RHinKenya PubMed abstracts.

1. J Urban Health. 2011 Jun 29. [Epub ahead of print]
Monitoring of Health and Demographic Outcomes in Poor Urban Settlements: Evidence
from the Nairobi Urban Health and Demographic Surveillance System.
Emina J, Beguy D, Zulu EM, Ezeh AC, Muindi K, Elung'ata P, Otsola JK, Yé Y.
African Population and Health Research Center (APHRC), Shelter Afrique Center,
Longonot Road, Nairobi, Kenya, [email protected]
The Nairobi Urban Health and Demographic Surveillance System (NUHDSS) was set up
in Korogocho and Viwandani slum settlements to provide a platform for
investigating linkages between urban poverty, health, and demographic and other
socioeconomic outcomes, and to facilitate the evaluation of interventions to
improve the wellbeing of the urban poor. Data from the NUHDSS confirm the high
level of population mobility in slum settlements, and also demonstrate that slum
settlements are long-term homes for many people. Research and intervention
programs should take account of the duality of slum residency. Consistent with
the trends observed countrywide, the data show substantial improvements in
measures of child mortality, while there has been limited decline in fertility in
slum settlements. The NUHDSS experience has shown that it is feasible to set up
and implement long-term health and demographic surveillance system in urban slum
settlements and to generate vital data for guiding policy and actions aimed at
improving the wellbeing of the urban poor.
PMID: 21713553 [PubMed - as supplied by publisher]
2. PLoS One. 2011;6(6):e21040. Epub 2011 Jun 21.
Population-based biochemistry, immunologic and hematological reference values for
adolescents and young adults in a rural population in Western kenya.
Zeh C, Amornkul PN, Inzaule S, Ondoa P, Oyaro B, Mwaengo DM, Vandenhoudt H,
Gichangi A, Williamson J, Thomas T, Decock KM, Hart C, Nkengasong J, Laserson K.
U.S. Centers for Disease Control and Prevention (CDC-Kenya), Kisumu, Kenya.
BACKGROUND: There is need for locally-derived age-specific clinical laboratory
reference ranges of healthy Africans in sub-Saharan Africa. Reference values from
North American and European populations are being used for African subjects
despite previous studies showing significant differences. Our aim was to
establish clinical laboratory reference values for African adolescents and young
adults that can be used in clinical trials and for patient management.
METHODS AND FINDINGS: A panel of 298, HIV-seronegative individuals aged 13-34
years was randomly selected from participants in two population-based
cross-sectional surveys assessing HIV prevalence and other sexually transmitted
infections in western Kenya. The adolescent (<18 years)-to-adults (≥18 years)
ratio and the male-to-female ratio was 1∶1. Median and 95% reference ranges were
calculated for immunohematological and biochemistry values. Compared with
U.S-derived reference ranges, we detected lower hemoglobin (HB), hematocrit
(HCT), red blood cells (RBC), mean corpuscular volume (MCV), neutrophil, glucose,
and blood urea nitrogen values but elevated eosinophil and total bilirubin
values. Significant gender variation was observed in hematological parameters in
addition to T-bilirubin and creatinine indices in all age groups, AST in the
younger and neutrophil, platelet and CD4 indices among the older age group. Age
variation was also observed, mainly in hematological parameters among males.
Applying U.S. NIH Division of AIDS (DAIDS) toxicity grading to our results, 40%
of otherwise healthy study participants were classified as having an abnormal
laboratory parameter (grade 1-4) which would exclude them from participating in
clinical trials.
CONCLUSION: Hematological and biochemistry reference values from African
population differ from those derived from a North American population, showing
the need to develop region-specific reference values. Our data also show
variations in hematological indices between adolescent and adult males which
should be considered when developing reference ranges. This study provides the
first locally-derived clinical laboratory reference ranges for adolescents and
young adults in western Kenya.
PMID: 21713038 [PubMed - in process]
3. J Acquir Immune Defic Syndr. 2011 Jun 18. [Epub ahead of print]
Unnecessary antiretroviral treatment switches and accumulation of HIV resistance
mutations; two arguments for viral load monitoring in Africa.
Sigaloff KC, Hamers RL, Wallis CL, Kityo C, Siwale M, Ive P, Botes ME, Mandaliya
K, Wellington M, Osibogun A, Stevens WS, Vugt MV, Wit TF; for the PharmAccess
African Studies to Evaluate Resistance (PASER).
1PharmAccess Foundation, Amsterdam, The Netherlands; 2 Department of Global
Health, Academic Medical Center of the University of Amsterdam, Amsterdam
Institute for Global Health and Development, Amsterdam, The Netherlands;
3University of the Witwatersrand, Johannesburg, South Africa; 4Joint Clinical
Research Centre, Kampala, Uganda; 5Lusaka Trust Hospital, Lusaka, Zambia;
6Muelmed Hospital, Pretoria, South Africa; 7Coast Province General Hospital,
International Center for Reproductive Health, Mombasa, Kenya; 8Newlands Clinic,
Harare, Zimbabwe; 9Lagos University Teaching Hospital, Lagos, Nigeria.
OBJECTIVES:: This study aimed to investigate the consequences of using
clinico-immunological criteria to detect antiretroviral treatment (ART) failure
and guide regimen switches in HIV-infected adults in sub-Saharan Africa.
Frequencies of unnecessary switches, patterns of HIV drug resistance and risk
factors for the accumulation of nucleoside reverse transcriptase inhibitor
(NRTI)-associated mutations were evaluated. METHODS:: Cross-sectional analysis of
adults switching ART regimens at 13 clinical sites in 6 African countries was
performed. Two types of failure identification were compared: diagnosis of
clinico-immunological failure without viral load testing ("CIF only") or
clinico-immunological failure with local targeted viral load testing ("targeted
VL"). After study enrolment, reference HIV-RNA and genotype were determined
retrospectively. Logistic regression assessed factors associated with multiple
thymidine analogue mutations (TAMs) and NRTI cross-resistance (≥2 TAMs or Q151M
or K65R/K70E). RESULTS:: Of 250 patients with CIF switching to second-line ART,
targeted VL was performed in 186. Unnecessary switch at reference HIV-RNA <1000
copies/ml occurred in 46.9% of CIF only patients versus 12.4% of patients with
targeted VL (p<0.001). NRTI cross-resistance was observed in 48.0% of 183
specimens available for genotypic analysis, comprising ≥2 TAMs (37.7%), K65R
(7.1%), K70E (3.3%) or Q151M (3.3%). The presence of NRTI cross-resistance was
associated with the duration of ART exposure and zidovudine use. CONCLUSIONS::
Clinico-immunological monitoring without viral load testing resulted in frequent
unnecessary regimen switches. Prolonged treatment failure was indicated by
extensive NRTI cross-resistance. Access to virological monitoring should be
expanded to prevent inappropriate switches, enable early failure detection and
preserve second-line treatment options in Africa.
PMID: 21694603 [PubMed - as supplied by publisher]
4. Health Res Policy Syst. 2011 Jun 16;9 Suppl 1:S7.
Engaging media in communicating research on sexual and reproductive health and
rights in sub-Saharan Africa: experiences and lessons learned.
Oronje RN, Undie CC, Zulu EM, Crichton J.
Institute of Development Studies, at the University of Sussex, Brighton, BN1 9RE,
UK. [email protected]
BACKGROUND: The mass media have excellent potential to promote good sexual and
reproductive health outcomes, but around the world, media often fail to
prioritize sexual and reproductive health and rights issues or report them in an
accurate manner. In sub-Saharan Africa media coverage of reproductive health
issues is poor due to the weak capacity and motivation for reporting these issues
by media practitioners. This paper describes the experiences of the African
Population and Health Research Center and its partners in cultivating the
interest and building the capacity of the media in evidence-based reporting of
reproductive health issues in sub-Saharan Africa.
METHODS: The paper utilizes a case study approach based primarily on the personal
experiences and reflections of the authors (who played a central role in
developing and implementing the Center's communication and policy engagement
strategies), a survey that the Center carried out with science journalists in
Kenya, and literature review.
RESULTS: The African Population and Health Research Center's media strategy
evolved over the years, moving beyond conventional ways of communicating research
through the media via news releases and newspaper stories, to varying approaches
that sought to inspire and build the capacity of journalists to do evidence-based
reporting of reproductive health issues. Specifically, the approach included 1)
enhancing journalists' interest in and motivation for reporting on reproductive
health issues through training and competitive grants for outstanding reporting ;
2) building the capacity of journalists to report reproductive health research
and the capacity of reproductive health researchers to communicate their research
to media through training for both parties and providing technical assistance to
journalists in obtaining and interpreting evidence; and 3) establishing and
maintaining trust and mutual relationships between journalists and researchers
through regular informal meetings between journalists and researchers, organizing
field visits for journalists, and building formal partnerships with professional
media associations and individual journalists.
CONCLUSION: Our experiences and reflections, and the experiences of others
reviewed in this paper, indicate that a sustained mix of strategies that
motivate, strengthen capacity of, and build relationships between journalists and
researchers can be effective in enhancing quality and quantity of media coverage
of research.
PMCID: PMC3121138
PMID: 21679388 [PubMed - in process]
5. Health Res Policy Syst. 2011 Jun 16;9 Suppl 1:S2.
Strengthening the research to policy and practice interface: exploring strategies
used by research organisations working on sexual and reproductive health and
Theobald S, Tulloch O, Crichton J, Hawkins K, Zulu E, Mayaud P, Parkhurst J,
Whiteside A, Standing H.
International Health Research Group, Liverpool School of Tropical Medicine,
Pembroke Place, Liverpool, L3 5QA, UK. [email protected]
This commentary introduces the HARPS supplement on getting research into policy
and practice in sexual and reproductive health (SRH). The papers in this
supplement have been produced by the Sexual Health and HIV Evidence into Practice
(SHHEP) collaboration of international research, practitioner and advocacy
organizations based in research programmes funded by the UK Department for
International Development.The commentary describes the increasing interest from
research and communication practitioners, policy makers and funders in expanding
the impact of research on policy and practice. It notes the need for contextually
embedded understanding of ways to engage multiple stakeholders in the
politicized, sensitive and often contested arenas of sexual and reproductive
health. The commentary then introduces the papers under their respective themes:
(1) The theory and practice of research engagement (two global papers); (2)
Applying policy analysis to explore the role of research evidence in SRH and
HIV/AIDS policy (two papers with examples from Ghana, Malawi, Uganda and Zambia);
(3) Strategies and methodologies for engagement (five papers on Kenya, South
Africa, Ghana, Tanzania and Swaziland respectively); (4) Advocacy and engagement
to influence attitudes on controversial elements of sexual health (two papers,
Bangladesh and global); and (5) Institutional approaches to inter-sectoral
engagement for action and strengthening research communications (two papers,
Ghana and global).The papers illustrate the many forms research impact can take
in the field of sexual and reproductive health. This includes discursive changes
through carving out legitimate spaces for public debate; content changes such as
contributing to changing laws and practices, procedural changes such as
influencing how data on SRH are collected, and behavioural changes through
partnerships with civil society actors such as advocacy groups and
journalists.The contributions to this supplement provide a body of critical
analysis of communication and engagement strategies across the spectrum of SRH
and HIV/AIDS research through the testing of different models for the
research-to-policy interface. They provide new insights on how researchers and
communication specialists can respond to changing policy climates to create
windows of opportunity for influence.
PMCID: PMC3121133
PMID: 21679383 [PubMed - in process]
6. BMC Public Health. 2011 Jun 9;11(1):456. [Epub ahead of print]
Do improvements in outreach, clinical, and family and community-based services
predict improvements in child survival? An analysis of serial cross-sectional
national surveys.
Binkin N, Chopra M, Simen-Kapeu A, Westhof D.
ABSTRACT: BACKGROUND: There are three main service delivery channels: clinical,
outreach, and family and community. To determine which delivery channels are
associated with the greatest reductions in under-5 mortality rates (U5MR), we
used data from sequential population-based surveys to examine the correlation
between changes in coverage of clinical, outreach, and family and community
services and in U5MR for 27 high-burden countries. METHODS: Household survey data
were abstracted from serial surveys in 27 countries. Average annual changes (AAC)
between the most recent and penultimate survey were calculated for under-five
mortality rates and for 22 variables in the domains of clinical, outreach, and
family- and community-based services. For all 27 countries and a subset of 19
African countries, we conducted principal component analysis to reduce the
variables into a few components in each domain and applied linear regression to
assess the correlation between changes in the principal components and changes in
under-five mortality rates after controlling for multiple potential confounding
factors RESULTS: AAC in under 5-mortality varied from 6.6% in Nepal to -0.9% in
Kenya, with six of the 19 African countries all experiencing less than a 1%
decline in mortality. The strongest correlation with reductions in U5MR was
observed for access to clinical services (all countries: p=0.02, r2=0.58; 19
African countries p< 0.001, r2=0.67). For outreach activities, AAC U5MR was
significantly correlated with antenatal care and family planning services, while
AAC in immunization services showed no association. In the family- and community
services domain, improvements in breastfeeding were associated with significant
changes in mortality in the 30 countries but not in the African subset, while in
the African countries nutritional status improvements were associated with a
significant decline in mortality. CONCLUSIONS: Our findings support the
importance of increasing access to clinical services, certain outreach services
and breastfeeding and, in Africa, of improving nutritional status. Integrated
programs that emphasize these services may lead to substantial mortality
PMID: 21658267 [PubMed - as supplied by publisher]
7. Int J Gynaecol Obstet. 2011 May 25. [Epub ahead of print]
Building capacity for cervical cancer screening in outpatient HIV clinics in the
Nyanza province of western Kenya.
Huchko MJ, Bukusi EA, Cohen CR.
Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for
Global Reproductive Health, University of California, San Francisco, USA.
OBJECTIVE: To evaluate outcomes of cervical cancer screening within HIV care and
treatment clinics in Kenya. METHODS: Beginning in October 2007, visual inspection
with acetic acid (VIA), colposcopy, and loop electrosurgical excision procedure
(LEEP) were added to the clinical services offered at Family AIDS Care and
Education Services (FACES) clinics in Kisumu, Kenya, after a systematic campaign
to build capacity and community awareness. RESULTS: From October 2007 to October
2010, 3642 women underwent VIA as part of routine HIV care. Cervical
intraepithelial neoplasia 2/3 was identified in 259 (7.1%) women, who were
offered excisional treatment by LEEP in the clinic. Among those women offered
screening, uptake was 87%. Clinical staff reported a high level of satisfaction
with training for and implementation of cervical cancer screening strategies.
CONCLUSION: Cervical cancer screening and prevention are feasible, acceptable,
and effective within HIV care and treatment clinics. Screening test performance
characteristics need to be defined for an HIV-positive population to determine
the cost/benefit ratio of lower cost strategies that will ultimately be necessary
to provide universal access to cervical cancer screening in low-resource
PMID: 21620403 [PubMed - as supplied by publisher]
8. BMC Public Health. 2011 May 26;11:396.
Patterns and determinants of breastfeeding and complementary feeding practices in
urban informal settlements, Nairobi Kenya.
Kimani-Murage EW, Madise NJ, Fotso JC, Kyobutungi C, Mutua MK, Gitau TM, Yatich
African Population and Health Research Center (APHRC), Nairobi, Kenya.
[email protected]
ABSTRACT:BACKGROUND: The World Health Organisation (WHO) recommends exclusive
breastfeeding during the first six months of life for optimal growth, development
and health. Breastfeeding should continue up to two years or more and
nutritionally adequate, safe, and appropriately-fed complementary foods should be
introduced at the age of six months to meet the evolving needs of the growing
infant. Little evidence exists on breastfeeding and infant feeding practices in
urban slums in sub-Saharan Africa. Our aim was to assess breastfeeding and infant
feeding practices in Nairobi slums with reference to WHO recommendations.
METHODS: Data from a longitudinal study conducted in two Nairobi slums are used.
The study used information on the first year of life of 4299 children born
between September 2006 and January 2010. All women who gave birth during this
period were interviewed on breastfeeding and complementary feeding practices at
recruitment and this information was updated twice, at four-monthly intervals.
Cox proportional hazard analysis was used to determine factors associated with
cessation of breastfeeding in infancy and early introduction of complementary
RESULTS: There was universal breastfeeding with almost all children (99%) having
ever been breastfed. However, more than a third (37%) were not breastfed in the
first hour following delivery, and 40% were given something to drink other than
the mothers' breast milk within 3 days after delivery. About 85% of infants were
still breastfeeding by the end of the 11th month. Exclusive breastfeeding for the
first six months was rare as only about 2% of infants were exclusively breastfed
for six months. Factors associated with sub-optimal infant breastfeeding and
feeding practices in these settings include child's sex; perceived size at birth;
mother's marital status, ethnicity; education level; family planning (pregnancy
desirability); health seeking behaviour (place of delivery) and; neighbourhood
(slum of residence).
CONCLUSIONS: The study indicates poor adherence to WHO recommendations for
breastfeeding and infant feeding practices. Interventions and further research
should pay attention to factors such as cultural practices, access to and
utilization of health care facilities, child feeding education, and family
PMCID: PMC3118248
PMID: 21615957 [PubMed - in process]
9. J Asian Afr Stud. 2011;46(1):19-37.
Localizing HIV/AIDS discourse in a rural Kenyan community.
Banda F, Oketch O.
University of the Western Cape, South Africa.
This paper examines the effectiveness of multimodal texts used in HIV/AIDS
campaigns in rural western Kenya using multimodal discourse analysis (Kress and
Van Leeuwen, 2006; Martin and Rose, 2004). Twenty HIV/AIDS documents (posters,
billboards and brochures) are analysed together with interview data (20
unstructured one-on-one interviews and six focus groups) from the target group to
explore the effectiveness of the multimodal texts in engaging the target rural
audience in meaningful interaction towards behavioural change. It is concluded
that in some cases the HIV/AIDS messages are misinterpreted or lost as the
multimodal texts used are unfamiliar and contradictory to the everyday life
experiences of the rural folk. The paper suggests localization of HIV/AIDS
discourse through use of local modes of communication and resources.
PMID: 21574281 [PubMed - indexed for MEDLINE]
10. Afr Health Sci. 2011 Mar;11(1):58-64.
Perceptions of risk and barriers to cervical cancer screening at Moi Teaching and
Referral Hospital (MTRH), Eldoret, Kenya.
Were E, Nyaberi Z, Buziba N.
Department of Reproductive Health, Moi University, Eldoret, Kenya.
[email protected]
BACKGROUND: Affordable screening cervical cancer methods using visual inspection
with acetic acid (VIA) and with Lugol's iodine (VILI) are being developed.
Scaling up of screening services requires an understanding of the user
perceptions about screening.
OBJECTIVES: Determine the perceptions of risk and barriers to previous cervical
cancer screening by women attending MCH-FP clinic of MTRH, Eldoret, Kenya.
METHODS: Cross-sectional questionnaire survey involving a consecutive sample of
219 consenting non-pregnant women about perceptions on cervical cancer risk,
barriers to screening and previous screening.
RESULTS: Of 219 women interviewed, 12.3% of participants had screened before.
Women of over 30 years were more likely to have screened before (p=0.012). While
22.8% felt that they were at risk of the cervical cancer, 65% of all
participants, nevertheless, wished to be screened. Perception of being at risk
was significantly associated with a felt need for screening (p=0.002), an
association that persisted only for women reporting multiple lifetime sex
partners (p=0.005). Fear of abnormal results and lack of finances were the
commonest barriers to screening reported by 22.4% and 11.4% of respondents,
CONCLUSIONS: Previous screening was uncommon. Cheaper screening methods are
needed. Messages about screening should clarify the meaning and consequences of
possible results.
PMCID: PMC3092325
PMID: 21572858 [PubMed - in process]
11. East Afr J Public Health. 2010 Sep;7(3):258-62.
The effect of pre-lacteal feeding on full breastfeeding in Nairobi, Kenya.
Lakati AS, Makokha OA, Binns CW, Kombe Y.
Institute of Tropical Medicine and Infectious Diseases, Jomo Kenyatta University,
Kenya. [email protected]
OBJECTIVE: To assess the effect of pre-lacteal feeding on full breastfeeding in
the first six months of life in selected hospitals, Nairobi Province. Pre-lacteal
feeding has been internationally discouraged because of its negative effect on
the duration of breastfeeding.
METHODS: A prospective cohort design was used with a sample of 692 mother-infant
pairs recruited at birth and followed up until 6 months of age. The sample was
drawn from five major hospitals in Nairobi. Data was analyzed using the SPSS
computer software. Descriptive analysis was used on all variables. Chi-test was
used for univariate analysis. Logistic regression analysis was used to determine
the effect of pre-lacteal feeding on full breastfeeding.
RESULTS: Slightly more than half (58.8%) of the mothers were formally employed
and their mean age was 28.3 +/- 4.9 years. The mean income was KES 26,360 +/34,696. The mean birth weight of the infants was 3.24 +/- 0.43 kg and 53.3% were
males. The prevalence of pre-lacteal feeding was 26.8% (95% CI 23.5%-30.1%). The
most common pre-lacteal feeds used at all hospitals were infant formula and
glucose solution. There were significant (P < 0.05) differences across the five
study hospitals in this practice. In one hospital nearly all (93%) infants
received a pre-lacteal feed. The use of pre-lacteal feeding was significant
predictor for early cessation of full breastfeeding at 6, 10, 14 and 19 weeks.
CONCLUSIONS: The practice of giving pre-lacteal feeds is a key determinant of
early cessation of full breastfeeding. Some hospitals do not appear to be
adhering to international recommendations on infant feeding. Polices to promote
exclusive and full breastfeeding are necessary to enable infants to attain
optimal health and lead to achievement of the Millennium Development Goals in our
PMID: 21516965 [PubMed - indexed for MEDLINE]
12. Stud Fam Plann. 2011 Mar;42(1):29-40.
Multiple transitions and HIV risk among orphaned Kenyan schoolgirls.
Mojola SA.
Department of Sociology, University of Colorado, Boulder, 219 Ketchum Hall, 327
UCB, Boulder, CO 80309, USA. [email protected]
Why are orphaned girls at particular risk of acquiring HIV infection? Using a
transition-to-adulthood framework, this study employs qualitative data from
Nyanza Province, Kenya, to explore pathways to HIV risk among orphaned and
nonorphaned high-school girls. It shows how simultaneous processes such as
leaving their parental home, negotiating financial access, and relationship
transitions interact to produce disproportionate risk for orphaned girls. The
role of financial provision and parental love in modifying girls' trajectories to
risk are also explored. A testable theoretical model is proposed based on the
qualitative findings, and policy implications are suggested.
PMID: 21500699 [PubMed - indexed for MEDLINE]
13. Afr J Reprod Health. 2010 Sep;14(3):165-9.
Responsiveness to HIV education and VCT services among Kenyan rural women: a
community-based survey.
Karau PB, Winnie MS, Geoffrey M, Mwenda M.
Department of Human Anatomy, the University of Nairobi. [email protected]
Uptake of VCT and other HIV prevention strategies among rural African women is
affected by various socio-cultural and economic factors which need elucidation.
