) were successfully traced. Thirty-seven (49%) were alive at tracing and 22 (59%) of these reported having transferred their antiretroviral care. In the final model, transfers were more likely to have salaried employment [Risk Ratio (RR), 2.7; 95% confidence interval (CI), 1.2-6.1; p=0.020)] and pay a higher monthly rent (RR, 5.8; 95% CI, 1.3-25.0; p=0.018) compared to those retained in clinic. LTFU who did not transfer care were three times as likely to be men (RR, 3.1; 95% CI, 1.1-8.1; p=0.028) and nearly 4 times as likely to have a primary education or less (RR, 3.8; 95% CI, 1.3-10.6; p=0.013). Overall, the most common reason for LTFU was moving residence, predominantly due to job loss or change in employment.

CONCLUSION

A broad definition of LTFU may include those who have transferred their antiretroviral care and thereby overestimate negative effects on ART continuation. Interventions targeting men and considering mobility due to employment may improve retention in urban African ART clinics.

CLINICAL TRIALS

The study's ClinicalTrials.gov identifier is NCT00273780.

Autosomal SNP typing of forensic samples with the GenPlex™ HID System: results of a collaborative study

The GenPlex™ HID System (Applied Biosystems - AB) offers typing of 48 of the 52 SNPforID SNPs and amelogenin. Previous studies have shown a high reproducibility of the GenPlex™ HID System using 250-500pg DNA of good quality. An international exercise was performed by 14 laboratories (9 in Europe and 5 in the US) in order to test the robustness and reliability of the GenPlex™ HID System on forensic samples. Three samples with partly degraded DNA and 10 samples with low amounts of DNA were analyzed in duplicates using various amounts of DNA. In order to compare the performance of the GenPlex™ HID System with the most commonly used STR kits, 500pg of partly degraded DNA from three samples was typed by the laboratories using one or more STR kits. The median SNP typing success rate was 92.3% with 500pg of partly degraded DNA. Three of the fourteen laboratories counted for more than two thirds of the locus dropouts. The median percentage of discrepant results was 0.2% with 500pg degraded DNA. An increasing percentage of locus dropouts and discrepant results were observed when lower amounts of DNA were used. Different success rates were observed for the various SNPs. The rs763869 SNP was the least successful. With the exception of the MiniFiler™ kit (AB), GenPlex™ HID performed better than five other tested STR kits. When partly degraded DNA was analyzed, GenPlex™ HID showed a very low mean mach probability, while all STR kits except MiniFiler™ had very limited discriminatory power.