Our aim was to establish the responsiveness to HIV education among rural women
attending three dispensaries in Kenya. This study was designed to assess gender
and psycho-social factors that influence HIV dynamics in rural Kenya. This was a
cross-sectional questionnaire based study of 1347 women, conducted in October
2009. Socio-economic status as well as knowledge on methods of HIV transmission
was assessed. Testing status, knowledge on existing VCT services and willingness
to share HIV information with their children was assessed. Majority of the women
have heard about VCT services, but significantly few of them have been tested.
Those with secondary school education and above are more knowledgeable on methods
of HIV transmission, while those with inadequate education are more likely to
cite shaking hands, sharing utensils, mosquito bites and hugging as means of
transmission (p = 0.001). 90% of educated women are willing to share HIV
information with their children, compared to 40% of uneducated women. Marital
status is seen to positively influence testing status, but has no significant
effect on dissemination of information to children. We conclude that despite the
aggressive HIV education and proliferation of VCT services in Kenya, women are
not heeding the call to get tested. Education has a positive impact on
dissemination of HIV information. Focus needs to shift into increasing
acceptability of testing by women in rural Kenya.
PMID: 21495609 [PubMed - indexed for MEDLINE]
14. Bull World Health Organ. 2011 Apr 1;89(4):258-66. Epub 2011 Feb 1.
Low use of contraception among poor women in Africa: an equity issue.
Creanga AA, Gillespie D, Karklins S, Tsui AO.
Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg
School of Public Health, 615 N Wolfe Street, Baltimore, MD 21205, United States
of America. [email protected]
OBJECTIVE: To examine the use of contraception in 13 countries in sub-Saharan
Africa; to assess changes in met need for contraception associated with
wealth-related inequity; and to describe the relationship between the use of
long-term versus short-term contraceptive methods and a woman's fertility
intentions and household wealth.
METHODS: The analysis was conducted with Demographic and Health Survey data from
13 sub-Saharan African countries. Wealth-related inequities in the use of
contraception were calculated using household wealth and concentration indices.
Logistic regression models were fitted for the likelihood of using a long-term
contraceptive method, with adjustments for: wealth index quintile, fertility
intentions (to space births versus to stop childbearing), residence
(urban/rural), education, number of living children, marital status and survey
FINDINGS: The use of contraception has increased substantially between surveys in
Ethiopia, Madagascar, Mozambique, Namibia and Zambia but has declined slightly in
Kenya, Senegal and Uganda. Wealth-related inequalities in the met need for
contraception have decreased in most countries and especially so in Mozambique,
but they have increased in Kenya, Uganda and Zambia with regard to spacing
births, and in Malawi, Senegal, Uganda, the United Republic of Tanzania and
Zambia with regard to limiting childbearing. After adjustment for fertility
intention, women in the richest wealth quintile were more likely than those in
the poorest quintile to practice long-term contraception.
CONCLUSION: Family planning programmes in sub-Saharan Africa show varying success
in reaching all social segments, but inequities persist in all countries.
PMCID: PMC3066524
PMID: 21479090 [PubMed - in process]
15. Contraception. 2011 May;83(5):486-90. Epub 2010 Oct 29.
Provider determinants of emergency contraceptive counseling and provision in
Kenya and Ethiopia.
Judge S, Peterman A, Keesbury J.
Department of Public Policy, The University of North Carolina at Chapel Hill,
Campus Box 3435, Chapel Hill, NC 27599-3435, USA. [email protected]
BACKGROUND: In a majority of sub-Saharan African countries, counseling and
provision of emergency contraception (EC) lag behind that of developed countries.
As policymakers expand EC programs in the region, an understanding of provider
knowledge and bias regarding EC is critical.
STUDY DESIGN: Using data from recent surveys of Kenyan and Ethiopian health care
providers in bivariate analyses and multivariate logit regression models, this
study assesses whether variation in provider knowledge and bias regarding EC is
associated with variation in EC counseling and provision.
RESULTS: Survey results indicate that 54% and 31% of Kenyan and Ethiopian
providers, respectively, display strong EC counseling behavior, while 61% and
55%, respectively, report having ever provided EC. Bivariate and multivariate
results show that, in Kenya, increased EC counseling and provision behaviors are
associated with higher levels of provider knowledge.
CONCLUSION: Training on EC can increase provider knowledge and lower bias,
leading to improved access for clients.
PMID: 21477694 [PubMed - in process]
16. Stud Fam Plann. 2010 Jun;41(2):109-16.
Reaching the urban poor with family planning services.
Ezeh AC, Kodzi I, Emina J.
African Population and Health Research Center, Shelter Afrique Center, Longonot
Road, Second Floor, Post Office Box 10787-00100, Nairobi, Kenya. [email protected]
PMID: 21466110 [PubMed - indexed for MEDLINE]
17. J Womens Health (Larchmt). 2011 May;20(5):733-8. Epub 2011 Mar 25.
Determinants of condom use among female sex workers in kenya: a case-crossover
Gallo MF, Warner L, Bell AJ, Bukusi EA, Sharma A, Njoroge B, Ngugi E, Jamieson
DJ, Eschenbach DA.
1 Division of Reproductive Health, Centers for Disease Control and Prevention ,
Atlanta, Georgia .
Abstract Background: We evaluated predictors of consistent condom use among
female sex workers (FSWs), a core group for controlling the spread of HIV.
Methods: In an analysis of data collected in 2004-2005 from 140 Kenyan FSWs who
completed questionnaires administered during a baseline study visit and three
bimonthly follow-up visits, we used a case-crossover design to identify
predictors of consistent condom use during all coital acts in the preceding 2
weeks, overall and by partner type. Results: Participants (n=140) completed the
baseline visit and 390 bimonthly follow-up visits. Alcohol use during sex was
negatively associated with consistent condom use with helping partners (defined
as regular sex partners to whom the woman could go for help or support if needed)
(adjusted odds ratio [AOR], 2.6, 95% confidence interval [CI] 1.0-6.5) but not
associated with condom use with other partners. Coital frequency was associated
with condom use with other partners only. Women who reported 1-5 (AOR 11.0, 95%
CI 4.3-28.3) or 6-9 recent coital acts (AOR 3.8, 95% CI 1.7-8.8) with other
partners were more likely to report consistent condom use with those partners
than were women who reported ≥10 acts. Having a recent partner delay payment was
inversely associated with consistent condom use with helping, other, or all
partners. Conclusions: Correlates of consistent condom use differed by partner
type. By using a case-crossover design, we were able to identify potentially
modifiable factors associated with consistent condom use by FSWs who used condoms
consistently with a given partner type during some periods but not others.
PMID: 21438697 [PubMed - in process]
18. J Midwifery Womens Health. 2011 Mar-Apr;56(2):161-6.
The experience of being a traditional midwife: living and working in relationship
with women.
Dietsch E, Mulimbalimba-Masururu L.
School of Nursing, and a Midwifery and Indigenous Health , Centre for Inland
Health at Charles Sturt University, Australia. [email protected]
INTRODUCTION: The purpose of this project was to learn from traditional midwives
about their experience of practicing in an area of rural Kenya.
METHODS: This qualitative, service-based research project used a simple
exploratory and descriptive design. Data were collected through in-depth
interviews and fieldwork notes taken during and immediately after the interviews
with 84 traditional midwives. Data were thematically analyzed and themes
identified through paired-author consensus. Exemplars using the participants'
translated words were used for analysis and presentation purposes.
RESULTS: In being humble, patient, and kind, the traditional midwives used their
relationships with women to create an enabling, calm, and physiologically sound
intrapartum environment.
DISCUSSION: Traditional midwives provide a valuable service to women in this area
of Kenya at a time when their role is being increasingly devalued by global
health agencies. We recommend a redirection of global policy from one that
esteems only professional caregivers to one that recognizes the potential value
of traditional midwives and supports them through sustainable, evidence-based
education and resourcing.
PMID: 21429082 [PubMed - indexed for MEDLINE]
19. BMC Public Health. 2011 Mar 23;11:177.
Evaluation of the impact of the voucher and accreditation approach on improving
reproductive health behaviors and status in Kenya.
Warren C, Abuya T, Obare F, Sunday J, Njue R, Askew I, Bellows B.
Population Council, General Accident Insurance House, Ralph Bunche Road, PO Box
17643, Nairobi 00500, Kenya.
BACKGROUND: Alternatives to the traditional 'supply-side' approach to financing
service delivery are being explored. These strategies are termed results-based
finance, demand-side health financing or output-based aid which includes a range
of interventions that channel government or donor subsidies to the user rather
than the provider. Initial pilot assessments of reproductive health voucher
programs suggest that, they can increase access and use, reducing inequities and
enhancing program efficiency and service quality. However, there is a paucity of
evidence describing how the programs function in different settings, for various
reproductive health services. Population Council, funded by the Bill and Melinda
Gates Foundation, intends to generate evidence around the 'voucher and
accreditation' approaches to improving the reproductive health of low income
women in Kenya. METHODS/DESIGN: A quasi-experimental study will investigate the
impact of the voucher approach on improving reproductive health behaviors,
reproductive health status and reducing inequities at the population level; and
assessing the effect of vouchers on increasing access to, and quality of, and
reducing inequities in the use of selected reproductive health services. The
study comprises of four populations: facilities, providers, women of reproductive
health age using facilities and women and men who have been pregnant and/or used
family planning within the previous 12 months. The study will be carried out in
samples of health facilities - public, private and faith-based in: three
districts; Kisumu, Kiambu, Kitui and two informal settlements in Nairobi which
are accredited to provide maternal and newborn health and family planning
services to women holding vouchers for the services; and compared with a matched
sample of non-accredited facilities. Health facility assessments (HFA) will be
conducted at two stages to track temporal changes in quality of care and
utilization. Facility inventories, structured observations, and client exit
interviews will be used to collect comparable data across facilities. Health
providers will also be interviewed and observed providing care. A population
survey of about 3000 respondents will also be carried out in areas where vouchers
are distributed and similar locations where vouchers are not distributed.
PMCID: PMC3074544
PMID: 21429207 [PubMed - in process]
20. Eur J Contracept Reprod Health Care. 2011 Jun;16(3):173-82. Epub 2011 Mar 17.
Contraceptive needs of female sex workers in Kenya - a cross-sectional study.
Sutherland EG, Alaii J, Tsui S, Luchters S, Okal J, King'ola N, Temmerman M,
Janowitz B.
MEASURE Evaluation Project, Carolina Population Center, University of North
Carolina at Chapel Hill, Chapel Hill, NC, USA. [email protected]
BACKGROUND AND OBJECTIVES: Female sex workers (FSWs) are thought to be at
heightened risk for unintended pregnancy, although sexual and reproductive health
interventions reaching these populations are typically focused on the increased
risk of sexually transmitted infections. The objective of this study of FSWs in
Kenya is to document patterns of contraceptive use and unmet need for
METHODS: This research surveys a large sample of female sex workers (N = 597) and
also uses qualitative data from focus group discussions.
RESULTS: The reported level of modern contraceptives in our setting was very
high. However, like in other studies, we found a great reliance on male condoms,
coupled with inconsistent use at last sex, which resulted in a higher potential
for unmet need for contraception than the elevated levels of modern
contraceptives might suggest. Dual method use was also frequently encountered in
this population and the benefits of this practice were clearly outlined by focus
group participants.
CONCLUSION: These findings suggest that the promotion of dual methods among this
population could help meet the broader reproductive health needs of FSWs.
Furthermore, this research underscores the necessity of considering consistency
of condom use when estimating the unmet or undermet contraceptive needs of this
PMID: 21413869 [PubMed - in process]
21. East Afr J Public Health. 2010 Mar;7(1):92-6.
Fear of being tested for HIV at ANC clinics associated with low uptake of
intermittent preventive treatment (IPT) of malaria among pregnant women attending
Bondo District Hospital, Western Kenya.
Sande JH, Kaseje D, Nyapada L, Owino VO.
Great Lakes University of Kisumu, P.O. Box 2224-40100, Kisumu, Kenya.
OBJECTIVE: Malaria is a major cause of morbidity and mortality in tropical and
subtropical regions, affecting mostly the impoverished sections of the
population. Pregnant women living in malaria-endemic areas are at higher risk of
malaria infection with higher density of parasitaemia than non-pregnant women.
The aim of this study was to assess factors affecting the uptake of IPT among
women attending antenatal clinics at Bondo District Hospital, Western Kenya.
METHODS: This study was a hospital-based cross-sectional survey among pregnant
women attending clinics. Malaria is endemic in Bondo district. Both women from
Bondo town (urban) and greater Bondo District (rural) who had been pregnant for
at least 35 weeks or had delivered not more than 6 weeks prior to the survey),
and had ANC cards were included in the study. The main outcomes were ANC
attendance, IPT doses received and client and provider factors.
RESULTS: Results showed that women's knowledge on ANC and IPT was high. The
uptake of IPT was low among pregnant women with those from urban areas more
likely to make more ANC visits and to get more IPT doses than women from the
rural areas. ANC attendance was hampered by the fear of being tested for HIV at
the clinic. Perceived side effects associated with IPT-SP hindered IPT uptake and
were linked to HIV-related symptoms. Negative attitude among health workers
towards pregnant women also adversely impacted IPT uptake. Women suggested that
IPT drugs be distributed through community health workers instead of the health
facility for improved uptake.
CONCLUSIONS: Retraining of health workers on the administration of IPT,
harmonization of health messages, and assessment of alternative community-based
IPT distribution channels ought to be urgently considered. More evidence on the
influence of HIV pandemic on perceptions and attitudes toward and uptake of other
health interventions is urgently needed.
PMID: 21413582 [PubMed - indexed for MEDLINE]
22. Health Care Women Int. 2011 Apr;32(4):278-99.
Where will this illness take me? Reactions to HIV diagnosis from women living
with HIV in Kenya.
Kako PM, Stevens PE, Karani AK.
College of Nursing, University of Wisconsin-Milwaukee, 53201, USA. [email protected]
The purpose of our study was to develop an in-depth understanding of the
reactions of 40 urban and rural HIV-infected Kenyan women to HIV diagnosis. We
employed narrative inquiry principles to guide this qualitative cross-sectional
study. We conducted individual in-depth interviews using open-ended questions in
April and May 2006. In this article we focus on women's reactions to HIV
diagnosis, under which four subthemes emerged: immediate intense emotions;
keeping HIV status secret; acceptance of HIV diagnosis; and finding liberation in
disclosure. We offer important implications for health care professionals serving
women in sub-Saharan Africa from the findings of our study.
PMID: 21409662 [PubMed - indexed for MEDLINE]
23. Med Anthropol. 2011 Mar;30(2):183-201.
Dynamics of care, situations of choice: HIV tests in times of ART.
Hardon A, Kageha E, Kinsman J, Kyaddondo D, Wanyenze R, Obermeyer CM.
Amsterdam Institute for Social Science Research (AISSR), University of Amsterdam,
Amsterdam, The Netherlands. [email protected]
In the 1990s, African AIDS programs followed a voluntary counseling and testing
(VCT) approach to HIV testing. In the wake of large scale AIDS treatment
programs, policymakers opted for routine provider-initiated testing (PITC) with
less emphasis on counseling, which led to concerns about the ethical conduct of
HIV testing. Inspired by Annemarie Mol, we ask if PITC can be framed as good
care, rather than as medical domination that threatens to violate patients'
rights. Based on fieldwork in Ugandan and Kenyan health facilities, we reveal
that situations of choice vary: patients in hospital wards, are given time to
decide whether they want a test, while in antenatal care testing women find it
very hard to opt-out. We argue that the medical context inherent in PITC provides
an attractive moral space for people to undergo HIV tests.
PMID: 21400352 [PubMed - indexed for MEDLINE]
24. Contraception. 2011 Apr;83(4):346-51.
Is repeat use of emergency contraception common among pharmacy clients? Evidence
from Kenya.
Keesbury J, Morgan G, Owino B.
Population Council, P/Bag RW 319x, 10101 Lusaka, Zambia.
BACKGROUND: As emergency contraception (EC) becomes more widely available in
African pharmacies, public concern in many countries has emerged over perceived
"repeat use" of the method. This study examines issues of repeat use in Kenya, a
country where women almost exclusively obtain EC from pharmacies.
STUDY DESIGN: Interviews were conducted with all clients who purchased EC from
private pharmacies located in five urban areas across Kenya. Over a period of 5
days, a total of 182 male and female EC purchasers were interviewed. χ(2) tests
were used to determine the statistical significance of differences between repeat
and nonrepeat users.
RESULTS: The majority (58%) of respondents had purchased EC at least twice in the
past 1 month. All women interviewed reported purchasing EC a mean of 3.8 times in
the 6 months prior to the survey. Those who purchased EC at least twice in the
past 1 month were significantly more likely to hold misperceptions about EC's
efficacy or side effects. Two thirds of all users reported having a chance to ask
questions at the pharmacy, although one quarter felt that they did not receive
adequate information.
CONCLUSIONS: This study indicates that many of the women surveyed, particularly
those who had sex on an infrequent basis, chose to use EC as a regular family
planning method. Among these women, it also indicates the need for better
information on EC's efficacy and side effects. Such information-sharing could
take place within pharmacies, although interventions must not undermine the core
benefits of pharmacy access: convenience and confidentiality.
PMID: 21397093 [PubMed - in process]
25. AIDS Care. 2011 May;23(5):612-8.
Sexual and physical violence against female sex workers in Kenya: a qualitative
Okal J, Chersich MF, Tsui S, Sutherland E, Temmerman M, Luchters S.
International Centre for Reproductive Health (ICRH), Mombasa, Kenya.
[email protected]
Few studies in Africa provide detailed descriptions of the vulnerabilities of
female sex workers (FSW) to sexual and physical violence, and how this impacts on
their HIV risk. This qualitative study documents FSW's experiences of violence in
Mombasa and Naivasha, Kenya. Eighty-one FSW who obtained clients from the
streets, transportation depots, taverns, discos and residential areas were
recruited through local sex workers trained as peer counsellors to participate in
eight focus-group discussions. Analysis showed the pervasiveness of sexual and
physical violence among FSW, commonly triggered by negotiation around condoms and
payment. Pressing financial needs of FSW, gender-power differentials, illegality
of trading in sex and cultural subscriptions to men's entitlement for sex sans
money underscore much of this violence. Sex workers with more experience had
developed skills to avoid threats of violence by identifying potentially violent
clients, finding safer working areas and minimising conflict with the police.
Addressing violence and concomitant HIV risks and vulnerabilities faced by FSW
should be included in Kenya's national HIV/AIDS strategic plan. This study
indicates the need for multilevel interventions, including legal reforms so that
laws governing sex work promote the health and human rights of sex workers in
PMID: 21390890 [PubMed - in process]
26. PLoS Med. 2011 Mar;8(3):e1000422. Epub 2011 Mar 1.
A randomized controlled trial comparing the effects of counseling and alarm
device on HAART adherence and virologic outcomes.
Chung MH, Richardson BA, Tapia K, Benki-Nugent S, Kiarie JN, Simoni JM, Overbaugh
J, Attwa M, John-Stewart GC.
Department of Global Health, University of Washington, Seattle, Washington, USA.
[email protected]
BACKGROUND: Behavioral interventions that promote adherence to antiretroviral
medications may decrease HIV treatment failure. Antiretroviral treatment programs
in sub-Saharan Africa confront increasing financial constraints to provide
comprehensive HIV care, which include adherence interventions. This study
compared the impact of counseling and use of an alarm device on adherence and
biological outcomes in a resource-limited setting.
METHODS AND FINDINGS: A randomized controlled, factorial designed trial was
conducted in Nairobi, Kenya. Antiretroviral-naïve individuals initiating free
highly active antiretroviral therapy (HAART) in the form of fixed-dose
combination pills (d4T, 3TC, and nevirapine) were randomized to one of four arms:
counseling (three counseling sessions around HAART initiation), alarm (pocket
electronic pill reminder carried for 6 months), counseling plus alarm, and
neither counseling nor alarm. Participants were followed for 18 months after
HAART initiation. Primary study endpoints included plasma HIV-1 RNA and CD4 count
every 6 months, mortality, and adherence measured by monthly pill count. Between
May 2006 and September 2008, 400 individuals were enrolled, 362 initiated HAART,
and 310 completed follow-up. Participants who received counseling were 29% less
likely to have monthly adherence <80% (hazard ratio [HR] = 0.71; 95% confidence
interval [CI] 0.49-1.01; p = 0.055) and 59% less likely to experience viral
failure (HIV-1 RNA ≥5,000 copies/ml) (HR 0.41; 95% CI 0.21-0.81; p = 0.01)
compared to those who received no counseling. There was no significant impact of
using an alarm on poor adherence (HR 0.93; 95% CI 0.65-1.32; p = 0.7) or viral
failure (HR 0.99; 95% CI 0.53-1.84; p = 1.0) compared to those who did not use an
alarm. Neither counseling nor alarm was significantly associated with mortality
or rate of immune reconstitution.
CONCLUSIONS: Intensive early adherence counseling at HAART initiation resulted in
sustained, significant impact on adherence and virologic treatment failure during
18-month follow-up, while use of an alarm device had no effect. As antiretroviral
treatment clinics expand to meet an increasing demand for HIV care in sub-Saharan
Africa, adherence counseling should be implemented to decrease the development of
treatment failure and spread of resistant HIV.
PMCID: PMC3046986
PMID: 21390262 [PubMed - indexed for MEDLINE]
27. BMC Public Health. 2011 Mar 8;11:151.
Is 'Opt-Out HIV Testing' a real option among pregnant women in rural districts in
Ujiji OA, Rubenson B, Ilako F, Marrone G, Wamalwa D, Wangalwa G, Ekström AM.
Karolinska Institutet, Department of Public Health Sciences, Division of Global
Health, Stockholm, Sweden. [email protected]
BACKGROUND: An 'opt-out' policy of routine HIV counseling and testing (HCT) is
being implemented across sub-Saharan Africa to expand prevention of
mother-to-child transmission (PMTCT). Although the underlying assumption is that
pregnant women in rural Africa are able to voluntarily consent to HIV testing,
little is known about the reality and whether 'opt-out' HCT leads to higher
completion rates of PMTCT. Factors associated with consent to HIV testing under
the 'opt-out' approach were investigated through a large cross-sectional study in
METHODS: Observations during HIV pre-test information sessions were followed by a
cross-sectional survey of 900 pregnant women in three public district hospitals
carrying out PMTCT in the Busia district. Women on their first antenatal care
(ANC) visit during the current pregnancy were interviewed after giving blood for
HIV testing but before learning their test results. Descriptive statistics and
multivariate regression analysis were performed.
RESULTS: Of the 900 women participating, 97% tested for HIV. Lack of testing kits
was the only reason for women not being tested, i.e. nobody declined HIV testing.
Despite the fact that 96% had more than four earlier pregnancies and 37% had been
tested for HIV at ANC previously, only 17% of the women surveyed knew that
testing was optional. Only 20% of those surveyed felt they could make an informed
decision to decline HIV testing. Making an informed decision to decline HIV
testing was associated with knowing that testing was optional (OR = 5.44, 95%CI
3.44-8.59), not having a stable relationship with the child's father (OR = 1.76,
95%CI 1.02-3.03), and not having discussed HIV testing with a partner before the
ANC visit (OR = 2.64 95%CI 1.79-3.86).
CONCLUSION: High coverage of HIV testing appears to be achieved at the cost of
pregnant women not understanding that testing is optional. Good quality HIV
pre-test information is central to ensure that pregnant women understand and
accept the reasons for testing and will thus come back to collect their test
results, an important prerequisite for completing PMTCT for those who test
PMCID: PMC3061915
PMID: 21385423 [PubMed - indexed for MEDLINE]
28. Med Sci Monit. 2011 Feb 25;17(3):CR154-8.
Confirmation of HIV-like sequences in respiratory tract bacteria of Cambodian and
Kenyan HIV-positive pediatric patients.
Zajac V, Matelova L, Liskova A, Mego M, Holec V, Adamcikova Z, Stevurkova V,
Shahum A, Krcmery V.
Department of Cancer Genetics, Cancer Research Institute, Bratislava, Slovakia.
BACKGROUND: Bacteria and yeasts isolated from respiratory tracts of 39 Cambodian
and 28 Kenyan HIV-positive children were tested for the presence of HIV-1
MATERIAL/METHODS: Bacteria and yeasts from the respiratory tract (nose,
pharyngeal swabs) were isolated from 39 Cambodian and 28 Kenyan HIV-positive
children. Bacterial chromosomal DNA was prepared by standard protocol and by
Qiagen kit. The PCR specific for HIV sequences was carried out using
HIV-1-specific primers.The analysis was performed by colony and dot-blot
hybridization using HIV-1-specific primers which represent gag, pol and env genes
of the virus. The sequencing of some PCR products was performed on the ABI 373
DNA Sequencer.
RESULTS: The majority of microbes were characterized as Staphylococcus aureus,
Klebsiella pneumoniae, and resp. Candida albicans. In some cases E. coli,
Streptococcus pyogenes, Proteus mirabilis and Candida tropicalis were identified.
Bacteria of 16 Cambodian (41%) and 8 Kenyan (31%) children were found to be
positive in colony and dot-blot DNA hybridization. By the sequencing of PCR
products synthesized on the template of patients' bacterial DNA using primers
68;69 for env HIV-1 gene, homology of greater than 90% with HIV-1 isolate HXB2
(HIVHXB2CG) was revealed.
CONCLUSIONS: Bacteria and yeasts from the respiratory tract of 41% of Cambodian
and 31% of Kenyan HIV-positive children bear HIV-like sequences. The role of
bacteria in the HIV disease process is discussed.
PMID: 21358602 [PubMed - indexed for MEDLINE]
29. AIDS Care. 2011 Mar;23(3):315-21.
Sexual risk-reduction strategies among HIV-infected men receiving ART in Kibera,
Ragnarsson A, Thorson A, Dover P, Carter J, Ilako F, Indalo D, Ekstrom AM.
Department of Public Health Sciences, Division of Global Health, IHCAR,
Karolinska Institutet, Stockholm, Sweden. [email protected]
This paper explores motivational factors and barriers to sexual behaviour change
among men receiving antiretroviral treatment (ART). Twenty in-depth interviews
were undertaken with male patients enrolled at the African Medical and Research
Foundation clinic in Africa's largest urban informal settlement, Kibera in
Nairobi, Kenya. All participants experienced prolonged and severe illness prior
to the initiation of ART. Fear of symptom relapse was the main trigger for sexual
behaviour change. Partner reduction was reported as a first option for behaviour
change since this decision could be made by the individual. Condom use was
perceived as more difficult as it had to be negotiated with female partners.
Cultural norms regarding expectations for reproduction and marriage were not
supportive of sexual risk-reduction strategies. Thus, local sociocultural
contexts of HIV-infected people must be incorporated into the contextual
adaptation and design of ART programmes and services as they have an over-riding
influence on sexual behaviour and programme effectiveness. Also, HIV-prevention
interventions need to address both personal, micro- and macro-level factors of
behaviour to encourage individuals to take on sexual risk-reduction strategies.
In order to achieve the anticipated preventive effect of ART, these issues are
important for the donor community and policy-makers, who are the major providers
of ART programme support within weak health systems in sub-Saharan Africa.
PMID: 21347894 [PubMed - indexed for MEDLINE]
30. AIDS Care. 2011 Mar;23(3):274-80.
Effectiveness of a PMTCT programme in rural Western Kenya.
Azcoaga-Lorenzo A, Ferreyra C, Alvarez A, Palma PP, Velilla E, del Amo J.
Medecins Sans Frontieres-Spain/Operational Centre Barcelona-Athens, Barcelona,
Spain. [email protected]
We assess the coverage of a Prevention of Mother-to-child Transmission (PMTCT)
programme in Busia (Kenya) from 1 January 2006 to 31 December 2008 and estimate
the risk of transmission of HIV. We also estimate the odds of HIV transmission
according to pharmacological intervention received. Programme coverage was
estimated as the proportion of mother-baby pairs receiving any antiretroviral
(ARV) regimen among all HIV-positive women attending services. We estimated the
mother-to-child transmission (MTCT) rate and their 95% confidence interval
(95%CI) using the direct method of calculation (intermediate estimate). A
case-control study was established among all children born to HIV-positive
mothers with information on outcome (HIV status of the babies) and exposure (data
on pharmacological intervention). Cases were all HIV-positive children and
controls were the HIV-negative ones. Exposure was defined as: (1) complete
protocol: ARV prescribed according World Health Organisation recommendations; (2)
partial protocol: does not meet criteria for complete protocol; and (3) no
intervention: ARVs were not prescribed to both mother and child. Babies were
tested using DNA Polymerase Chain Reaction at six weeks of life and six weeks
after breastfeeding ceased. In the study period, 22,566 women accepted testing,
1668 were HIV positive (7.4%; 95%CI 7.05-7.73); 1036 (62%) registered in the
programme and 632 were lost. Programme coverage was 40.4% (95%CI 37.9-42.7). Out
of the 767 newborns, 28 (3.6%) died, 148 (19.3%) defaulted, 282 (36.7%) were
administratively censored and 309 (40.2%) babies completed the follow-up as per
protocol; 49 were HIV positive and MTCT risk was 15.86% (95%CI 11.6-20.1). The
odds of having an HIV-positive baby was 4.6 times higher among pairs receiving a
partial protocol compared to those receiving a complete protocol and 43 times
higher among those receiving no intervention. Our data show a good level of
enrolment but low global coverage rate. It demonstrates that ARV regimens can be
implemented in low resource rural settings with marked decreases of MTCT.
Increasing the coverage of PMTCT programmes remains the main challenge.
PMID: 21347890 [PubMed - indexed for MEDLINE]
31. J Acquir Immune Defic Syndr. 2011 Feb 21. [Epub ahead of print]
The Shang Ring Device for Adult Male Circumcision: A Proof of Concept Study in
Barone MA, Ndede F, Li PS, Masson P, Awori Q, Okech J, Cherutich P, Muraguri N,
Perchal P, Lee R, Kim HH, Goldstein M.
1EngenderHealth, New York, USA; 2Formerly with EngenderHealth, Kenya; 3Center for
Male Reproductive Medicine and Microsurgery, Department of Urology, Weill Cornell
Medical College, New York, USA; 4Center for Biomedical Research, The Population
Council, New York, USA; 5 EngenderHealth, Kenya; 6Homa Bay District Hospital,
Homa Bay, Kenya; 7National AIDS/STD Control Programme, Nairobi, Kenya; 8 Formerly
with the Center for Male Reproductive Medicine and Microsurgery, Department of
Urology, Weill Cornell Medical College, New York, USA.
OBJECTIVE:: To assess safety, preliminary efficacy and acceptability of the Shang
Ring, a novel disposable device, for adult male circumcision in Kenya. METHODS::
Forty HIV-negative men were recruited in Homa Bay, Kenya. Circumcisions were
performed by a trained physician or nurse working with one assistant. Follow-up
was conducted at 2, 7, 9, 14, 21, 28, 35 and 42 days after circumcision. Rings
were removed on day 7. Pain was assessed using a visual analog scale (0=no
pain,10=worst possible). Men were interviewed at enrollment and on days 7 and 42.
RESULTS:: All 40 procedures were completed successfully. Mean procedure and
device removal times were 4.8 (sd±2.0) and 3.9 (sd±2.6) minutes, respectively.
There were six mild adverse events, including three penile skin injuries, two
cases of edema, and one infection; all resolved with conservative management. In
addition, there were three partial ring detachments between days 2-7. None
required treatment or early ring removal. Erections with the ring were well
tolerated, with a mean pain score of 3.5 (sd±2.3). By day 2, 80% of men were back
to work. At 42 days all participants were very satisfied with their circumcision
and would recommend the procedure to others. CONCLUSION:: Our results demonstrate
that the Shang Ring is safe for further study in Africa. Acceptability of the
Shang Ring among participants was excellent. With short procedure times, less
surgical skill required, and the ease with which it can be used by
non-physicians, the Shang Ring could facilitate rapid roll-out of male
circumcision in sub-Saharan Africa.
PMID: 21346586 [PubMed - as supplied by publisher]
32. J Nurs Scholarsh. 2011 Mar;43(1):54-63. doi: 10.1111/j.1547-5069.2010.01382.x.
Epub 2011 Jan 14.
An integrative review of comprehensive sex education for adolescent girls in
Agbemenu K, Schlenk EA.
University of Pittsburgh, School of Nursing, Pittsburgh, PA, USA. [email protected]
PURPOSE: The purposes of this article are to identify and review comprehensive
sex education programs (CSEPs) available to adolescent females in Kenya, East
Africa, to discuss barriers to implementing CSEPs in Kenya, and to highlight the
role of nurses in improving and institutionalizing available CSEPs in Kenya.
DESIGN: Integrative review.
METHODS: A systematic search of six databases and other Internet sources was
conducted to identify CSEPs currently available to adolescent girls in Kenya.
Five CSEPs were identified. The CSEPs were evaluated using established criteria.
FINDINGS: All of the CSEPs were well designed and almost all were implemented
with fidelity. Four of the five CSEPs met all of the criteria for well-designed
CSEPs with only one showing lack of sustainability. Tuko Pamoja (We Are One)
shows promise for wider implementation.
CONCLUSIONS: CSEPs are a valid intervention leading to the reduction of teenage
pregnancy, HIV/AIDS, and sexually transmitted infections. The reach of the
identified CSEPs varies, and sustainability is challenging due to lack of
government and community support, lack of funding, and unsustainable teaching
CLINICAL RELEVANCE: Nurses can serve as liaisons between adolescents, the
community, and the Kenyan government in promoting CSEPs. Nurses should be more
readily utilized in educating community members and policy makers about the need
for CSEPs in all Kenyan high schools. Nursing students can also be utilized in
their community health role to teach curricula of CSEPs. Nurses should advocate
for all adolescents to access reproductive health services and for all healthcare
providers to provide comprehensive reproductive health care to them.
PMID: 21342425 [PubMed - in process]
33. BMC Pediatr. 2011 Feb 18;11:18.
Evaluation of a single round polymerase chain reaction assay using dried blood
spots for diagnosis of HIV-1 infection in infants in an African setting.
Chohan BH, Emery S, Wamalwa D, John-Stewart G, Majiwa M, Ng'ayo M, Froggett S,
Overbaugh J.
Department of Medical Microbiology, University of Nairobi-College of Health
Sciences, off Ngong Road, Nairobi, Box 19767-00202, Kenya.
BACKGROUND: The aim of this study was to develop an economical 'in-house' single
round polymerase chain reaction (PCR) assay using filter paper-dried blood spots
(FP-DBS) for early infant HIV-1 diagnosis and to evaluate its performance in an
African setting.
METHODS: An 'in-house' single round PCR assay that targets conserved regions in
the HIV-1 polymerase (pol) gene was validated for use with FP-DBS; first we
validated this assay using FP-DBS spiked with cell standards of known HIV-1 copy
numbers. Next, we validated the assay by testing the archived FP-DBS (N=115) from
infants of known HIV-1 infection status. Subsequently this 'in-house' HIV-1 pol
PCR FP-DBS assay was then established in Nairobi, Kenya for further evaluation on
freshly collected FP-DBS (N=186) from infants, and compared with findings from a
reference laboratory using the Roche Amplicor® HIV-1 DNA Test, version 1.5 assay.
RESULTS: The HIV-1 pol PCR FP-DBS assay could detect one HIV-1 proviral copy in
38.7% of tests, 2 copies in 46.9% of tests, 5 copies in 72.5% of tests and 10
copies in 98.1% of tests performed with spiked samples. Using the archived FP-DBS
samples from infants of known infection status, this assay was 92.8% sensitive
and 98.3% specific for HIV-1 infant diagnosis. Using 186 FP-DBS collected from
infants recently defined as HIV-1 positive using the commercially available Roche
Amplicor v1.5 assay, 178 FP-DBS tested positive by this 'in-house' single-round
HIV-1 pol PCR FP-DBS PCR assay. Upon subsequent retesting, the 8 infant FP-DBS
samples that were discordant were confirmed as HIV-1 negative by both assays
using a second blood sample.
CONCLUSIONS: HIV-1 was detected with high sensitivity and specificity using both
archived and more recently collected samples. This suggests that this 'in-house'
HIV-1 pol FP-DBS PCR assay can provide an alternative cost-effective, reliable
and rapid method for early detection of HIV-1 infection in infants.
PMCID: PMC3050718
PMID: 21332984 [PubMed - indexed for MEDLINE]
34. Sex Transm Dis. 2011 Feb 10. [Epub ahead of print]
Sex Worker Studies: The Science, Semantics, and Politics of Targeting Our HIV
Prevention Response.
Price JE, Cates W Jr.
From the *Family Health International, Nairobi, Kenya; and †Research Triangle
Park, NC.
PMID: 21317687 [PubMed - as supplied by publisher]
35. Trop Med Int Health. 2011 May;16(5):579-84. doi:
10.1111/j.1365-3156.2011.02740.x. Epub 2011 Feb 9.
Demographic characteristics and opportunistic diseases associated with attrition
during preparation for antiretroviral therapy in primary health centres in
Kibera, Kenya.
Tayler-Smith K, Zachariah R, Manzi M, Kizito W, Vandenbulcke A, Dunkley S, von
Rege D, Reid T, Arnould L, Suleh A, Harries AD.
Medecins sans Frontieres, Medical Department (Operational Research), Brussels
Operational Center, Luxembourg, Luxembourg.
Using routine data from HIV-positive adult patients eligible for antiretroviral
therapy (ART), we report on routinely collected demographic characteristics and
opportunistic diseases associated with pre-ART attrition (deaths and loss to
follow-up). Among 2471 ART eligible patients, enrolled between January 2005 and
November 2008, 446 (18%) were lost to attrition pre-ART. Adjusted risk factors
significantly associated with pre-ART attrition included age <35 years (Odds
Ratio, OR 1.4, 95% Confidence Interval, CI 1.1-1.8), severe malnutrition (OR 1.5,
95% CI 1.1-2.0), active pulmonary tuberculosis (OR 1.6, 95% CI 1.1-2.4), severe
bacterial infections including severe bacterial pneumonia (OR 1.9, 95% CI
1.2-2.8) and prolonged unexplained fever (>1 month), (OR 2.6, 95% CI 1.3-5.2).
This study highlights a number of clinical markers associated with pre-ART
attrition that could serve as 'pointers' or screening tools to identify patients
who merit fast-tracking onto ART and/or closer clinical attention and follow-up.
PMID: 21306485 [PubMed - indexed for MEDLINE]
36. AIDS. 2011 Mar 27;25(6):825-34.
Mobile phone technologies improve adherence to antiretroviral treatment in a
resource-limited setting: a randomized controlled trial of text message
Pop-Eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, de Walque
D, MacKeen L, Haberer J, Kimaiyo S, Sidle J, Ngare D, Bangsberg DR.
School of International and Public Affairs, Columbia University, New York, New
York, USA.
Comment in
AIDS. 2011 May 15;25(8):1137; reply 1138-9.
OBJECTIVE: There is limited evidence on whether growing mobile phone availability
in sub-Saharan Africa can be used to promote high adherence to antiretroviral
therapy (ART). This study tested the efficacy of short message service (SMS)
reminders on adherence to ART among patients attending a rural clinic in Kenya.
DESIGN: A randomized controlled trial of four SMS reminder interventions with 48
weeks of follow-up.
METHODS: Four hundred and thirty-one adult patients who had initiated ART within
3 months were enrolled and randomly assigned to a control group or one of the
four intervention groups. Participants in the intervention groups received SMS
reminders that were either short or long and sent at a daily or weekly frequency.
Adherence was measured using the medication event monitoring system. The primary
outcome was whether adherence exceeded 90% during each 12-week period of analysis
and the 48-week study period. The secondary outcome was whether there were
treatment interruptions lasting at least 48 h.
RESULTS: In intention-to-treat analysis, 53% of participants receiving weekly SMS
reminders achieved adherence of at least 90% during the 48 weeks of the study,
compared with 40% of participants in the control group (P = 0.03). Participants
in groups receiving weekly reminders were also significantly less likely to
experience treatment interruptions exceeding 48 h during the 48-week follow-up
period than participants in the control group (81 vs. 90%, P = 0.03).
CONCLUSION: These results suggest that SMS reminders may be an important tool to
achieve optimal treatment response in resource-limited settings.
PMID: 21252632 [PubMed - indexed for MEDLINE]
37. J S Afr Vet Assoc. 2010 Jun;81(2):82-6.
Questionnaire survey on urban and peri-urban livestock farming practices and
disease control in Kisumu municipality, Kenya.
Kagira JM, Kanyari PW.
Trypanosomiasis Research Centre, Kenya Agricultural Research Institute, PO Box
362, Kikuyu, Kenya. [email protected]
To characterise the urban livestock keeping practices and constraints in Kisumu
municipality, Kenya, a questionnaire survey was carried out. Thirty-four contact
farmers were interviewed on general farm characteristics and production
constraints. The farming activities were categorised as either livestock only
(41%), or mixed crops and livestock (59%). The surveyed farmers kept mainly
cattle (100%), chickens (82%) and goats (74%). Most (94%) of the farmers had kept
livestock for prolonged periods mainly for income generation (97%) and domestic
consumption (59%). These data show that livestock keeping was popular and could
be harnessed to increase food security, although the farmers kept mainly
low-producing indigenous cattle (98%) which were grazed on unutilised land. The
main production constraints mentioned by farmers included diseases (100%), poor
fertility (68%) and lack of feed (56%). The diseases varied with species of
ruminants and included lumpy skin disease (71%), diarrhoea (65%) and helminthosis
(62%). The source of advice on management and treatment of the livestock was
almost equally from private and government veterinary personnel. To improve
livestock productivity, it is recommended that key stakeholders address the
constraints mentioned in this study and in particular that the occurrence of
diseases should be investigated with a view to developing sustainable control
PMID: 21247012 [PubMed - indexed for MEDLINE]
38. BMC Public Health. 2011 Jan 18;11:43.
Assessing access barriers to tuberculosis care with the tool to Estimate
Patients' Costs: pilot results from two districts in Kenya.
Mauch V, Woods N, Kirubi B, Kipruto H, Sitienei J, Klinkenberg E.
KNCV Tuberculosis Foundation, Den Haag, The Netherlands. [email protected]
BACKGROUND: The poor face geographical, socio-cultural and health system barriers
in accessing tuberculosis care. These may cause delays to timely diagnosis and
treatment resulting in more advanced disease and continued transmission of TB. By
addressing barriers and reasons for delay, costs incurred by TB patients can be
effectively reduced. A Tool to Estimate Patients' Costs has been developed. It
can assist TB control programs in assessing such barriers. This study presents
the Tool and results of its pilot in Kenya.
METHODS: The Tool was adapted to the local setting, translated into Kiswahili and
pretested. Nine public health facilities in two districts in Eastern Province
were purposively sampled. Responses gathered from TB patients above 15 years of
age with at least one month of treatment completed and signed informed consent
were double entered and analyzed. Follow-up interviews with key informants on
district and national level were conducted to assess the impact of the pilot and
to explore potential interventions.
RESULTS: A total of 208 patients were interviewed in September 2008. TB patients
in both districts have a substantial burden of direct (out of pocket; USD 55.8)
and indirect (opportunity; USD 294.2) costs due to TB. Inability to work is a
major cause of increased poverty. Results confirm a 'medical poverty trap'
situation in the two districts: expenditures increased while incomes decreased.
Subsequently, TB treatment services were decentralized to fifteen more facilities
and other health programs were approached for nutritional support of TB patients
and sputum sample transport. On the national level, a TB and poverty
sub-committee was convened to develop a comprehensive pro-poor approach.
CONCLUSIONS: The Tool to Estimate Patients' Costs proved to be a valuable
instrument to assess the costs incurred by TB patients, socioeconomic situations,
health-seeking behavior patterns, concurrent illnesses such as HIV, and social
and gender-related impacts. The Tool helps to identify and tackle bottlenecks in
access to TB care, especially for the poor. Reducing delays in diagnosis,
decentralization of services, fully integrated TB/HIV care and expansion of
health insurance coverage would alleviate patients' economic constraints due to
PMCID: PMC3033813
PMID: 21244656 [PubMed - indexed for MEDLINE]
39. Lancet Infect Dis. 2011 Mar;11(3):171-80. Epub 2011 Jan 13.
Triple antiretroviral compared with zidovudine and single-dose nevirapine
prophylaxis during pregnancy and breastfeeding for prevention of mother-to-child
transmission of HIV-1 (Kesho Bora study): a randomised controlled trial.
Kesho Bora Study Group, de Vincenzi I.
Collaborators: Farley T, Gaillard P, Meda N, Rollins N, Luchters S, Nduati R,
Newell ML, Read J, Dioulasso B, Faso B, Meda N, Fao P, Ky-Zerbo O, Gouem C, Somda
P, Hien H, Ouedraogo PE, Kania D, Sanou A, Kossiwavi IA, Sanogo B, Ouedraogo M,
Siribie I, Valéa D, Ouedraogo S, Somé R, Rouet F, Rollins N, McFetridge L, Naidu
K, Luchters S, Reyners M, Irungu E, Katingima C, Mwaura M, Ouattara G, Mandaliya
K, Wambua S, Thiongo M, Nduati R, Kose J, Njagi E, Mwaura P, Newell ML, Mepham S,
Viljoen J, Bland R, Mthethwa L, Bazin B, Rekacewicz C, Taylor A, Flowers N,
Thigpen M, Fowler MG, Jamieson D, Read J, Bork K, Cames C, Cournil A, Claeys P,
Temmerman M, Luchters S, Van de Perre P, Becquart P, Foulongne V, Segondy M, de
Vincenzi I, Gaillard P, Farley T, Habib N, Landoulsi S.
Erratum in
Lancet Infect Dis. 2011 Mar;11(3):159. Read, Jennifer S [corrected to Read,
Comment in
Lancet Infect Dis. 2011 Mar;11(3):154-5.
BACKGROUND: Breastfeeding is essential for child health and development in
low-resource settings but carries a significant risk of transmission of HIV-1,
especially in late stages of maternal disease. We aimed to assess the efficacy
and safety of triple antiretroviral compared with zidovudine and single-dose
nevirapine prophylaxis in pregnant women infected with HIV.
METHODS: Pregnant women with WHO stage 1, 2, or 3 HIV-1 infection who had CD4
cell counts of 200-500 cells per μL were enrolled at five study sites in Burkina
Faso, Kenya, and South Africa to start study treatment at 28-36 weeks' gestation.
Women were randomly assigned (1:1) by a computer generated random sequence to
either triple antiretroviral prophylaxis (a combination of 300 mg zidovudine, 150
mg lamivudine, and 400 mg lopinavir plus 100 mg ritonavir twice daily until
cessation of breastfeeding to a maximum of 6·5 months post partum) or zidovudine
and single-dose nevirapine (300 mg zidovudine twice daily until delivery and a
dose of 600 mg zidovudine plus 200 mg nevirapine at the onset of labour and,
after a protocol amendment in December, 2006, 1 week post-partum zidovudine 300
mg twice daily and lamivudine 150 mg twice daily). All infants received a 0·6 mL
dose of nevirapine at birth and, from December, 2006, 4 mg/kg twice daily of
zidovudine for 1 week after birth. Patients and investigators were not masked to
treatment. The primary endpoints were HIV-free infant survival at 6 weeks and 12
months; HIV-free survival at 12 months in infants who were ever breastfed;
AIDS-free survival in mothers at 18 months; and serious adverse events in mothers
and babies. Analysis was by intention to treat. This trial is registered with
Current Controlled Trials, ISRCTN71468401.
FINDINGS: From June, 2005, to August, 2008, 882 women were enrolled, 824 of whom
were randomised and gave birth to 805 singleton or first, liveborn infants. The
cumulative rate of HIV transmission at 6 weeks was 3·3% (95% CI 1·9-5·6%) in the
triple antiretroviral group compared with 5·0% (3·3-7·7%) in the zidovudine and
single-dose nevirapine group, and at 12 months was 5·4% (3·6-8·1%) in the triple
antiretroviral group compared with 9·5% (7·0-12·9%) in the zidovudine and
single-dose nevirapine group (p=0·029). The cumulative rate of HIV transmission
or death at 12 months was 10·2% (95% CI 7·6-13·6%) in the triple antiretroviral
group compared with 16·0% (12·7-20·0%) in the zidovudine and single-dose
nevirapine group (p=0·017). In infants whose mothers declared they intended to
breastfeed, the cumulative rate of HIV transmission at 12 months was 5·6% (95% CI
3·4-8·9%) in the triple antiretroviral group compared with 10·7% (7·6-14·8%) in
the zidovudine and single-dose nevirapine group (p=0·02). AIDS-free survival in
mothers at 18 months will be reported in a different publication. The incidence
of laboratory and clinical serious adverse events in both mothers and their
babies was similar between groups.
INTERPRETATION: Triple antiretroviral prophylaxis during pregnancy and
breastfeeding is safe and reduces the risk of HIV transmission to infants.
Revised WHO guidelines now recommend antiretroviral prophylaxis (either to the
mother or to the baby) during breastfeeding if the mother is not already
receiving antiretroviral treatment for her own health.
FUNDING: Agence nationale de recherches sur le sida et les hépatites virales,
Department for International Development, European and Developing Countries
Clinical Trials Partnership, Thrasher Research Fund, Belgian Directorate General
for International Cooperation, Centers for Disease Control and Prevention, Eunice
Kennedy Shriver National Institute of Child Health and Human Development, and
UNDP/UNFPA/World Bank/WHO Special Programme of Research, Development and Research
Training in Human Reproduction.
PMID: 21237718 [PubMed - indexed for MEDLINE]
40. Acta Paediatr. 2011 May;100(5):758-61. doi: 10.1111/j.1651-2227.2011.02152.x.
Epub 2011 Feb 14.
Menarcheal age among urban Kenyan primary school girls.
Ogeng'o DN, Obimbo MM, Ogeng'o JA.
Catholic University of Eastern Africa, Nairobi, Kenya.
AIM: To determine the mean menarcheal age among urban primary school girls in
SUBJECTS AND METHODS: A structured questionnaire was administered to 820 primary
grade 6-8 girls aged between 12 and 17 years in five public primary schools,
Langata division of Nairobi West district, Nairobi Kenya. The girls came from low
and middle socioeconomic status residences. Declared menarcheal age by recall to
the nearest month was recorded. Data were analysed using SPSS version 15.0 for
windows. The results are presented using tables and bar charts.
RESULTS: The mean menarcheal age was 12.5 ± 2.8 years with peak at 12-14 years. A
substantial number of girls (10.8%) attained menarche before the age of 11 years,
with 2% of them attaining it before 10 years. None attained menarche before nine
or after 16 years. Of those who attained early menarche, 64.3% were from middle
while only 35.7% came from low socioeconomic status residence, respectively.
CONCLUSION: Mean menarcheal age of 12.5 years is lower than previously reported
with over 10% of the girls attaining menarche by 11 years. Early commencement of
reproductive health education and follow-up for complications of early menarche
is recommended.
PMID: 21226762 [PubMed - in process]
41. Sex Transm Dis. 2011 Jan 6. [Epub ahead of print]
Association Between Participant Self-Report and Biological Outcomes Used to
Measure Sexual Risk Behavior in Human Immunodeficiency Virus-1-Seropositive
Female Sex Workers in Mombasa, Kenya.
McClelland RS, Richardson BA, Wanje GH, Graham SM, Mutunga E, Peshu N, Kiarie JN,
Kurth AE, Jaoko W.
From the Departments of *Medicine, †Epidemiology, and ‡Global Health, University
of Washington, Seattle, WA; §Institute of Tropical and Infectious Diseases,
University of Nairobi, Nairobi, Kenya; ¶Department of Biostatistics, University
of Washington, Seattle, WA; ∥Department of Medical Microbiology, University of
Nairobi, Nairobi, Kenya; **Kenya Medical Research Institute, Kilifi, Kenya;
††Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi,
Kenya; and ‡‡College of Nursing, New York University, New York, NY.
BACKGROUND:: Few studies have examined the association between self-reported
sexual risk behaviors and biologic outcomes in human immunodeficiency virus
(HIV)-1-seropositive African adults. METHODS:: We conducted a prospective cohort
study in 898 HIV-1-seropositive women who reported engaging in transactional sex
in Mombasa, Kenya. Primary outcome measures included detection of sperm in
genital secretions, pregnancy, and sexually transmitted infections. Because 3
outcomes were evaluated, data are presented with odds ratios [OR] and 96.7%
confidence intervals [CI] to reflect that we would reject a null hypothesis if a
P-value was ≤0.033 (Simes' methodology). RESULTS:: During 2404 person-years of
follow-up, self-reported unprotected intercourse was associated with
significantly higher likelihood of detecting sperm in genital secretions (OR:
2.32, 96.7% CI: 1.93, 2.81), and pregnancy (OR: 2.78, 96.7% CI: 1.57, 4.92), but
not with detection of sexually transmitted infections (OR: 1.20, 96.7% CI: 0.98,
1.48). At visits where women reported being sexually active, having >1 sex
partner in the past week was associated with lower likelihood of detecting sperm
in genital secretions (OR: 0.74, 96.7% CI: 0.56, 0.98). This association became
nonsignificant after adjustment for reported condom use (adjusted OR: 0.81, 96.7%
CI: 0.60, 1.08). CONCLUSIONS:: Combining behavioral and biologic outcomes, which
provide complementary information, is advantageous for understanding sexual risk
behavior in populations at risk for transmitting HIV-1. The paradoxical
relationship between higher numbers of sex partners and less frequent
identification of sperm in genital secretions highlights the potential importance
of context-specific behavior, such as condom use dependent on partner type, when
evaluating sexual risk behavior.
PMID: 21217420 [PubMed - as supplied by publisher]
42. BMC Pregnancy Childbirth. 2011 Jan 10;11:1.
Utilization of maternal health services among young women in Kenya: insights from
the Kenya Demographic and Health Survey, 2003.
Ochako R, Fotso JC, Ikamari L, Khasakhala A.
African Population and Health Research Center (APHRC), P,O, Box 10787, 00100
Nairobi, Kenya. [email protected]
BACKGROUND: Use of maternal health services is an effective means for reducing
the risk of maternal morbidity and mortality, especially in places where the
general health status of women is poor. This study was guided by the following
objectives: 1) To determine the relationship between timing of first antenatal
care (ANC) visit and type of delivery assistance 2) To establish the determinants
of timing of first ANC visit and type delivery assistance.
METHODS: Data used were drawn from the 2003 Kenya Demographic and Health Survey,
with a focus on young women aged 15-24. The dependent variables were: Timing of
first ANC visit coded as "None"; "Late" and "Early", and type of delivery
assistance coded as "None"; "Traditional Birth Attendant (TBA)" and "Skilled
professional". Control variables included: education, household wealth,
urban-rural residence, ethnicity, parity, age at birth of the last child and
marital status. Multivariate ordered logistic regression model was used.
RESULTS: The study results show that place of residence, household wealth,
education, ethnicity, parity, marital status and age at birth of the last child
had strong influences on timing of first ANC visit and the type of delivery
assistance received. The major finding is an association between early timing of
the first ANC visit and use of skilled professionals at delivery.
CONCLUSION: This study confirms that timing of first antenatal care is indeed an
important entry point for delivery care as young women who initiated antenatal
care early were more likely to use skilled professional assistance at delivery
than their counterparts who initiated ANC late. The results indicate that a large
percentage of young pregnant women do not seek ANC during their first trimester
as is recommended by the WHO, which may affect the type of assistance they
receive during delivery. It is important that programs aimed at improving
maternal health include targeting young women, especially those from rural areas,
with low levels of education, higher parity and from poor households, given their
high risk during pregnancy. The finding that a considerably high proportion of
young women use TBAs as opposed to use of skilled professionals is baffling and
calls for further research.
PMCID: PMC3022772
PMID: 21214960 [PubMed - indexed for MEDLINE]
43. AIDS Care. 2010;22 Suppl 2:1652-61.
Community relations and child-led microfinance: a case study of caregiving
children in Kenya.
Skovdal M.
Institute of Social Psychology, London School of Economics and Political Science,
London, UK. [email protected]
Rampant levels of AIDS and poverty have made many children in sub-Saharan Africa
the primary caregivers of their ageing or ailing guardians. This paper reports on
a social action fund initiative that brought caregiving children together to
set-up and run income generating activities as a group with the aim of
strengthening their coping capabilities. To further our understanding of
child-led microfinance activities, this paper explores how intra-community
relations can both facilitate and undermine child-led activities, and how these
activities in turn can further strengthen some intra-community relations.
Twenty-one children (aged 12-17) and six guardians participated in this study.
Data included draw-and-write compositions (n=21), essays (n=16), workshop notes
and proposals (n=8) and in-depth interviews (n=16). A thematic analysis revealed
that the children actively drew on the expertise and involvement of some
guardians in the project as well as on each other, developing supportive peer
relations that helped strengthen their coping capabilities. However, the
children's disenfranchised position in the community meant that some adults took
advantage of the child-led activities for their own personal gain. Some children
also showed a lack of commitment to collective work, undermining the morale of
their more active peers. Nevertheless, both guardians and the children themselves
began to look at caregiving children differently as their engagement in the
project began to earn them respect from the community - changing guardian/child
relations. The paper concludes that microfinance interventions targeting children
and young people must consider children's relationships with each other and with
adults as key determinants of Project success.
PMID: 21161771 [PubMed - indexed for MEDLINE]
44. BMC Pregnancy Childbirth. 2010 Dec 14;10:82.
Communities, birth attendants and health facilities: a continuum of emergency
maternal and newborn care (the Global Network's EmONC trial).
Pasha O, Goldenberg RL, McClure EM, Saleem S, Goudar SS, Althabe F, Patel A,
Esamai F, Garces A, Chomba E, Mazariegos M, Kodkany B, Belizan JM, Derman RJ,
Hibberd PL, Carlo WA, Liechty EA, Hambidge KM, Buekens P, Wallace D,
Howard-Grabman L, Stalls S, Koso-Thomas M, Jobe AH, Wright LL.
Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
[email protected]
BACKGROUND: Maternal and newborn mortality rates remain unacceptably high,
especially where the majority of births occur in home settings or in facilities
with inadequate resources. The introduction of emergency obstetric and newborn
care services has been proposed by several organizations in order to improve
pregnancy outcomes. However, the effectiveness of emergency obstetric and
neonatal care services has never been proven. Also unproven is the effectiveness
of community mobilization and community birth attendant training to improve
pregnancy outcomes.
METHODS/DESIGN: We have developed a cluster-randomized controlled trial to
evaluate the impact of a comprehensive intervention of community mobilization,
birth attendant training and improvement of quality of care in health facilities
on perinatal mortality in low and middle-income countries where the majority of
births take place in homes or first level care facilities. This trial will take
place in 106 clusters (300-500 deliveries per year each) across 7 sites of the
Global Network for Women's and Children's Health Research in Argentina,
Guatemala, India, Kenya, Pakistan and Zambia. The trial intervention has three
key elements, community mobilization, home-based life saving skills for
communities and birth attendants, and training of providers at obstetric
facilities to improve quality of care. The primary outcome of the trial is
perinatal mortality. Secondary outcomes include rates of stillbirth, 7-day
neonatal mortality, maternal death or severe morbidity (including obstetric
fistula, eclampsia and obstetrical sepsis) and 28-day neonatal mortality.
DISCUSSION: In this trial, we are evaluating a combination of interventions
including community mobilization and facility training in an attempt to improve
pregnancy outcomes. If successful, the results of this trial will provide
important information for policy makers and clinicians as they attempt to improve
delivery services for pregnant women and newborns in low-income countries.
TRIAL REGISTRATION: ClinicalTrials.gov NCT01073488.
PMCID: PMC3017016
PMID: 21156060 [PubMed - indexed for MEDLINE]
45. PLoS One. 2010 Nov 30;5(11):e14149.
Adjusting mortality for loss to follow-up: analysis of five ART programmes in
sub-Saharan Africa.
Brinkhof MW, Spycher BD, Yiannoutsos C, Weigel R, Wood R, Messou E, Boulle A,
Egger M, Sterne JA; International epidemiological Database to Evaluate AIDS
Division of International and Environmental Health, Institute of Social and
Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.
BACKGROUND: Evaluation of antiretroviral treatment (ART) programmes in
sub-Saharan Africa is difficult because many patients are lost to follow-up.
Outcomes in these patients are generally unknown but studies tracing patients
have shown mortality to be high. We adjusted programme-level mortality in the
first year of antiretroviral treatment (ART) for excess mortality in patients
lost to follow-up.
METHODS AND FINDINGS: Treatment-naïve patients starting combination ART in five
programmes in Côte d'Ivoire, Kenya, Malawi and South Africa were eligible.
Patients whose last visit was at least nine months before the closure of the
database were considered lost to follow-up. We filled missing survival times in
these patients by multiple imputation, using estimates of mortality from studies
that traced patients lost to follow-up. Data were analyzed using Weibull models,
adjusting for age, sex, ART regimen, CD4 cell count, clinical stage and treatment
programme. A total of 15,915 HIV-infected patients (median CD4 cell count 110
cells/µL, median age 35 years, 68% female) were included; 1,001 (6.3%) were known
to have died and 1,285 (14.3%) were lost to follow-up in the first year of ART.
Crude estimates of mortality at one year ranged from 5.7% (95% CI 4.9-6.5%) to
10.9% (9.6-12.4%) across the five programmes. Estimated mortality hazard ratios
comparing patients lost to follow-up with those remaining in care ranged from 6
to 23. Adjusted estimates based on these hazard ratios ranged from 10.2%
(8.9-11.6%) to 16.9% (15.0-19.1%), with relative increases in mortality ranging
from 27% to 73% across programmes.
CONCLUSIONS: Naïve survival analysis ignoring excess mortality in patients lost
to follow-up may greatly underestimate overall mortality, and bias ART programme
evaluations. Adjusted mortality estimates can be obtained based on excess
mortality rates in patients lost to follow-up.
PMCID: PMC2994756
PMID: 21152392 [PubMed - indexed for MEDLINE]
46. AIDS. 2011 Jan 14;25(2):247-55.
Exploring the condom gap: is supply or demand the limiting factor - condom access
and use in an urban and a rural setting in Kilifi district, Kenya.
Papo JK, Bauni EK, Sanders EJ, Brocklehurst P, Jaffe HW.
Department of Public Health, University of Oxford, Headington, UK.
[email protected]
OBJECTIVE: to explore the extent of the condom gap, investigating the relative
roles of supply-side and demand-side factors in determining condom use.
DESIGN: GPS mapping of condom outlets, and population-based survey.
METHODS: an urban and a rural site were selected within the Epidemiological and
Demographic Surveillance Site in Kilifi district, Kenya. Potential condom outlets
(n = 281) were mapped and surveyed, and questionnaires on condom access and use
(n = 630) were administered to a random sample of men and women aged 15-49.
Multivariate logistic regression was performed to assess the relative roles of
supply-side and demand-side barriers on condom use.
RESULTS: the median straight-line distance to free condoms was 18-fold higher in
the rural versus urban site. Among sexually active respondents, 42% had ever used
a condom, and 23% had used a condom over the past 12 months, with lower levels
among rural versus urban respondents (P < 0.05). The mean number of condoms used
was 2.2/person per year among all sexually active individuals (condom users and
nonusers), amounting to 8.2% protected sex acts/person per year. The adjusted
odds of condom use (past 12 months) were 8.1 times greater among individuals
experiencing no supply-side or demand-side barriers, compared with individuals
experiencing both types of barriers. Despite low levels of usage and the presence
of supply-side and demand-side barriers, reported unmet need for condoms was low.
CONCLUSIONS: there is an urgent need for renewed condom promotion efforts aimed
at building demand, in addition to improving physical access, in resource-limited
settings with generalized HIV epidemics in sub-Saharan Africa.
PMID: 21150559 [PubMed - indexed for MEDLINE]
47. J Infect Dis. 2011 Jan 1;203(1):117-21.
Herpes simplex virus type 2 suppressive therapy with acyclovir or valacyclovir
does not select for specific HIV-1 resistance in HIV-1/HSV-2 dually infected
Baeten JM, Lingappa J, Beck I, Frenkel LM, Pepper G, Celum C, Wald A, Fife KH,
Were E, Mugo N, Sanchez J, Essex M, Makhema J, Kiarie J, Farquhar C, Corey L.
Department of Global Health, University of Washington, Seattle, Washington, USA.
Recent in vitro studies suggest that acyclovir may directly inhibit HIV-1
replication and can select for a specific HIV-1 reverse transcriptase mutation
(V75I) with concomitant loss of an anti-HIV-1 effect. We tested for HIV-1
genotypic resistance at reverse transcriptase codon 75 in plasma from 168
HIV-1-infected persons from Botswana, Kenya, Peru, and the United States taking
daily acyclovir or valacyclovir for between 8 weeks and 24 months. No V75I cases
were detected (95% confidence interval, 0%-2.2%). These prospective in vivo
studies suggest that standard-dose acyclovir or valacyclovir does not select for
HIV-1 resistance.
PMCID: PMC3024584 [Available on 2012/1/1]
PMID: 21148504 [PubMed - indexed for MEDLINE]
48. Soc Sci Med. 2011 Jan;72(2):149-56. Epub 2010 Nov 23.
Fishing in dangerous waters: Ecology, gender and economy in HIV risk.
Mojola SA.
Department of Sociology, University of Colorado-Boulder, 219 Ketchum Hall, 327
UCB, Boulder, CO 80309-0327, USA. [email protected]
This paper focuses on a neglected factor in literature on the HIV epidemic in
sub-Saharan Africa: the role of the eco-social environment in shaping HIV risk. I
argue that the changing ecological environment of Lake Victoria, Africa's largest
freshwater lake, mapping onto a gendered economy, shaped fisherfolk's sexual
relationships and sexual mixing patterns in ways that were consequential for
their HIV risk. Specifically, I show how disrupted lake and fish ecology had an
impact on fishermen's sexual, domestic and economic partnerships, as well as how
it contributed to the "sex for fish" economy in Nyanza Province, Kenya. I also
show the consequences of fishermen's relative wealth on transactional
relationships with school girls and women in lakeside communities. The paper is
based on ethnographic fieldwork over a seven month period among the Luo ethnic
group, which has the highest HIV rates in Kenya. The study included 74 individual
and focus group interviews in communities around Lake Victoria, as well as 20 key
informant interviews. Additionally, literature reviews on fishing and sexual
economies as well as on ecological research in Lake Victoria are employed.
Exploring linkages between these literatures and fieldwork findings forms the
basis of this paper. I argue that solely focusing on individual level HIV
prevention strategies is limited without taking into account the eco-social
context of individual sexual decision making.
PMID: 21146910 [PubMed - indexed for MEDLINE]
49. Int J STD AIDS. 2010 Oct;21(10):708-13.
Prevalence and risk factors for sexually transmitted infections in a high-risk
occupational group: the case of fishermen along Lake Victoria in Kisumu, Kenya.
Kwena ZA, Bukusi EA, Ng'ayo MO, Buffardi AL, Nguti R, Richardson B, Sang NM,
Holmes K.
RCTP, Center for Microbiology Research, Kenya Medical Research Institute,
Nairobi, Kenya. [email protected]
The aim of this study was to assess prevalence and risk factors for sexually
transmitted infections (STIs) among fishermen along Lake Victoria, Kenya. This
cross-sectional study surveyed 250 fishermen from beaches in Kisumu District
using proportional-to-size sampling based on the number of registered boats per
beach. Participants provided demographic and sexual behaviour information, blood
for HIV-1 herpes simplex virus type 2 (HSV-2) and syphilis serological tests
urine for transcription-mediated amplification assays for Neisseria gonorrhoeae
and Chlamydia trachomatis and penile and scrotal swabs for human papillomavirus
(HPV) DNA assay. Consistent condom use with the three most recent sexual partners
was reported by 30%; 38% reported concurrent sexual partnerships and 65% reported
ever having transactional sex. HIV seroprevalence was 26%, HSV-2 seroprevalence
by Western blot assay was 58% and 9.5% were rapid plasma reagin and Treponema
pallidum particle agglutination assay positive. Genital HPV DNA of any type was
detected in 57.2% with 74% of these having two or more HPV types. C. trachomatis
and N. gonorrhoeae were detected in 3.2% and 1.2% respectively. Risk factors for
syphilis seropositivity included working on multiple beaches during the past year
(adjusted odds ratio [AOR] 3.81; 95% confidence interval [CI] 1.29-11.28). HPV
infection was associated with owning a radio which is a marker for higher
socioeconomic status (AOR 6.33; 95% CI 2.94-7.14) and reporting transactional sex
with the most recent sexual partner (AOR 3.03; 95% CI 1.23-7.69). In conclusion,
90% of fishermen had evidence of one or more STIs. This exceptionally high-risk
occupational group represents a high priority for preventive interventions.
PMID: 21139150 [PubMed - indexed for MEDLINE]
50. Sex Transm Infect. 2010 Dec;86 Suppl 2:ii84-92.
Flexible epidemiological model for estimates and short-term projections in
generalised HIV/AIDS epidemics.
Hogan DR, Zaslavsky AM, Hammitt JK, Salomon JA.
Center for Health Decision Science, Harvard School of Public Health, 718
Huntington Avenue, Boston, MA 02115, USA. [email protected]
OBJECTIVE: UNAIDS and country analysts use a simple infectious disease model,
embedded in the Estimation and Projection Package (EPP), to generate annual
updates on the global HIV/AIDS epidemic. Our objective was to develop
modifications to the current model that improve fit to recently observed
prevalence trends across countries.
METHODS: Our proposed alternative to the current EPP approach simplifies the
model structure and explicitly models changes in average infection risk over
time, operationalised using penalised B-splines in a Bayesian framework. We also
present an alternative approach to initiating the epidemic that improves
standardisation and efficiency, and add an informative prior distribution for
changes in infection risk beyond the last data point that enhances the
plausibility of short-term extrapolations.
RESULTS: The spline-based model produces better fits than the current model to
observed prevalence trends in settings that have recently experienced levelling
or rising prevalence following a steep decline, such as Uganda and urban Rwanda.
The model also predicts a deceleration of the decline in prevalence for countries
with recent experience of steady declines, such as Kenya and Zimbabwe. Estimates
and projections from our alternative model are comparable to those from the
current model where the latter performs well.
CONCLUSIONS: A more flexible epidemiological model that accommodates changing
infection risk over time can provide better estimates and short-term projections
of HIV/AIDS incidence, prevalence and mortality than the current EPP model. The
alternative model specification can be incorporated easily into existing
analytical tools that are used to produce updates on the global HIV/AIDS
PMID: 21106520 [PubMed - indexed for MEDLINE]
51. Sex Transm Infect. 2010 Dec;86 Suppl 2:ii72-ii83.
Trends in HIV prevalence and sexual behaviour among young people aged 15-24 years
in countries most affected by HIV.
International Group on Analysis of Trends in HIV Prevalence and Behaviours in
Young People in Countries most Affected by HIV.
Collaborators: Ghys PD, Gouws E, Lyerla R, Garcia-Calleja JM, Barrerre B, Serrano
D, Velasquez C, Deleveaux C, Gill W, Mmelesi M, Niyongere A, Mboui Bilon E, Longo
Jde D, Massanga M, Guidaoussou D, Konan Diby JP, Kibangou N, Woldu A, Bikoma F,
Duval N, Spring K, Barsigo A, Nkonyana J, Wandonda N, Jonas A, Kawu I, Mutagoma
M, Mosala T, Mndzebele S, Odido H, Agbogan YD, Musinguzi J, Somi G, Gboun M,
Phiri D, Gonese E, Gregson S, Mugurungi O.
Strategic Intelligence and Analysis Division, UNAIDS, 20 Avenue Appia, 1211
Geneva, Switzerland.
Erratum in
Sex Transm Infect. 2011 Feb;87(1):8.
OBJECTIVES: In 2001 the United Nations (UN) Declaration of Commitment was signed
by 189 countries with a goal to reduce HIV prevalence among young people by 25%
by 2010. Progress towards this target is assessed. In addition, changes in
reported sexual behaviour among young people aged 15-24 years are investigated.
METHODS: Thirty countries most affected by HIV were invited to participate in the
study. Trends in HIV prevalence among young antenatal clinic (ANC) attendees were
analysed using data from sites that were consistently included in surveillance
between 2000 and 2008. Regression analysis was used to determine if the UN target
had been reached. Trends in prevalence data from repeat national population-based
surveys were also analysed. Trends in sexual behaviour were analysed using data
from repeat standardised national population-based surveys between 1990 and 2008.
RESULTS: Seven countries showed a statistically significant decline of 25% or
more in HIV prevalence among young ANC attendees by 2008, in rural or urban areas
or in both: Botswana, Côte d'Ivoire, Ethiopia, Kenya, Malawi, Namibia and
Zimbabwe. Three further countries showed a significant decline in HIV prevalence
among young women (Zambia) or men (South Africa, Tanzania) in national surveys.
Seven other countries are on track, whereas four are unlikely to reach the goal
by 2010. Nine countries did not have adequate data to assess prevalence trends.
Indications suggestive of changes towards less risky sexual behaviour were
observed in the majority of countries. In eight countries with significant
declines in HIV prevalence, significant changes were also observed in sexual
behaviour in either men or women for at least two of the three sexual behaviour
CONCLUSIONS: Declines in HIV prevalence among young people were documented in the
majority of countries with adequate data and in most cases were accompanied by
changes in sexual behaviour. Further data, research and more rigorous analysis at
country level are needed to understand the associations between programmatic
efforts, reported behavioural changes and changes in prevalence and incidence of
PMID: 21106519 [PubMed - indexed for MEDLINE]
52. Contraception. 2011 Jan;83(1):88-93. Epub 2010 Oct 6.
The promise of affordable implants: is cost recovery possible in Kenya?
Tumlinson K, Steiner MJ, Rademacher KH, Olawo A, Solomon M, Bratt J.
Department of Epidemiology, School of Public Health, The University of North
Carolina at Chapel Hill, Chapel Hill, NC 27599, USA. [email protected]
BACKGROUND: Contraceptive implants are one of the most effective methods of
family planning but remain underutilized due to their relatively high upfront
cost. The increasing availability of a low-cost implant may reduce financial
barriers and increase uptake of implants. The commodity cost of Sino-implant (II)
is approximately 60% less than two other widely available implants, and a direct
service delivery cost of approximately US$12 makes it one of the most
cost-effective methods available. This study was conducted to assess whether
implant clients in Kenya are paying as much or more than the direct service
delivery cost of Sino-implant (II).
STUDY DESIGN: A study was conducted in 22 facilities throughout Kenya, including
public (n=8), private for-profit (n=6) and private not-for-profit facilities
(n=8). Interviews were conducted with a convenience sample of 293 current and
returning implant clients after at least 6 months of product use.
RESULTS: The median price for implant insertion paid by clients in the public,
private for-profit and private not-for-profit sectors was US$1.30, US$13.30 and
US$20.00, respectively.
CONCLUSION: Patient fees in both private sectors allow for 100% recovery of the
direct cost of providing Sino-implant (II). Currently in Kenya, all sectors can
receive donated commodities free of charge; Sino-implant (II) has the potential
to reduce reliance on donor-supplied implants and thereby improve contraceptive
PMID: 21134509 [PubMed - indexed for MEDLINE]
53. BMC Womens Health. 2010 Dec 1;10:33.
Women, poverty and adverse maternal outcomes in Nairobi, Kenya.
Izugbara CO, Ngilangwa DP.
African Population and Health Research Center, Box 10787-00100 GPO, Nairobi,
Kenya. [email protected]
BACKGROUND: The link between poverty and adverse maternal outcomes has been
studied largely by means of quantitative data. We explore poor urban Kenyan
women's views and lived experiences of the relationship between economic
disadvantage and unpleasant maternal outcomes.
METHOD: Secondary analysis of focus group discussions and in-depth individual
interviews data with women in two slums in Nairobi, Kenya.
RESULTS: Urban poor women in Nairobi associate poverty with adverse maternal
outcomes. However, their accounts and lived experiences of the impact of poverty
on maternal outcomes underscore dynamics other than those typically stressed in
the extant literature. To them, poverty primarily generates adverse maternal
outcomes by exposing women to exceedingly hard and heavy workloads during
pregnancy and the period surrounding it; to intimate partner violence; as well as
to inhospitable and unpleasant treatment by service providers.
CONCLUSIONS: Poverty has wider and more intricate implications for maternal
outcomes than are acknowledged in extant research. To deliver their expected
impact, current efforts to promote better maternal outcomes must be guided by a
more thorough perspective of the link between women's livelihoods and their
health and wellbeing.
PMCID: PMC3014866
PMID: 21122118 [PubMed - indexed for MEDLINE]
54. AIDS Behav. 2011 Feb;15(2):454-68.
Influence of culture on contraceptive utilization among HIV-positive women in
Brazil, Kenya, and South Africa.
Todd CS, Stibich MA, Laher F, Malta MS, Bastos FI, Imbuki K, Shaffer DN, Sinei
SK, Gray GE.
Department of Obstetrics and Gynecology, Columbia University, 622 West 168th
Street, New York, NY 10032, USA. [email protected]
Contraceptive choice and discontinuation are poorly understood among HIV-positive
women, and HIV disease and culture may influence decisions. We assessed factors
influencing contraceptive decision-making among HIV-positive women in three
countries. This qualitative assessment of 108 HIV-positive women (36/site,
selected by age and parity strata) was conducted in Rio de Janeiro, Brazil;
Kericho, Kenya; and Soweto, South Africa. Freelist interviews assessed knowledge
and attitudes towards contraception and were analyzed enumerating frequency and
saliency of mentions. There was intersite consensus around list items but
priority and themes varied. Site-specific factors influencing contraceptive
choice were male partner wishes and fertility desire (Brazil), side-effects
(South Africa), and impact on health and HIV progression (Kenya). Age, parity,
and taking antiretroviral therapy (ART) impacted some themes. Contraceptive use
among HIV-positive women is substantially influenced by culture and other
factors. Counseling efforts should consider individual factors in method
selection and offer method variety to accommodate changing needs.
PMID: 21110078 [PubMed - indexed for MEDLINE]
55. PLoS Negl Trop Dis. 2010 Nov 16;4(11):e889.
Inference of population structure of Leishmania donovani strains isolated from
different Ethiopian visceral leishmaniasis endemic areas.
Gelanew T, Kuhls K, Hurissa Z, Weldegebreal T, Hailu W, Kassahun A, Abebe T,
Hailu A, Schönian G.
Institut für Mikrobiologie und Hygiene, Charité Universitätsmedizin Berlin,
Berlin, Germany. [email protected]
BACKGROUND: Parasites' evolution in response to parasite-targeted control
strategies, such as vaccines and drugs, is known to be influenced by their
population genetic structure. The aim of this study was to describe the
population structure of Ethiopian strains of Leishmania donovani derived from
different areas endemic for visceral leishmaniasis (VL) as a prerequisite for the
design of effective control strategies against the disease.
METHODOLOGY/PRINCIPAL FINDINGS: Sixty-three strains of L. donovani newly isolated
from VL cases in the two main Ethiopian foci, in the north Ethiopia (NE) and
south Ethiopia (SE) of the country were investigated by using 14 highly
polymorphic microsatellite markers. The microsatellite profiles of 60 previously
analysed L. donovani strains from Sudan, Kenya and India were included for
comparison. Multilocus microsatellite typing placed strains from SE and Kenya (n
= 30) in one population and strains from NE and Sudan (n = 65) in another. These
two East African populations corresponded to the areas of distribution of two
different sand fly vectors. In NE and Sudan Phlebotomus orientalis has been
implicated to transmit the parasites and in SE and Kenya P. martini. The genetic
differences between parasites from NE and SE are also congruent with some
phenotypic differences. Each of these populations was further divided into two
subpopulations. Interestingly, in one of the subpopulations of the population NE
we observed predominance of strains isolated from HIV-VL co-infected patients and
of strains with putative hybrid genotypes. Furthermore, high inbreeding
irreconcilable from strict clonal reproduction was found for strains from SE and
Kenya indicating a mixed-mating system.
CONCLUSIONS/SIGNIFICANCE: This study identified a hierarchical population
structure of L. donovani in East Africa. The existence of two main, genetically
and geographically separated, populations could reflect different parasite-vector
associations, different ecologies and varying host backgrounds and should be
further investigated.
PMCID: PMC2982834
PMID: 21103373 [PubMed - indexed for MEDLINE]
56. PLoS One. 2010 Nov 17;5(11):e14028.
Widow inheritance and HIV prevalence in Bondo District, Kenya: baseline results
from a prospective cohort study.
Agot KE, Vander Stoep A, Tracy M, Obare BA, Bukusi EA, Ndinya-Achola JO, Moses S,
Weiss NS.
Department of Research, Impact Research and Development Organization, Kisumu,
Kenya. [email protected]
BACKGROUND: Widow Inheritance is a widespread cultural practice in sub-Saharan
Africa that has been postulated as contributing to risk of HIV transmission. We
present baseline results from a study designed to investigate the association
between widow inheritance and HIV acquisition.
METHODS AND FINDINGS: We performed a cross-sectional analysis of baseline data
from a prospective cohort study to investigate if widow inheritance is a risk
practice for HIV infection. Study participants were 1,987 widows who were
interviewed regarding their inheritance status and sexual behavior profile and
tested for HIV. Of these widows, 56.3% were inherited. HIV prevalence, at 63%,
was similar among non-inherited and inherited widows. We stratified exposure
status by the relationship of the widow to the inheritor and the reason for
inheritance, and reexamined the HIV status of four subgroups of inherited women
relative to the HIV status of non-inherited women. When adjusting for age and
level of formal education, widows who were inherited by non-relatives for sexual
ritual were significantly more likely to be infected than widows who were not
inherited (OR = 2.07; 95%CI 1.49-2.86); widows who were inherited by relatives
for sexual ritual also had elevated odds of HIV infection (OR = 1.34;
95%CI = 1.07-1.70). Widows who were inherited by relatives for companionship were
less likely than women who were not inherited to be infected with HIV (OR = 0.85;
95%CI 0.63-1.14).
CONCLUSIONS: HIV prevalence among inherited widows varied depending upon why and
by whom they were inherited. The cohort study will determine the risk for HIV
acquisition among the HIV seronegative widows in this sample.
PMCID: PMC2984493
PMID: 21103347 [PubMed - indexed for MEDLINE]
57. MMWR Morb Mortal Wkly Rep. 2010 Nov 26;59(46):1514-7.
HIV testing and treatment among tuberculosis patients --- Kenya, 2006-2009.
Centers for Disease Control and Prevention (CDC).
In resource-limited settings, high case-fatality rates are seen among
tuberculosis (TB) patients with human immunodeficiency virus (HIV) infection,
especially during the early months of TB treatment. HIV prevalence among TB
patients has been estimated to be as high as 80%--90% in some areas of
sub-Saharan Africa. In 2004, the World Health Organization (WHO) recommended
increasing collaboration between HIV and TB programs. Since then, many countries,
including Kenya, have worked to increase TB/HIV collaborative activities. In
2005, the Kenya Division of Leprosy, Tuberculosis, and Lung Disease (DLTLD) added
questions regarding HIV testing and treatment to the existing TB surveillance
system.* This report summarizes HIV data collected from Kenya's extended TB
surveillance system during 2006--2009. During this period, HIV testing among TB
patients increased from 60% in 2006 to 88% in 2009, and the prevalence of HIV
infection among TB patients tested decreased from 52% to 44%. In 2009, 92% of
HIV-infected TB patients received cotrimoxazole prophylaxis for the prevention of
opportunistic infections. Although these data highlight the increase in HIV
services provided to TB patients, only 34% of HIV-infected TB patients started
antiretroviral therapy (ART) while being treated for TB. Innovative interventions
are needed to increase HIV treatment among TB patients in Kenya, especially
considering the 2009 WHO guidelines recommending that all HIV-infected TB
patients be started on ART as soon as possible, regardless of CD4 count. Although
these guidelines have not yet been implemented in Kenya, officials are working to
identify methods of increasing access to ART for TB patients.
PMID: 21102405 [PubMed - indexed for MEDLINE]
58. J Acquir Immune Defic Syndr. 2011 Jan 1;56(1):76-82.
Male antenatal attendance and HIV testing are associated with decreased infant
HIV infection and increased HIV-free survival.
Aluisio A, Richardson BA, Bosire R, John-Stewart G, Mbori-Ngacha D, Farquhar C.
Stony Brook University Medical Center, Stony Brook, NY, USA.
[email protected]
OBJECTIVE: To investigate the relationship between male involvement in prevention
of mother-to-child HIV transmission services and infant HIV acquisition and
mortality, a prospective cohort study was undertaken between 1999 and 2005 in
Nairobi, Kenya.
METHODS: HIV-infected pregnant women were enrolled and followed with their
infants for 1 year with infant HIV DNA testing at birth, 1, 3, 6, 9, and 12
months postpartum. Women were encouraged to invite male partners for prevention
counseling and HIV testing.
RESULTS: Among 456 female participants, 140 partners (31%) attended the antenatal
clinic. Eighty-two (19%) of 441 infants tested were HIV infected by 1 year of
age. Adjusting for maternal viral load, vertical transmission risk was lower
among women with partner attendance compared with those without [adjusted hazard
ratio (aHR) = 0.56, 95% confidence interval (CI): 0.33 to 0.98; P = 0.042] and
among women reporting versus not reporting previous partner HIV testing (aHR =
0.52, 95% CI: 0.32 to 0.84; P = 0.008). The combined risk of HIV acquisition or
infant mortality was lower with male attendance (aHR = 0.55; 95% CI: 0.35 to
0.88; P = 0.012) and report of prior male HIV testing (aHR = 0.58; 95% CI: 0.34
to 0.88; P = 0.01) when adjusting for maternal viral load and breastfeeding.
CONCLUSIONS: Including men in antenatal prevention of mother-to-child HIV
transmission services with HIV testing may improve infant health outcomes.
PMCID: PMC3005193 [Available on 2012/1/1]
PMID: 21084999 [PubMed - indexed for MEDLINE]
59. AIDS. 2011 Jan 28;25(3):345-55.
Younger age at HAART initiation is associated with more rapid growth
McGrath CJ, Chung MH, Richardson BA, Benki-Nugent S, Warui D, John-Stewart GC.
Department of Epidemiology, University of Washington, Seattle, Washington, USA.
[email protected]
OBJECTIVES: Patterns of growth following highly active antiretroviral therapy
(HAART) administration among children are not well defined. The objective of this
study was to determine rates and predictors of growth reconstitution among
children on HAART.
METHODS: A study was conducted among HIV-1-infected children initiating HAART at
an HIV treatment clinic in Kenya. Kaplan-Meier survival curves and Cox
proportional hazards regression models compared catch-up growth (Z-score ≥ 0) at
12 months post-HAART. Multivariate linear mixed-effects models determined rates
and predictors of growth following HAART.
RESULTS: One hundred and seventy-three HIV-1-infected children initiated HAART
with a median age of 4.7 years [interquartile range (IQR) 2.4, 7.0]. At baseline,
children below 3 years had lower weight-for-age (WAZ) and weight-for-height (WHZ)
Z-scores than children 3-5 and 6-10 years (WAZ: P = 0.03; WHZ: P = 0.006).
Adjusting for baseline growth, children below 3 years were two to three-fold more
likely to attain population age-norms (Z-score = 0) than 6-10 years (WAZ: P =
0.055; WHZ: P = 0.005) at 12 months post-HAART. After adjustment, children below
3 years had higher increases in WAZ and WHZ following HAART than 6-10 years (WAZ:
P = 0.006; WHZ: P = 0.005). Children at WHO stage at least 3 at baseline
experienced more rapid WHZ reconstitution (P = 0.002). Food supplementation while
on HAART was associated with increased monthly gains in weight indices (WAZ: P =
0.001; WHZ: P = 0.005), and multivitamins were associated with greater increases
in height (P < 0.01).
CONCLUSION: Following HAART initiation, younger children had more rapid catch-up
to the population-average weight of their peers than older children,
demonstrating growth benefit of earlier HAART. In addition to HAART, food
supplementation and multivitamins may also accelerate growth reconstitution.
PMID: 21102302 [PubMed - indexed for MEDLINE]
60. Malar J. 2010 Nov 16;9:328.
Local topographic wetness indices predict household malaria risk better than
land-use and land-cover in the western Kenya highlands.
Cohen JM, Ernst KC, Lindblade KA, Vulule JM, John CC, Wilson ML.
Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA.
[email protected]
BACKGROUND: Identification of high-risk malaria foci can help enhance
surveillance or control activities in regions where they are most needed.
Associations between malaria risk and land-use/land-cover are well-recognized,
but these environmental characteristics are closely interrelated with the land's
topography (e.g., hills, valleys, elevation), which also influences malaria risk
strongly. Parsing the individual contributions of land-cover/land-use variables
to malaria risk requires examining these associations in the context of their
topographic landscape. This study examined whether environmental factors like
land-cover, land-use, and urban density improved malaria risk prediction based
solely on the topographically-determined context, as measured by the topographic
wetness index.
METHODS: The topographic wetness index, an estimate of predicted water
accumulation in a defined area, was generated from a digital terrain model of the
landscape surrounding households in two neighbouring western Kenyan highland
communities. Variables determined to best encompass the variance in this
topographic wetness surface were calculated at a household level.
Land-cover/land-use information was extracted from a high-resolution satellite
image using an object-based classification method. Topographic and land-cover
variables were used individually and in combination to predict household-level
malaria in the communities through an iterative split-sample model fitting and
testing procedure. Models with only topographic variables were compared to those
with additional predictive factors related to land-cover/land-use to investigate
whether these environmental factors improved prediction of malaria based on the
shape of the land alone.
RESULTS: Variables related to topographic wetness proved most useful in
predicting the households of individuals contracting malaria in this region of
rugged terrain. Other variables related to human modification of the environment
also demonstrated clear associations with household malaria. However, these
land-cover/land-use variables failed to produce unambiguous improvements in
statistical predictive models controlling for important topographic factors, with
none improving prediction of household-level malaria more than 75% of the time.
CONCLUSIONS: Topographic wetness values in this region of highly varied terrain
more accurately predicted houses at greater risk of malaria than did
consideration of land-cover/land-use characteristics. As such, those planning
control or local elimination strategies in similar highland regions may use
topographic and geographic characteristics to effectively identify
high-receptivity regions that may require enhanced vigilance.
PMCID: PMC2993734
PMID: 21080943 [PubMed - indexed for MEDLINE]
61. Clin Perinatol. 2010 Dec;37(4):787-805, ix.
Immune-based approaches to the prevention of mother-to-child transmission of
HIV-1: active and passive immunization.
Lohman-Payne B, Slyker J, Rowland-Jones SL.
Department of Paediatrics and Child Health, University of Nairobi, Nairobi 00202,
Despite more than 2 decades of research, an effective vaccine that can prevent
HIV-1 infection in populations exposed to the virus remains elusive. In the
pursuit of an HIV-1 vaccine, does prevention of exposure to maternal HIV-1 in
utero, at birth or in early life through breast milk require special
consideration? This article reviews what is known about the immune mechanisms of
susceptibility and resistance to mother-to-child transmission (MTCT) of HIV-1 and
summarizes studies that have used passive or active immunization strategies to
interrupt MTCT of HIV-1. Potentially modifiable infectious cofactors that may
enhance transmission and/or disease progression (especially in the developing
world) are described. An effective prophylactic vaccine against HIV-1 infection
needs to be deployed as part of the Extended Program of Immunization recommended
by the World Health Organization for use in developing countries, so it is
important to understand how the infant immune system responds to HIV-1 antigens,
both in natural infection and presented by candidate vaccines.
PMCID: PMC2998888 [Available on 2011/12/1]
PMID: 21078451 [PubMed - indexed for MEDLINE]
62. Patient Educ Couns. 2010 Dec;81(3):338-42. Epub 2010 Nov 12.
Performances of sexuality counselling: a framework for provider-client
van der Kwaak A, Ferris K, van Kats J, Dieleman M.
Royal Tropical Institute, Development Policy and Practice, Amsterdam, The
Netherlands. [email protected]
OBJECTIVE: Adequately assessing quality of care poses enormous challenges. While
conducting fieldwork, we were struck by the need for a framework that
encapsulates provider-client encounters. Little evidence exists concerning the
most effective training, and management of health staff engaged in sexuality,
reproductive health and HIV related health services. This paper proposes a
framework for analysing these encounters.
METHODS: This paper is based on five studies. Mixed method studies were carried
out in Uganda and Kenya. Two additional studies looked into the effect of HIV on
health worker performance in Uganda and Zambia. As a result of the findings, a
desk review looked into factors affecting provider-client encounters in order to
improve the responsiveness of programs.
RESULTS: Positive encounters between provider and client are built on trust and
respect, consist of communication, practice and process, and are influenced by
space, place and context. Combining these facets allows for a better
understanding of their interactions.
CONCLUSION: A holistic perspective in which the breadth of dynamics and processes
are described should be used when assessing the quality of provider-client
PRACTICE IMPLICATIONS: Within training, management and human resource planning,
these dynamics need to be utilized to realize the best possible care.
PMID: 21074961 [PubMed - indexed for MEDLINE]
63. Int J Epidemiol. 2011 Apr 21. [Epub ahead of print]
Cohort Profile: The PharmAccess African (PASER-M) and the TREAT Asia (TASER-M)
Monitoring Studies to Evaluate Resistance--HIV drug resistance in sub-Saharan
Africa and the Asia-Pacific.
Hamers RL, Oyomopito R, Kityo C, Phanuphak P, Siwale M, Sungkanuparph S, Conradie
F, Kumarasamy N, Botes ME, Sirisanthana T, Abdallah S, Li PC, Ngorima N,
Kantipong P, Osibogun A, Lee CK, Stevens WS, Kamarulzaman A, Derdelinckx I, Chen
YM, Schuurman R, Vugt MV, Rinke de Wit TF; on behalf of the PharmAccess African
(PASER) and TREAT Asia (TASER) Studies to Evaluate Resistance.
PharmAccess Foundation, Amsterdam Institute for Global Health and Development,
Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands,
National Centre in HIV Epidemiology and Clinical Research, UNSW, Sydney,
Australia, School of Public Health and Community Medicine, UNSW, Sydney,
Australia, Joint Clinical Research Center, Kampala, Uganda, HIV-NAT/Thai Red
Cross AIDS Research Centre, Bangkok, Thailand, Lusaka Trust Hospital, Lusaka,
Zambia, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok,
Thailand, Themba Lethu Clinic, Clinical HIV Research Unit, University of the
Witwatersrand, Johannesburg, South Africa, YRG Centre for AIDS Research and
Education, Chennai, India, Muelmed Hospital, Pretoria, South Africa, Research
Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand,
International Center for Reproductive Health Kenya, Mombasa, Kenya, Department of
Medicine, Queen Elizabeth Hospital, Hong Kong, China, Newlands Clinic, Harare,
Zimbabwe, Chiang Rai Regional Hospital, Chiang Rai, Thailand, Lagos University
Teaching Hospital, Lagos, Nigeria, Hospital Sungai Buloh, Kuala Lumpur, Malaysia,
Department of Molecular Medicine and Haematology, University of the
Witwatersrand, and National Health Laboratory Services, Johannesburg, South
Africa, University of Malaya, Kuala Lumpur, Malaysia, Department of Virology,
University Medical Center, Utrecht, The Netherlands and AIDS Prevention and
Research Centre, National Yang-Ming University, Taipei, Taiwan.
PMID: 21071386 [PubMed - as supplied by publisher]
64. Lancet. 2010 Nov 27;376(9755):1838-45. Epub 2010 Nov 9.
Effects of a mobile phone short message service on antiretroviral treatment
adherence in Kenya (WelTel Kenya1): a randomised trial.
Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana
J, Sadatsafavi M, Najafzadeh M, Marra CA, Estambale B, Ngugi E, Ball TB, Thabane
L, Gelmon LJ, Kimani J, Ackers M, Plummer FA.
Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya.
[email protected]
Comment in
Lancet. 2010 Nov 27;376(9755):1807-8.
BACKGROUND: Mobile (cell) phone communication has been suggested as a method to
improve delivery of health services. However, data on the effects of mobile
health technology on patient outcomes in resource-limited settings are limited.
We aimed to assess whether mobile phone communication between health-care workers
and patients starting antiretroviral therapy in Kenya improved drug adherence and
suppression of plasma HIV-1 RNA load.
METHODS: WelTel Kenya1 was a multisite randomised clinical trial of HIV-infected
adults initiating antiretroviral therapy (ART) in three clinics in Kenya.
Patients were randomised (1:1) by simple randomisation with a random number
generating program to a mobile phone short message service (SMS) intervention or
standard care. Patients in the intervention group received weekly SMS messages
from a clinic nurse and were required to respond within 48 h. Randomisation,
laboratory assays, and analyses were done by investigators masked to treatment
allocation; however, study participants and clinic staff were not masked to
treatment. Primary outcomes were self-reported ART adherence (>95% of prescribed
doses in the past 30 days at both 6 and 12 month follow-up visits) and plasma
HIV-1 viral RNA load suppression (<400 copies per mL) at 12 months. The primary
analysis was by intention to treat. This trial is registered with
ClinicalTrials.gov, NCT00830622.
FINDINGS: Between May, 2007, and October, 2008, we randomly assigned 538
participants to the SMS intervention (n=273) or to standard care (n=265).
Adherence to ART was reported in 168 of 273 patients receiving the SMS
intervention compared with 132 of 265 in the control group (relative risk [RR]
for non-adherence 0·81, 95% CI 0·69-0·94; p=0·006). Suppressed viral loads were
reported in 156 of 273 patients in the SMS group and 128 of 265 in the control
group, (RR for virologic failure 0·84, 95% CI 0·71-0·99; p=0·04). The number
needed to treat (NNT) to achieve greater than 95% adherence was nine (95% CI
5·0-29·5) and the NNT to achieve viral load suppression was 11 (5·8-227·3).
INTERPRETATION: Patients who received SMS support had significantly improved ART
adherence and rates of viral suppression compared with the control individuals.
Mobile phones might be effective tools to improve patient outcome in
resource-limited settings.
FUNDING: US President's Emergency Plan for AIDS Relief.
PMID: 21071074 [PubMed - indexed for MEDLINE]
65. Lancet. 2010 Nov 27;376(9755):1807-8. Epub 2010 Nov 9.
Mobile phones to improve HIV treatment adherence.
Chi BH, Stringer JS.
Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. [email protected]
Comment on
Lancet. 2010 Nov 27;376(9755):1838-45.
PMID: 21071073 [PubMed - indexed for MEDLINE]
66. J Infect Dis. 2010 Dec 15;202(12):1826-35. Epub 2010 Nov 10.
Latent tuberculosis detection by interferon γ release assay during pregnancy
predicts active tuberculosis and mortality in human immunodeficiency virus type
1-infected women and their children.
Jonnalagadda S, Lohman Payne B, Brown E, Wamalwa D, Maleche Obimbo E, Majiwa M,
Farquhar C, Otieno P, Mbori-Ngacha D, John-Stewart G.
Department of Epidemiology, University of Washington, Seattle, USA.
BACKGROUND: We evaluated the prognostic usefulness of interferon γ release assays
(IGRAs) for active tuberculosis and mortality in Kenyan human immunodeficiency
virus type 1 (HIV-1)-infected women and their infants.
METHODS: Prevalence and correlates of Mycobacterium tuberculosis-specific
T-SPOT.TB IGRA positivity were determined during pregnancy in a historical cohort
of HIV-1-infected women. Hazard ratios, adjusted for baseline maternal CD4 cell
count (aHR(CD4)), were calculated for associations between IGRA positivity and
risk of active tuberculosis and mortality over 2-year postpartum follow-up among
women and their infants.
RESULTS: Of 333 women tested, 52 (15.6%) had indeterminate IGRA results. Of the
remaining 281 women, 120 (42.7%) had positive IGRA results, which were associated
with a 4.5-fold increased risk of active tuberculosis (aHR(CD4), 4.5; 95%
confidence interval [CI], 1.1-18.0; P = .030). For immunosuppressed women (CD4
cell count, <250 cells/μL), positive IGRA results were associated with increased
risk of maternal mortality (aHR(CD4), 3.5; 95% CI, 1.02-12.1;), maternal active
tuberculosis or mortality (aHR(CD4), 5.2; 95% CI, 1.7-15.6; P = .004), and infant
active tuberculosis or mortality overall (aHR(CD4), 3.0; 95% CI, 1.0-8.9; P =
.05) and among HIV-1-exposed uninfected infants (aHR(CD4), 7.3; 95% CI, 1.6-33.5;
P = .01).
CONCLUSIONS: Positive IGRA results for HIV-1-infected pregnant women were
associated with postpartum active tuberculosis and mortality among mothers and
their infants.
PMCID: PMC3058232 [Available on 2011/12/15]
PMID: 21067370 [PubMed - indexed for MEDLINE]
67. Food Nutr Bull. 2010 Sep;31(3 Suppl):S272-86.
Developing nutrition information systems in Eastern and Southern Africa.
Regional Technical Working Group, Nairobi.
PMID: 21049847 [PubMed - indexed for MEDLINE]
68. Food Nutr Bull. 2010 Sep;31(3 Suppl):S209-18.
Impact of drought and HIV on child nutrition in Eastern and Southern Africa.
Mason JB, Chotard S, Bailes A, Mebrahtu S, Hailey P.
Department of International Health and Development, Tulane University School of
Public Health and Tropical Medicine, New Orleans, Louisiana 70112, USA.
[email protected]
BACKGROUND: Intermittent food insecurity due to drought and the effects of
HIV/AIDS affect child nutritional status in sub-Saharan Africa. In Southern
Africa in 2001-3 drought and HIV were previously shown to interact to cause
substantial deterioration in child nutrition. With additional data available from
Southern and Eastern Africa, the size of the effects of drought and HIV on child
underweight up to 2006 were estimated.
OBJECTIVE: To determine short- and long-term trends in child malnutrition in
Eastern and Southern Africa and how these are affected by drought and HIV.
METHODS: A secondary epidemiologic analysis was conducted of area-level data
derived from national surveys, generally from the mid-1990s to the mid-2000s.
Data from countries in the Horn of Africa (Ethiopia, Kenya, and Uganda) and
Southern Africa (Lesotho, Malawi, Mozambique, Swaziland, Zambia, and Zimbabwe)
were compiled from available survey results. Secondary data were obtained on
weight-for-age for preschool children, HIV prevalence data were derived from
antenatal clinic surveillance, and food security data were obtained from United
Nations sources (Food and Agriculture Organization, International Labour Office,
and others).
RESULTS: Overall trends in child nutrition are improving as national averages;
the improvement is slowed but not stopped by the effects of intermittent
droughts. In Southern Africa, the prevalence rates of underweight showed signs of
recovery from the 2001-03 crisis. As expected, food production and price
indicators were related (although weakly) to changes in malnutrition prevalence;
the association was strongest between changes in food production and price
indicators and changes in malnutrition prevalence in the following year. Areas of
higher HIV prevalence had better nutrition (in both country groups), but this
counterintuitive association is removed after controlling for socioeconomic
status. In low-HIV areas in Eastern Africa, nutrition deteriorates during
drought, with prevalence rates of underweight 5 to 12 percentage points higher
than in nondrought periods; less difference was seen in high-HIV areas, in
contrast to Southern Africa, where drought and HIV together interact to produce
higher prevalence rates of underweight.
CONCLUSIONS: Despite severe intermittent droughts and the HIV/AIDS epidemic (now
declining but still with very high prevalence rates), underlying trends in child
underweight are improving when drought is absent: resilience may be better than
feared. Preventing effects of drought and HIV could release potential for
improvement and, when supported by national nutrition programs, help to
accelerate the rates of improvement, now generally averaging around 0.3
percentage points per year, to those needed to meet Millennium Development Goals
(0.4 to 0.9 percentage points per year).
PMID: 21049842 [PubMed - indexed for MEDLINE]
69. PLoS One. 2010 Oct 25;5(10):e13613.
Long-term adherence to antiretroviral treatment and program drop-out in a
high-risk urban setting in sub-Saharan Africa: a prospective cohort study.
Unge C, Södergård B, Marrone G, Thorson A, Lukhwaro A, Carter J, Ilako F, Ekström
Division of Global Health, IHCAR, Department of Public Health Sciences,
Karolinska Institutet, Stockholm, Sweden. [email protected]
BACKGROUND: Seventy percent of urban populations in sub-Saharan Africa live in
slums. Sustaining HIV patients in these high-risk and highly mobile settings is a
major future challenge. This study seeks to assess program retention and to find
determinants for low adherence to antiretroviral treatment (ART) and drop-out
from an established HIV/ART program in Kibera, Nairobi, one of Africa's largest
informal urban settlements.
METHODS AND FINDINGS: A prospective open cohort study of 800 patients was
performed at the African Medical Research Foundation (AMREF) clinic in the Kibera
slum. Adherence to ART and drop-out from the ART program were independent
outcomes. Two different adherence measures were used: (1) "dose adherence" (the
proportion of a prescribed dose taken over the past 4 days) and (2) "adherence
index" (based on three adherence questions covering dosing, timing and special
instructions). Drop-out from the program was calculated based on clinic
appointment dates and number of prescribed doses, and a patient was defined as
being lost to follow-up if over 90 days had expired since the last prescribed
dose. More than one third of patients were non-adherent when all three aspects of
adherence--dosing, timing and special instructions--were taken into account.
Multivariate logistic regression revealed that not disclosing HIV status, having
a low level of education, living below the poverty limit (US$ 2/day) and not
having a treatment buddy were significant predictors for non-adherence.
Additionally, one quarter of patients dropped out for more than 90 days after the
last prescribed ART dose. Not having a treatment buddy was associated with
increased risk for drop-out (hazard ratio 1.4, 95% CI = 1.0-1.9).
CONCLUSION: These findings point to the dilemma of trying to sustain a growing
number of people on life-long ART in conditions where prevailing stigma, poverty
and food shortages threatens the long-term success of HIV treatment.
PMCID: PMC2963610
PMID: 21049045 [PubMed - indexed for MEDLINE]
70. Trop Med Int Health. 2011 Jan;16(1):84-96. doi: 10.1111/j.1365-3156.2010.02667.x.
Epub 2010 Nov 2.
Systematic Review: the use of vouchers for reproductive health services in
developing countries: systematic review.
Bellows NM, Bellows BW, Warren C.
Independent Consultant, Nairobi, Kenya. [email protected]
OBJECTIVES: To identify where vouchers have been used for reproductive health
(RH) services, to what extent RH voucher programmes have been evaluated, and
whether the programmes have been effective.
METHODS: A systematic search of the peer review and grey literature was conducted
to identify RH voucher programmes and evaluation findings. Experts were consulted
to verify RH voucher programme information and identify further programmes and
studies not found in the literature search. Studies were examined for outcomes
regarding targeting, costs, knowledge, utilization, quality, and population
health impact. Included studies used cross-sectional, before-and-after and
quasi-experimental designs.
RESULTS: Thirteen RH voucher programmes fitting established criteria were
identified. RH voucher programmes were located in Bangladesh, Cambodia, China,
Kenya (2), Korea, India, Indonesia, Nicaragua (3), Taiwan, and Uganda. Among RH
voucher programmes, 7 were quantitatively evaluated in 15 studies. All
evaluations reported some positive findings, indicating that RH voucher
programmes increased utilization of RH services, improved quality of care, and
improved population health outcomes.
CONCLUSIONS: The potential for RH voucher programmes appears positive; however,
more research is needed to examine programme effectiveness using strong study
designs. In particular, it is important to see stronger evidence on
cost-effectiveness and population health impacts, where the findings can best
direct governments and external funders.
PMID: 21044235 [PubMed - indexed for MEDLINE]
71. Int J STD AIDS. 2010 Aug;21(8):549-52.
Diagnosis of sexually transmitted infections and bacterial vaginosis among
HIV-1-infected pregnant women in Nairobi.
Marx G, John-Stewart G, Bosire R, Wamalwa D, Otieno P, Farquhar C.
Department of Medicine, University of Washington, Seattle, USA.
[email protected]
HIV-infected women with sexually transmitted infections (STIs) or bacterial
vaginosis (BV) during pregnancy are at increased risk for poor obstetric
outcomes. In resource-limited settings, diagnostic testing for STIs and BV is
often not available and most pregnant women are managed using syndromic
algorithms. As part of a Nairobi perinatal cohort, HIV-1-infected pregnant women
were interviewed and samples were collected for STIs and BV testing. Diagnostic
accuracy of STIs and BV by syndromic algorithms was evaluated with comparison to
the reference standard. Among 441 women, prevalence of BV was 37%, trichomoniasis
16%, chlamydia 4%, syphilis 3% and gonorrhoea 2%. Significantly more women with
STIs were aged 21-years-old, had not attended secondary school and had a history
of STIs. Syndromic diagnosis of STIs and BV demonstrated a sensitivity of 45% and
57%, and positive predictive value of 30% and 42%, respectively. Among these
HIV-infected, pregnant women, STIs and vaginal infections were common and
syndromic diagnosis was insensitive, resulting in missed opportunities to
intervene and improve infant and maternal health.
PMCID: PMC3050991
PMID: 20975086 [PubMed - indexed for MEDLINE]
72. Glob Health Action. 2010 Sep 27;3. doi: 10.3402/gha.v3i0.5420.
Health inequalities among older men and women in Africa and Asia: evidence from
eight Health and Demographic Surveillance System sites in the INDEPTH WHO-SAGE
Ng N, Kowal P, Kahn K, Naidoo N, Abdullah S, Bawah A, Binka F, Chuc NT, Debpuur
C, Egondi T, Xavier Gómez-Olivé F, Hakimi M, Hirve S, Hodgson A, Juvekar S,
Kyobutungi C, Van Minh H, Mwanyangala MA, Nathan R, Razzaque A, Sankoh O, Kim
Streatfield P, Thorogood M, Wall S, Wilopo S, Byass P, Tollman SM, Chatterji S.
Department of Public Health and Clinical Medicine, Centre for Global Health
Research, Epidemiology and Global Health, Umeå University, Umeå, Sweden.
BACKGROUND: Declining rates of fertility and mortality are driving demographic
transition in all regions of the world, leading to global population ageing and
consequently changing patterns of global morbidity and mortality. Understanding
sex-related health differences, recognising groups at risk of poor health and
identifying determinants of poor health are therefore very important for both
improving health trajectories and planning for the health needs of ageing
OBJECTIVES: To determine the extent to which demographic and socio-economic
factors impact upon measures of health in older populations in Africa and Asia;
to examine sex differences in health and further explain how these differences
can be attributed to demographic and socio-economic determinants.
METHODS: A total of 46,269 individuals aged 50 years and over in eight Health and
Demographic Surveillance System (HDSS) sites within the INDEPTH Network were
studied during 2006-2007 using an abbreviated version of the WHO Study on global
AGEing and adult health (SAGE) Wave I instrument. The survey data were then
linked to longitudinal HDSS background information. A health score was calculated
based on self-reported health derived from eight health domains. Multivariable
regression and post-regression decomposition provide ways of measuring and
explaining the health score gap between men and women.
RESULTS: Older men have better self-reported health than older women. Differences
in household socio-economic levels, age, education levels, marital status and
living arrangements explained from about 82% and 71% of the gaps in health score
observed between men and women in South Africa and Kenya, respectively, to almost
nothing in Bangladesh. Different health domains contributed differently to the
overall health scores for men and women in each country.
CONCLUSION: This study confirmed the existence of sex differences in
self-reported health in low- and middle-income countries even after adjustments
for differences in demographic and socio-economic factors. A decomposition
analysis suggested that sex differences in health differed across the HDSS sites,
with the greatest level of inequality found in Bangladesh. The analysis showed
considerable variation in how differences in socio-demographic and economic
characteristics explained the gaps in self-reported health observed between older
men and women in African and Asian settings. The overall health score was a
robust indicator of health, with two domains, pain and sleep/energy, contributing
consistently across the HDSS sites. Further studies are warranted to understand
other significant individual and contextual determinants to which these sex
differences in health can be attributed. This will lay a foundation for a more
evidence-based approach to resource allocation, and to developing health
promotion programmes for older men and women in these settings.
PMCID: PMC2958198
PMID: 20967141 [PubMed - in process]
73. Sex Transm Infect. 2011 Mar;87(2):88-93. Epub 2010 Oct 21.
Will circumcision provide even more protection from HIV to women and men? New
estimates of the population impact of circumcision interventions.
Hallett TB, Alsallaq RA, Baeten JM, Weiss H, Celum C, Gray R, Abu-Raddad L.
Department of Infectious Disease Epidemiology, Imperial College London, St Mary's
Campus, Norfolk Place, London W2 1PG, UK. [email protected]
BACKGROUND: Mathematical modelling has indicated that expansion of male
circumcision services in high HIV prevalence settings can substantially reduce
population-level HIV transmission. However, these projections need revision to
incorporate new data on the effect of male circumcision on the risk of acquiring
and transmitting HIV.
METHODS: Recent data on the effect of male circumcision during wound healing and
the risk of HIV transmission to women were synthesised based on four trials of
circumcision among adults and new observational data of HIV transmission rates in
stable partnerships from men circumcised at younger ages. New estimates were
generated for the impact of circumcision interventions in two mathematical
models, representing the HIV epidemics in Zimbabwe and Kisumu, Kenya. The models
did not capture the interaction between circumcision, HIV and other sexually
transmitted infections.
RESULTS: An increase in the risk of HIV acquisition and transmission during wound
healing is unlikely to have a major impact of circumcision interventions.
However, it was estimated that circumcision confers a 46% reduction in the rate
of male-to-female HIV transmission. If this reduction begins 2 years after the
procedure, the impact of circumcision is substantially enhanced and accelerated
compared with previous projections with no such effect-increasing by 40% the
infections averted by the intervention overall and doubling the number of
infections averted among women.
CONCLUSIONS: Communities, and especially women, may benefit much more from
circumcision interventions than had previously been predicted, and these results
provide an even greater imperative to increase scale-up of safe male circumcision
PMID: 20966458 [PubMed - indexed for MEDLINE]
74. Emerg Med J. 2010 Oct 14. [Epub ahead of print]
A novel ED-based sexual assault centre in western Kenya: description of patients
and analysis of treatment patterns.
Ranney ML, Rennert-May E, Spitzer R, Chitai MA, Mamlin SE, Mabeya H.
Injury Prevention Center, Department of Emergency Medicine, Alpert Medical School
of Brown University, Providence, Rhode Island, USA.
Background The aim of this study was to establish the feasibility of a Kenyan
emergency department (ED)-based sexual assault centre; and to improve knowledge
of the characteristics of sexual assault in the region. Methods The Center for
Assault Recovery-Eldoret (CAR-E) was established to provide timely, culturally
sensitive treatment of Kenyan sexual assault survivors using a standardised
evaluation/treatment protocol. A retrospective review of charts of all sexual
assault survivors attending CAR-E from May 2007-May 2008 was performed. Simple
descriptive statistics, t tests, and OR were calculated. Results CAR-E treated
321 survivors over 13 months. Patients' mean age was 15.9 years;
50% were younger than 14 years old. Survivors were predominately female
and single. Most knew their assailant. Younger age was associated with increased
likelihood of genital trauma. Only 43% of assaults were reported to the police.
Sexually transmitted infection prophylaxis was given per protocol to 84%
eligible; emergency contraception to 64%; and HIV prophylaxis to 63%. Only 44%
received counselling. Survivors were more likely to get sexually transmitted
infection and HIV prophylaxis, and emergency contraception if they had genital
injury. Conclusions Development of an ED-based sexual assault centre at a
referral hospital in Kenya using a standardised history, physical, and treatment
protocol was feasible, and high rates of prophylaxis were provided. Based on
characteristics of people who have been assaulted, community prevention efforts
should concentrate on decreasing the societal acceptability of rape. In
conjunction with improvement of protocols at the centre under consideration,
development of similar centres in sub-Saharan African ED should be encouraged.
PMID: 20947922 [PubMed - as supplied by publisher]
75. BMC Pregnancy Childbirth. 2010 Oct 14;10:62.
The utility of clinical care pathways in determining perinatal outcomes for women
with one previous caesarean section; a retrospective service evaluation.
Wanyonyi SZ, Karuga RN.
Department of Obstetrics and Gynaecology, Aga Khan University Hospital, 3rd
Parklands Avenue, Nairobi, Kenya. [email protected]
BACKGROUND: The rising rates of primary caesarean section have resulted in a
larger obstetric population with scarred uteri. Subsequent pregnancies in these
women are risk-prone and may complicate. Besides ensuring standardised
management, care pathways could be used to evaluate for perinatal outcomes in
these high risk pregnancies. We aim to demonstrate the use of a care pathway for
vaginal birth after caesarean section as a service evaluation tool to determine
perinatal outcomes.
METHODS: A retrospective service evaluation by review of delivery case notes and
records was undertaken at the Aga Khan University Hospital, Nairobi, Kenya
between January 2008 and December 2009. Women with ≥2 previous caesarean
sections, previous classical caesarean section, multiple gestation, breech
presentation, severe pre-eclampsia, transverse lie, placenta praevia, conditions
requiring induction of labour and incomplete records were excluded. Outcome
measures included the proportion of eligible women who opted for test of scar
(ToS), success rate of vaginal birth after caesarean section (VBAC); proportion
on women opting for elective repeat caesarean section (ERCS) and their perinatal
RESULTS: A total of 215 women with one previous caesarean section were followed
up using a standard care pathway. The median parity (minimum-maximum) was
1.01234. The other demographic characteristics were comparable. Only 44.6% of
eligible mothers opted to have a ToS. The success rate for VBAC was 49.4% with
the commonest (31.8%) reason for failure being protracted active phase of labour.
Maternal morbidity was comparable for the failed and successful VBAC group. The
incidence of hemorrhage was 2.3% and 4.4% for the successful and failed VBAC
groups respectively. The proportion of babies with acidotic arterial PH (< 7.10)
was 3.1% and 22.2% among the successful and failed VBAC groups respectively. No
perinatal mortality was reported.
CONCLUSIONS: Besides ensuring standardised management, care pathways could be
objective audit and service evaluation tools for determining perinatal outcomes.
PMCID: PMC2964563
PMID: 20946628 [PubMed - indexed for MEDLINE]
76. Cancer Causes Control. 2010 Dec;21(12):2309-13. Epub 2010 Oct 12.
The prevalence of human papillomavirus infection in Mombasa, Kenya.
De Vuyst H, Parisi MR, Karani A, Mandaliya K, Muchiri L, Vaccarella S, Temmerman
M, Franceschi S, Lillo F.
International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Lyon
cedex 08, France. [email protected]
OBJECTIVES: A human papillomavirus (HPV) prevalence survey was done in Mombasa,
Kenya, to improve the knowledge of HPV prevalence and genotype distribution in
sub-Saharan African countries overall, and in women of different ages.
METHODS: HPV prevalence was assessed using PCR in women older than 15 years
attending family planning and mother-child care services.
RESULTS: Among 496 women, HPV prevalence was high (42.3%; 95% CI: 37.9-46.8;
world age-standardized). Moreover, 46% of HPV-positive women harbored
multiple-type infections. The most common types were HPV58 (10.5% of women),
HPV16 (7.7%), HPV53 (6.7%), HPV18 (4.6%), and HPV6 (4.4%), and the prevalence of
any high-risk HPV type was 28.8%. HPV prevalence was elevated among all
age-groups (range 36.4-45.7%). Independent associations with HPV positivity were
found for being in a polygamous marriage (OR = 1.7) and lifetime number of sexual
partners (OR for ≥ 3 vs. 1 = 1.5), although they were of only borderline
statistical significance.
CONCLUSIONS: These findings differ from other world regions, showing a high HPV
burden in all age-groups with a high proportion of multiple-type infections. Our
data strengthen the urgency of HPV vaccination in Kenya but also highlight the
elevated number of women who would have positive results in an HPV-based
screening program in the country.
PMID: 20938733 [PubMed - indexed for MEDLINE]
77. Patient Educ Couns. 2010 Dec;81(3):368-73. Epub 2010 Oct 8.
Can private pharmacy providers offer comprehensive reproductive health services
to users of emergency contraceptives? Evidence from Nairobi, Kenya.
Liambila W, Obare F, Keesbury J.
Reproductive Health Program, Population Council, Nairobi, Kenya.
OBJECTIVE: To evaluate the provision of reproductive health information and
services to users of emergency contraceptives (ECs) by private pharmacists.
METHODS: The study involved intervention (9) and control (8) pharmacies, with
baseline and endline assessments of EC provision through the use of mystery
clients. Intervention pharmacies received weekly updates on EC, fliers with three
key messages on EC, and information, education, and communication materials.
Logistic regression models are estimated to predict the provision of reproductive
health services to EC clients.
RESULTS: The differences between the control and intervention pharmacies with
respect to the provision of additional information on EC and regular family
planning services are in the expected direction but statistically insignificant.
In contrast, the likelihood of providing information or referral for counseling
or testing for sexually transmitted infections or HIV was lower in the
intervention than in the control pharmacies but the difference was also not
statistically significant.
CONCLUSION: Pharmacy providers in the country face institutional challenges in
providing reproductive health services to EC clients.
PRACTICE IMPLICATIONS: The challenges could be addressed through pre-service
training, targeted in-service training, sensitization of clients, and
point-of-sale materials such as brochures, posters and package inserts.
PMID: 20934833 [PubMed - indexed for MEDLINE]
78. J Infect Dis. 2010 Nov 15;202(10):1538-42. Epub 2010 Oct 5.
Antiretroviral adherence and development of drug resistance are the strongest
predictors of genital HIV-1 shedding among women initiating treatment.
Graham SM, Masese L, Gitau R, Jalalian-Lechak Z, Richardson BA, Peshu N,
Mandaliya K, Kiarie JN, Jaoko W, Ndinya-Achola J, Overbaugh J, McClelland RS.
University of Washington, Seattle, Washington 98104-2499, USA.
[email protected]
Persistent genital human immunodeficiency virus type 1 (HIV-1) shedding among
women receiving antiretroviral therapy (ART) may present a transmission risk. We
investigated the associations between genital HIV-1 suppression after ART
initiation and adherence, resistance, pretreatment CD4 cell count, and hormonal
contraceptive use. First-line ART was initiated in 102 women. Plasma and genital
HIV-1 RNA levels were measured at months 0, 3, and 6. Adherence was a strong and
consistent predictor of genital HIV-1 suppression (P < .001), whereas genotypic
resistance was associated with higher vaginal HIV-1 RNA level at month 6 (P =
.04). These results emphasize the importance of adherence to optimize the
potential benefits of ART for reducing HIV-1 transmission risk.
PMCID: PMC2957525 [Available on 2011/11/1]
PMID: 20923373 [PubMed - indexed for MEDLINE]
79. BMC Public Health. 2010 Sep 29;10:584.
Multi-centred mixed-methods PEPFAR HIV care & support public health evaluation:
study protocol.
Harding R, Simms V, Penfold S, McCrone P, Moreland S, Downing J, Powell RA,
Mwangi-Powell F, Namisango E, Fayers P, Curtis S, Higginson IJ.
King's College London, Cicely Saunders Institute, Department of Palliative Care,
Policy and Rehabilitation School of Medicine at Guy's, King's and St Thomas'
Hospitals Bessemer Road, London SE5 9PJ, UK. [email protected]
BACKGROUND: A public health response is essential to meet the multidimensional
needs of patients and families affected by HIV disease in sub-Saharan Africa. In
order to appraise current provision of HIV care and support in East Africa, and
to provide evidence-based direction to future care programming, and Public Health
Evaluation was commissioned by the PEPFAR programme of the US Government.
METHODS/DESIGN: This paper described the 2-Phase international mixed methods
study protocol utilising longitudinal outcome measurement, surveys, patient and
family qualitative interviews and focus groups, staff qualitative interviews,
health economics and document analysis. Aim 1) To describe the nature and scope
of HIV care and support in two African countries, including the types of
facilities available, clients seen, and availability of specific components of
care [Study Phase 1]. Aim 2) To determine patient health outcomes over time and
principle cost drivers [Study Phase 2]. The study objectives are as follows. 1)
To undertake a cross-sectional survey of service configuration and activity by
sampling 10% of the facilities being funded by PEPFAR to provide HIV care and
support in Kenya and Uganda (Phase 1) in order to describe care currently
provided, including pharmacy drug reviews to determine availability and supply of
essential drugs in HIV management. 2) To conduct patient focus group discussions
at each of these (Phase 1) to determine care received. 3) To undertake a
longitudinal prospective study of 1200 patients who are newly diagnosed with HIV
or patients with HIV who present with a new problem attending PEPFAR care and
support services. Data collection includes self-reported quality of life, core
palliative outcomes and components of care received (Phase 2). 4) To conduct
qualitative interviews with staff, patients and carers in order to explore and
understand service issues and care provision in more depth (Phase 2). 5) To
undertake document analysis to appraise the clinical care procedures at each
facility (Phase 2). 6) To determine principle cost drivers including staff,
overhead and laboratory costs (Phase 2).
DISCUSSION: This novel mixed methods protocol will permit transparent
presentation of subsequent dataset results publication, and offers a substantive
model of protocol design to measure and integrate key activities and outcomes
that underpin a public health approach to disease management in a low-income
PMCID: PMC2955697
PMID: 20920241 [PubMed - indexed for MEDLINE]
80. Rural Remote Health. 2010 Jul-Sep;10(3):1481. Epub 2010 Sep 20.
The experience of being a traditional midwife: relationships with skilled birth
Dietsch E.
Charles Sturt University, Wagga Wagga, New South Wales, Australia.
[email protected]
INTRODUCTION: This article focuses on an unexpected finding of a research project
which explored the experience of being a traditional midwife. The unexpected
finding was that traditional midwives often perceive skilled (professional) birth
attendants to be abusive of both them and the women who are transferred to
hospital for emergency obstetric care.
METHODS: Eighty-four traditional midwives in the Western Province of Kenya were
interviewed individually or in groups with a Bukusu/Kiswahili/English-speaking
interpreter. Interviews were audiotaped and the English components were
transcribed verbatim. Interview transcripts and observations were thematically
RESULTS: A minority of relationships between traditional midwives and skilled
birth attendants were based on mutual respect and collaborative practice.
However, the majority of encounters with skilled birth attendants were perceived
by the traditional midwives to be abusive for them and the women requiring
emergency obstetric care. In the interests of improving health outcomes for women
and their newborns, interpersonal skills, including maintaining respectful
communication and relationships must be a core competency for all caregivers.
Providing opportunities for reciprocal learning and strategies to enhance
relationships between traditional midwives and skilled birth attendants are
CONCLUSION: Current global strategies to reduce maternal and newborn mortality by
increasing the number of women birthing with a skilled (professional) birth
attendant in an enabling environment may be limited while the reasons for
traditional midwives being the caregiver of choice for the majority of women
living in areas such as Western Kenya remain unaddressed.
PMID: 20887084 [PubMed - indexed for MEDLINE]
81. PLoS One. 2010 Sep 21;5(9):e12873.
Safety and immunogenicity study of Multiclade HIV-1 adenoviral vector vaccine
alone or as boost following a multiclade HIV-1 DNA vaccine in Africa.
Jaoko W, Karita E, Kayitenkore K, Omosa-Manyonyi G, Allen S, Than S, Adams EM,
Graham BS, Koup RA, Bailer RT, Smith C, Dally L, Farah B, Anzala O, Muvunyi CM,
Bizimana J, Tarragona-Fiol T, Bergin PJ, Hayes P, Ho M, Loughran K, Komaroff W,
Stevens G, Thomson H, Boaz MJ, Cox JH, Schmidt C, Gilmour J, Nabel GJ, Fast P,
Bwayo J.
Kenya AIDS Vaccine Initiative (KAVI), Nairobi, Kenya.
BACKGROUND: We conducted a double-blind, randomized, placebo-controlled Phase I
study of a recombinant replication-defective adenovirus type 5 (rAd5) vector
expressing HIV-1 Gag and Pol from subtype B and Env from subtypes A, B and C,
given alone or as boost following a DNA plasmid vaccine expressing the same HIV-1
proteins plus Nef, in 114 healthy HIV-uninfected African adults.
METHODOLOGY/PRINCIPAL FINDINGS: Volunteers were randomized to 4 groups receiving
the rAd5 vaccine intramuscularly at dosage levels of 1×10(10) or 1×10(11)
particle units (PU) either alone or as boost following 3 injections of the DNA
vaccine given at 4 mg/dose intramuscularly by needle-free injection using
Biojector® 2000. Safety and immunogenicity were evaluated for 12 months. Both
vaccines were well-tolerated. Overall, 62% and 86% of vaccine recipients in the
rAd5 alone and DNA prime - rAd5 boost groups, respectively, responded to the
HIV-1 proteins by an interferon-gamma (IFN-γ) ELISPOT. The frequency of immune
responses was independent of rAd5 dosage levels. The highest frequency of
responses after rAd5 alone was detected at 6 weeks; after DNA prime - rAd5 boost,
at 6 months (end of study). At baseline, neutralizing antibodies against Ad5 were
present in 81% of volunteers; the distribution was similar across the 4 groups.
Pre-existing immunity to Ad5 did not appear to have a significant impact on
reactogenicity or immune response rates to HIV antigens by IFN-γ ELISPOT. Binding
antibodies against Env were detected in up to 100% recipients of DNA prime - rAd5
boost. One volunteer acquired HIV infection after the study ended, two years
after receipt of rAd5 alone.
CONCLUSIONS/SIGNIFICANCE: The HIV-1 rAd5 vaccine, either alone or as a boost
following HIV-1 DNA vaccine, was well-tolerated and immunogenic in African
adults. DNA priming increased the frequency and magnitude of cellular and humoral
immune responses, but there was no effect of rAd5 dosage on immunogenicity
TRIAL REGISTRATION: ClinicalTrials.gov NCT00124007.
PMCID: PMC2943475
PMID: 20877623 [PubMed - indexed for MEDLINE]
82. Sex Transm Infect. 2010 Oct;86(5):388-90.
Changes in antiretroviral therapy guidelines: implications for public health
policy and public purses.
Hamilton A, Garcia-Calleja JM, Vitoria M, Gilks C, Souteyrand Y, De Cock K,
Crowley S.
St Vincent’s Hospital, NSW, Australia.
INTRODUCTION: The World Health Organization (WHO) published a revision of the
antiretroviral therapy (ART) guidelines and now recommends ART for all those with
a CD4 cell count ≤350/mm(3), for people with HIV and active tuberculosis (TB) or
chronic active hepatitis B irrespective of CD4 cell count and all HIV-positive
pregnant women. A study was undertaken to estimate the impact of the new
guidelines using four countries as examples.
METHODS: The current WHO/UNAIDS country projections were accessed based on the
2007 estimates for Zambia, Kenya, Cameroon and Vietnam. New projections were
created using Spectrum. CD4 progression rates to need for ART were modified and
compared with the baseline projections.
RESULTS: The pattern of increased need for treatment is similar across the four
projections. Initiating treatment at a CD4 count <250/mm(3) will increase the
need for treatment by a median of 22% immediately, initiating ART at a CD4 count
<350/mm(3) increases the need for treatment by a median of 60%, and the need for
treatment doubles if ART is commenced at a CD4 count <500/mm(3). Initiating ART
at a CD4 cell count <250/mm(3) would increase the need for treatment by a median
of around 15% in 2012; initiating treatment at a CD4 count <350/mm(3) increases
the need for treatment by a median of 42% across the same projections and about
84% if CD4 <500/mm(3) was used.
CONCLUSIONS: The projections indicate that initiating ART earlier in the course
of the disease by increasing the threshold for the initiation of ART would
increase the numbers of adults in need of treatment immediately and in the
PMID: 20876757 [PubMed - indexed for MEDLINE]
83. AIDS. 2010 Nov 13;24(17):2733-7.
Effect of acquisition and treatment of cervical infections on HIV-1 shedding in
women on antiretroviral therapy.
Gitau RW, Graham SM, Masese LN, Overbaugh J, Chohan V, Peshu N, Richardson BA,
Jaoko W, Ndinya-Achola JO, McClelland RS.
Department of Medical Microbiology, University of Nairobi, Kenya.
[email protected]
BACKGROUND: Cervicitis increases the quantity of HIV-1 RNA in cervical secretions
when women are not taking antiretroviral therapy (ART), and successful treatment
of cervicitis reduces HIV-1 shedding in this setting.
OBJECTIVE: To determine the effect of acquisition and treatment of cervical
infections on genital HIV-1 shedding in women receiving ART.
DESIGN: Prospective cohort study.
METHODS: We followed 147 women on ART monthly for incident nonspecific
cervicitis, gonorrhea, and chlamydia. Cervical swabs for HIV-1 RNA quantitation
were collected at every visit. The lower limit for linear quantitation was 100
copies per swab. We compared the prevalence of HIV-1 RNA detection before
(baseline) versus during and after treatment of cervical infections.
RESULTS: Thirty women contributed a total of 31 successfully treated episodes of
nonspecific cervicitis (N = 13), gonorrhea (N = 17), and chlamydia (N = 1). HIV-1
RNA was detected in cervical secretions before, during, and after cervicitis at
one (3.2%), five (16.1%), and three (9.7%) visits, respectively. Compared with
baseline, detection of HIV-1 RNA was increased when cervical infections were
present (adjusted odds ratio 5.7, 95% confidence interval 1.0-30.3, P = 0.04).
However, even in the subset of women with cervical HIV-1 RNA levels above the
threshold for quantitation, most had low concentrations during cervical
infections (median 115, range 100-820 copies per swab).
CONCLUSION: Although these data show a statistically significant increase in
cervical HIV-1 RNA detection when cervical infections are present, most cervical
HIV-1 RNA concentrations were near the threshold for detection, suggesting that
infectivity remains low. Antiretroviral therapy appears to limit increases in
genital HIV-1 shedding caused by cervical infections.
PMCID: PMC2978313 [Available on 2011/11/1]
PMID: 20871388 [PubMed - indexed for MEDLINE]
84. Popul Stud (Camb). 2010 Nov;64(3):247-61.
Concurrent sexual partnerships among youth in urban Kenya: Prevalence and
partnership effects.
Xu H, Luke N, Msiyaphazi Zulu E.
Department of Sociology, Brown University, Box 1916, 112 George Street,
Providence, RI 02912, USA.
Research on concurrent sexual partnerships is hindered by lack of accurate
partnership data. Using unique life-history calendar data from a population-based
sample of youths aged 18-24 in urban Kenya, we estimated the prevalence and
correlates of concurrency. In the sixth month before the survey, 3.5 per cent of
females and 4.0 per cent of males were engaged in concurrent sexual partnerships.
In the previous 9.5 years, males experienced more concurrent partnerships than
females and they were of shorter duration. Using survival analysis, we find that
the characteristics of initial partnerships affect entry into a second
(concurrent) relationship. For females, geographic separation from a partner
increases the risk of concurrency, while concurrency is positively associated
with the duration of the initial relationship for males. For both sexes, the
perception of partner infidelity increases the risk, suggesting that concurrency
expands individuals' sexual networks and bridges additional networks involving
partners' other sexual partners.
PMID: 20865631 [PubMed - indexed for MEDLINE]
85. Bull World Health Organ. 2010 Sep 1;88(9):681-8. Epub 2010 Apr 16.
Influence of gender on loss to follow-up in a large HIV treatment programme in
western Kenya.
Ochieng-Ooko V, Ochieng D, Sidle JE, Holdsworth M, Wools-Kaloustian K, Siika AM,
Yiannoutsos CT, Owiti M, Kimaiyo S, Braitstein P.
United States Agency for International Development, Academic Model Providing
Access To Healthcare Partnership, Eldoret, Kenya.
OBJECTIVE: To determine the incidence of loss to follow-up in a treatment
programme for people living with human immunodeficiency virus (HIV) infection in
Kenya and to investigate how loss to follow-up is affected by gender.
METHODS: Between November 2001 and November 2007, 50 275 HIV-positive individuals
aged ≥ 14 years (69% female; median age: 36.2 years) were enrolled in the study.
An individual was lost to follow-up when absent from the HIV treatment clinic for
> 3 months if on combination antiretroviral therapy (cART) or for > 6 months if
not. The incidence of loss to follow-up was calculated using Kaplan-Meier methods
and factors associated with loss to follow-up were identified by logistic and Cox
multivariate regression analysis.
FINDINGS: Overall, 8% of individuals attended no follow-up visits, and 54% of
them were lost to follow-up. The overall incidence of loss to follow-up was 25.1
per 100 person-years. Among the 92% who attended at least one follow-up visit,
the incidence of loss to follow-up before and after starting cART was 27.2 and
14.0 per 100 person-years, respectively. Baseline factors associated with loss to
follow-up included younger age, a long travel time to the clinic, patient
disclosure of positive HIV status, high CD4+ lymphocyte count, advanced-stage HIV
disease, and rural clinic location. Men were at an increased risk overall and
before and after starting cART.
CONCLUSION: The risk of being lost to follow-up was high, particularly before
starting cART. Men were more likely to become lost to follow-up, even after
adjusting for baseline sociodemographic and clinical characteristics.
Interventions designed for men and women separately could improve retention.
PMCID: PMC2930357
PMID: 20865073 [PubMed - indexed for MEDLINE]
86. PLoS One. 2010 Aug 26;5(8):e12435.
Rapid implementation of an integrated large-scale HIV counseling and testing,
malaria, and diarrhea prevention campaign in rural Kenya.
Lugada E, Millar D, Haskew J, Grabowsky M, Garg N, Vestergaard M, Khan JG,
Muraguri N, Mermin J.
CHF International, Nairobi, Kenya. [email protected]
Erratum in
PLoS One. 2010;5(9). doi:
10.1371/annotation/cd255375-7cf9-4b56-a81f-ec57e360c472. Kahn, James [corrected
to Khan, James G].
BACKGROUND: Integrated disease prevention in low resource settings can increase
coverage, equity and efficiency in controlling high burden infectious diseases. A
public-private partnership with the Ministry of Health, CDC, Vestergaard Frandsen
and CHF International implemented a one-week integrated multi-disease prevention
METHOD: Residents of Lurambi, Western Kenya were eligible for participation. The
aim was to offer services to at least 80% of those aged 15-49. 31 temporary sites
in strategically dispersed locations offered: HIV counseling and testing, 60 male
condoms, an insecticide-treated bednet, a household water filter for women or an
individual filter for men, and for those testing positive, a 3-month supply of
cotrimoxazole and referral for follow-up care and treatment.
FINDINGS: Over 7 days, 47,311 people attended the campaign with a 96% uptake of
the multi-disease preventive package. Of these, 99.7% were tested for HIV (87% in
the target 15-49 age group); 80% had previously never tested. 4% of those tested
were positive, 61% were women (5% of women and 3% of men), 6% had median CD4
counts of 541 cell/µL (IQR; 356, 754). 386 certified counselors attended to an
average 17 participants per day, consistent with recommended national figures for
mass campaigns. Among women, HIV infection varied by age, and was more likely
with an ended marriage (e.g. widowed vs. never married, OR.3.91; 95% CI.
2.87-5.34), and lack of occupation. In men, quantitatively stronger relationships
were found (e.g. widowed vs. never married, OR.7.0; 95% CI. 3.5-13.9). Always
using condoms with a non-steady partner was more common among HIV-infected women
participants who knew their status compared to those who did not (OR.5.4 95% CI.
CONCLUSION: Through integrated campaigns it is feasible to efficiently cover
large proportions of eligible adults in rural underserved communities with
multiple disease preventive services simultaneously achieving various national
and international health development goals.
PMCID: PMC2928737
PMID: 20865049 [PubMed - indexed for MEDLINE]
87. AIDS Res Hum Retroviruses. 2010 Oct;26(10):1051-61. Epub 2010 Sep 19.
Evaluating the BED capture enzyme immunoassay to estimate HIV incidence among
adults in three countries in sub-Saharan Africa.
Kim AA, McDougal JS, Hargrove J, Rehle T, Pillay-Van Wyk V, Puren A, Ekra A,
Borget-Alloue MY, Adje-Toure C, Abdullahi AS, Odawo L, Marum L, Parekh BS.
Global AIDS Program, Centers for Disease Control and Prevention (CDC), Atlanta,
Georgia 30333, USA. [email protected]
Serological assays for estimating HIV-1 incidence are prone to misclassification,
limiting the accuracy of the incidence estimate. Adjustment factors have been
developed and recommended for estimating assay-based HIV-1 incidence in
cross-sectional settings. We evaluated the performance of the recommended
adjustment factors for estimating incidence in national HIV surveys in three
countries in sub-Saharan Africa. The BED-capture enzyme immunoassay was applied
to stored blood specimens from (1) pregnant women aged 15-49 years attending
antenatal clinics in Côte d'Ivoire (1998-2004), (2) adults aged 15-49 years
participating in a demographic health survey in Kenya (2003), and (3) adults aged
15-49 years participating in a national household serosurvey in South Africa
(2005). Assay-derived incidence estimates were corrected for misclassification
using recommended adjustment factors and, where possible, were compared to
mathematically modeled incidence in the same populations. Trends in HIV
prevalence were compared to trends in assay-derived incidence to assess
plausibility in the assay-derived trends. Unadjusted incidence was 3.8% [95%
confidence interval (CI) 3.3-4.5] in Côte d'Ivoire, 3.5% (2.7-4.3) in Kenya, and
4.4% (CI 2.3-6.5]) in South Africa. Adjusted incidence was 2.9% (CI 2.1-3.7) in
Côte d'Ivoire, 2.6% (CI 2.0-3.2) in Kenya, and 2.4% (CI 1.7-3.1) in South Africa.
After adjustment, peak incidence shifted from older to younger age groups in Côte
d'Ivoire and South Africa. Modeled HIV incidence was 1.0% (CI 1.02-1.08) in Kenya
and 2.0% (CI 1.7-2.4) in South Africa. After applying the recommended adjustments
factors, adjusted assay-derived estimates remained implausibly high in two of
three populations evaluated. For more accurate measures of assay-derived
population incidence, adjustment factors must be locally derived and validated.
Until improved assays are available, caution should be applied in the use and
interpretation of data from incidence assays.
PMID: 20849299 [PubMed - indexed for MEDLINE]
88. Acta Obstet Gynecol Scand. 2010 Oct;89(10):1338-45.
Pharmacokinetics of chemotherapeutic agents in pregnancy: a preclinical and
clinical study.
Van Calsteren K, Verbesselt R, Ottevanger N, Halaska M, Heyns L, Van Bree R, de
Bruijn E, Chai D, Delforge M, Noens L, Renard V, Witteveen E, Rob L, de Hoon J,
Amant F.
Department of Obstetrics & Gynecology, Division of Gynecological Oncology,
University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven,
OBJECTIVE: To determine the impact of physiologic changes of pregnancy on
pharmacokinetics of chemotherapeutic agents.
DESIGN: A preclinical and a clinical case-control trial.
SETTING: Institute of Primate Research Nairobi and collaborating hospitals in
Belgium, the Netherlands and Czech Republic.
POPULATION: Pregnant and nonpregnant women and baboons receiving chemotherapy.
METHODS: Chemotherapy pharmacokinetics was compared between the pregnant and
nonpregnant state. Standard-dosed chemotherapy regimens were administered in
pregnant and nonpregnant baboons/women, followed by serial blood samplings. Drug
plasma levels were determined using high performance liquid chromatography and
atomic absorption spectrometry.
MAIN OUTCOME MEASURES: Area under the curve (AUC), maximal plasma concentration,
terminal elimination half-life, clearance and distribution volume of each drug in
pregnant and nonpregnant state.
RESULTS: Intraindividual comparative pharmacokinetic data were obtained for
doxorubicin and paclitaxel/platinum in three and two baboons, respectively. In
the clinical trial, two patients were exposed to doxorubicin and one patient was
exposed to paclitaxel/platinum during and after pregnancy. Furthermore, a pooled
analysis was performed based on 16 cycles of pregnant and 11 cycles of
nonpregnant women. Numbers of pregnant/nonpregnant patients were 5/2, 7/5, 4/4
and 2/2 for paclitaxel, doxorubicin, epirubicin and platinum, respectively. For
all drugs tested in the preclinical and clinical study, a decreased AUC and
maximal plasma concentration and an increased distribution volume and clearance
were observed in pregnancy.
CONCLUSIONS: Although numbers were too small for statistical significance,
pregnancy-associated physiologic alterations appear to lead to a decrease in
plasma exposure of chemotherapeutic drugs. The importance of long-term follow-up
of women treated with chemotherapy during pregnancy is underscored.
PMID: 20846067 [PubMed - indexed for MEDLINE]
89. AIDS Patient Care STDS. 2010 Oct;24(10):639-49.
The perceived impact of disclosure of pediatric HIV status on pediatric
antiretroviral therapy adherence, child well-being, and social relationships in a
resource-limited setting.
Vreeman RC, Nyandiko WM, Ayaya SO, Walumbe EG, Marrero DG, Inui TS.
Children's Health Services Research, Diabetes Translational Research Center,
Department of Medicine, Indiana University School of Medicine, Indianapolis,
Indiana 46202, USA. [email protected]
In resource-limited settings, beliefs about disclosing a child's HIV status and
the subsequent impacts of disclosure have not been well studied. We sought to
describe how parents and guardians of HIV-infected children view the impact of
disclosing a child's HIV status, particularly for children's antiretroviral
therapy (ART) adherence. A qualitative study was conducted using involving focus
groups and interviews with parents and guardians of HIV-infected children
receiving ART in western Kenya. Interviews covered multiple aspects of the
experience of having children take medicines. Transcribed interview dialogues
were coded for analysis. Data were collected from 120 parents and guardians
caring for children 0–14 years (mean 6.8 years, standard deviation [SD] 6.4); 118
of 120 had not told the children they had HIV. Children's caregivers (parents and
guardians) described their views on disclosure to children and to others,
including how this information-sharing impacted pediatric ART adherence,
children's well-being, and their social relationships. Caregivers believed that
disclosure might have benefits such as improved ART adherence, especially for
older children, and better engagement of a helping social network. They also
feared, however, that disclosure might have both negative psychological effects
for children and negative social effects for their families, including
discrimination. In western Kenya, caregivers' views on the risks and benefits to
disclosing children's HIV status emerged a key theme related to a family's
experience with HIV medications, even for families who had not disclosed the
child's status. Assessing caregivers' views of disclosure is important to
understanding and monitoring pediatric ART.
PMID: 20836704 [PubMed - indexed for MEDLINE]
90. Lancet. 2010 Sep 11;376(9744):846.
Providing paediatric palliative care in Kenya.
[No authors listed]
Comment in
Lancet. 2010 Dec 11;376(9757):1988.
PMID: 20833285 [PubMed - indexed for MEDLINE]
91. J Ethnopharmacol. 2010 Dec 1;132(3):600-6. Epub 2010 Sep 9.
East African discourses on khat and sex.
Beckerleg S.
School of Health and Social Studies, University of Warwick, Coventry CV47AL, UK.
[email protected]
AIM OF THE STUDY: The study aims to review and analyse the varied East African
discourses on the effects of khat use on libido, fertility, transmission of HIV,
prostitution and rape.
MATERIALS AND METHODS: The data were gathered between 2004 and 2009 in Kenya and
Uganda. Between 2004 and 2005 across Kenya and Uganda a broad survey approach was
adopted, involving identification of and travel to production areas, interviews
with producers and consumers in rural and urban settings. In addition, a survey
of 300 Ugandan consumers was carried out in late 2004. Between 2007 and 2009, an
in-depth study of khat production, trade and consumption was conducted in Uganda.
This study also employed a mixture of methods, including key informant interviews
participant-observation and a questionnaire survey administered to 210 khat
RESULTS: Khat is associated, by consumers and its detractors alike, with changes
in libido and sexual performance. Although there is no evidence to support their
claims, detractors of khat use argue that khat causes sexual violence, causes
women to enter sex work, and that chewing causes the spread of sexually
transmitted diseases, including the HIV virus.
CONCLUSIONS: In East Africa the discourse on khat and sex has led to consumption
of the substances being associated by many people with uncontrolled sexual
behaviour. There is no evidence that khat use fuels promiscuity, commercial sex,
sexually transmitted diseases or rape. The current discourse on khat and sex
touches on all these topics. Local religious and political leaders invoke khat
use as a cause of what they argue is a breakdown of morals and social order. In
Kenya and Uganda it is women khat consumers who are seen as sexually
uncontrolled. In Uganda, the argument is extended even to men: with male khat
chewers labelled as prone to commit rape.
PMID: 20832464 [PubMed - indexed for MEDLINE]
92. Int J Tuberc Lung Dis. 2010 Sep;14(9):1140-6.
Piloting the use of personal digital assistants for tuberculosis and human
immunodeficiency virus surveillance, Kenya, 2007.
Auld AF, Wambua N, Onyango J, Marston B, Namulanda G, Ackers M, Oluoch T, Karisa
A, Hightower A, Shiraishi RW, Nakashima A, Sitienei J.
Care and Treatment Team, Global AIDS Program, National Center for HIV, Hepatitis,
STD and TB Prevention, Global AIDS Program, US Centers for Disease Control and
Prevention, Atlanta, Georgia 30333, USA. [email protected]
SETTING: Improved documentation of human immunodeficiency virus (HIV) testing and
care among tuberculosis (TB) patients is needed to strengthen TB-HIV programs. In
2007, Kenya piloted the use of personal digital assistants (PDAs) instead of
paper registers to collect TB-HIV surveillance data from TB clinics.
OBJECTIVE: To evaluate the acceptability, data quality and usefulness of PDAs.
DESIGN: We interviewed four of 31 district coordinators who collected data in
PDAs for patients initiating TB treatment from April to June 2007. In 10 of 93
clinics, we randomly selected patient records for comparison with corresponding
records in paper registers or PDAs. Using Cochran-Mantel-Haenszel tests, we
compared missing data proportions in paper registers with PDAs. We evaluated PDA
usefulness by analyzing PDA data from all 93 clinics.
RESULTS: PDAs were well accepted. Patient records were more frequently missing
(28/97 vs. 1/112, P < 0.001) and data fields more frequently incomplete (148/1449
vs. 167/2331, P = 0.03) in PDAs compared with paper registers. PDAs, however,
facilitated clinic-level analyses: 48/93 (52%) clinics were not reaching the
targets of testing >or=80% of TB patients for HIV, and 8 (9%) clinics were
providing <80% of TB-HIV co-infected patients with cotrimoxazole (CTX).
CONCLUSION: PDAs had high rates of missing data but helped identify clinics that
were undertesting for HIV or underprescribing CTX.
PMID: 20819259 [PubMed - indexed for MEDLINE]
93. J Infect Dis. 2010 Oct 15;202(8):1273-7.
Maternal human leukocyte antigen A*2301 is associated with increased
mother-to-child HIV-1 transmission.
Mackelprang RD, Carrington M, John-Stewart G, Lohman-Payne B, Richardson BA,
Wamalwa D, Gao X, Majiwa M, Mbori-Ngacha D, Farquhar C.
Departments of 1Epidemiology, 2Medicine, 3Global Health, and 4Biostatistics,
University of Washington, Seattle, Washington; 5Cancer and Inflammation Program,
Laboratory of Experimental Immunology, SAIC-Frederick, Inc, National Cancer
Institute at Frederick, Maryland; and 6Department of Paediatrics, University of
Nairobi, Kenya.
We examined associations between maternal human leukocyte antigen (HLA) and
vertical human immunodeficiency virus type 1 (HIV-1) transmission in a perinatal
cohort of 277 HIV-infected women in Nairobi. HLA class I genes were amplified by
using sequence-specific oligonucleotide probes, and analyses were performed using
logistic regression. Maternal HLA-A*2301 was associated with increased
transmission risk before and after adjusting for maternal viral load (unadjusted:
odds ratio [OR], 3.21; 95% confidence interval [CI], 1.42-7.27; P = .005; Pcorr =
0.04; adjusted: OR, 3.07; 95% CI, 1.26-7.51; P =.01; Pcorr is not significant).
That maternal HLA-A*2301 was associated with transmission independent of plasma
HIV-1 RNA levels suggests that HLA may alter infectivity through mechanisms other
than influencing HIV-1 load.
PMID: 20812845 [PubMed - indexed for MEDLINE]
94. PLoS One. 2010 Aug 25;5(8):e12366.
"When I was circumcised I was taught certain things": risk compensation and
protective sexual behavior among circumcised men in Kisumu, Kenya.
Riess TH, Achieng' MM, Otieno S, Ndinya-Achola JO, Bailey RC.
School of Public Health, University of Illinois at Chicago, Chicago, Illinois,
United States of America. [email protected]
BACKGROUND: Male circumcision has been shown to reduce the transmission of HIV
from women to men through vaginal sex by approximately 60%. There is concern that
men may engage in risk compensation after becoming circumcised, diminishing the
benefits of male circumcision.
METHODS AND FINDINGS: We conducted qualitative interviews with 30 sexually active
circumcised men in Kisumu, Kenya from March to November 2008. Most respondents
reported no behavior change or increasing protective sexual behaviors including
increasing condom use and reducing the number of sexual partners. A minority of
men reported engaging in higher risk behaviors either not using condoms or
increasing the number of sex partners. Circumcised respondents described being
able to perform more rounds of sex, easier condom use, and fewer cuts on the
penis during sex.
CONCLUSIONS: Results illustrate that information about MC's protection against
HIV has disseminated into the larger community and MC accompanied by counseling
and HIV testing can foster positive behavior change and maintain sexual behavior.
PMCID: PMC2928269
PMID: 20811622 [PubMed - indexed for MEDLINE]
95. Afr Health Sci. 2010 Mar;10(1):58-65.
Integrating cervical cancer and genital tract infection screening into mother,
child health and family planning clinics in Eldoret, Kenya.
Were E, Nyaberi Z, Buziba N.
Department of Reproductive Health, Moi University, Eldoret, Kenya.
[email protected]
BACKGROUND: Visual inspection, with acetic acid (VIA) and with Lugol's iodine
(VILI), has been demonstrated to have test characteristics comparable to those of
Pap smear but are more affordable and easier implement. It also presents an
opportunity for management of female genital tract infection.
OBJECTIVES: Pilot test integration of cervical cancer screening using visual
inspection with genital tract infection identification into an existing MCH-FP in
METHODS: Cross sectional, descriptive study in which consecutive women were
screened for genital tract inflammatory morbidity and cervical cancer through
visual inspection.
RESULTS: Two hundred and nineteen women with a mean age of 31-3 years, parity of
3.1 were screened. About 54% of study participants had multiple sex partners, 62%
had sexual debut earlier than 20 years, while use of tobacco was reported by 4%.
The test positivity rate was 13.9% and 16.9% for VIA and VILI respectively.
Positive test finding was significantly related to contraceptive never-use after
controlling for previous screening (p=0.006).Symptoms of genital tract infections
were reported by 38% of the participants with features of cervicitis being
reported by nearly 24%.
CONCLUSION: Integration of cervical cancer screening and genital tract infection
identification and treatment into the existing MCH-FP appears feasible.
PMCID: PMC2895794
PMID: 20811526 [PubMed - indexed for MEDLINE]
96. Am J Trop Med Hyg. 2010 Sep;83(3):565-70.
Implementation of a validated peripheral neuropathy screening tool in patients
receiving antiretroviral therapy in Mombasa, Kenya.
Mehta SA, Ahmed A, Kariuki BW, Said S, Omasete F, Mendillo M, Laverty M, Holzman
R, Valentine F, Sivapalasingam S.
Division of Infectious Diseases, and Center for AIDS Research, Department of
Medicine, New York University School of Medicine, New York, New York, USA.
[email protected]
Limited objective data are available for the prevalence of peripheral neuropathy
(PN) among antiretroviral (ART)-treated human immunodeficiency virus
(HIV)-infected patients in resource-limited settings. A validated
neuropathy-screening tool was integrated into routine ART visits at an HIV clinic
in Mombasa, Kenya. Diagnosis of PN required at least one symptom and either
abnormal vibratory sensation or deep tendon reflex bilaterally. Among 102
consecutively screened patients, 63% were women, 62% were receiving ART for < or
= 1 year, and 86% were receiving a stavudine (D4T)-based regimen. Thirty-seven
(36%) had PN. Univariate analysis showed that current D4T use was protective
against PN (P = 0.03) and older age was a marginal risk factor (P = 0.05).
Multivariate analysis showed that older age was a risk factor for neuropathy (P =
0.04). Peripheral neuropathy was common, particularly among older HIV-infected
adults in Kenya. The protective association with current D4T use likely
represents survivor effect bias. Longitudinal studies using this screen will help
further characterize PN in resource-limited settings.
PMCID: PMC2929052 [Available on 2011/9/1]
PMID: 20810821 [PubMed - indexed for MEDLINE]
97. Health Policy. 2010 Oct;97(2-3):232-7. Epub 2010 Jun 8.
Staff attrition among community health workers in home-based care programmes for
people living with HIV and AIDS in western Kenya.
Olang'o CO, Nyamongo IK, Aagaard-Hansen J.
Institute of Anthropology, Gender and African Studies, University of Nairobi,
Nairobi, Kenya. [email protected]
OBJECTIVES: This paper examines trends and underlying causes of attrition among
volunteer community health workers in home-based care for people living with HIV
and AIDS in western Kenya.
METHODS: Ethnographic data were collected between January and November 2006
through participant observation, focus group discussions and in-depth interviews
with 30 CHWs, NGO staff and health care providers and 70 PLWHA.
RESULTS: An attrition rate of 33% was observed among the CHWs. The reasons for
dropout included: the cultural environment within which CHWs operated; lack of
adequate support from area NGOs; poor selection criteria for CHWs; and power
differences between NGO officials and CHWs which fostered lack of transparency in
the NGOs' operations.
CONCLUSIONS: In order to achieve well functioning and sustainable HBC services,
factors which influence retention/dropout of CHWs should be addressed taking into
account the socio-cultural, programmatic and economic contexts within which CHW
activities are implemented.
PMID: 20807685 [PubMed - indexed for MEDLINE]
98. Vox Sang. 2011 Feb;100(2):212-8. doi: 10.1111/j.1423-0410.2010.01376.x. Epub 2010
Aug 25.
Blood donors in Kenya: a comparison of voluntary and family replacement donors
based on a population-based survey.
Kimani D, Mwangi J, Mwangi M, Bunnell R, Kellogg TA, Oluoch T, Gichangi A, Kaiser
R, Mugo N, Odongo T, Oduor M, Marum L; KAIS Study Group.
Collaborators: Arnold M, Baltazar G, Baya I, Bore J, Dadabhai S, Dale H, Ichwara
J, Hightower A, Galgalo T, Gichimu C, Kichamu G, Kim A, Kim E, Kipruto S, K'opiyo
G, Makokha E, Marston B, Marum L, Mburu M, Mermin J, Mirjahangir J, Mpazanje R,
Mohamed I, Muriithi P, Muttunga J, Ngare C, Nyoka R, Odawo L, Ogola S, Omolo C,
Shiraishi R, Wanyungu J, Waruru A.
Global AIDS Program, Centers for Disease Control and Prevention, Nairobi, Kenya.
[email protected]
BACKGROUND AND OBJECTIVES: Blood safety and sufficiency are major challenges in
Kenya and other sub-Saharan African countries forcing many countries to rely on
family replacement donors (FRD). We analysed data from a national AIDS indicator
survey to describe blood donors in Kenya and potential risks of transfusion
transmissible infections (TTI) comparing voluntary donors and FRD.
MATERIALS AND METHODS: A population-based, cross-sectional survey was conducted
in 2007 among 15- to 64-year-olds. Consenting participants were interviewed about
blood donation history and were tested for HIV, HSV-2 and syphilis.
RESULTS: Of the 17,940 people surveyed, 445 (2·3%) reported donating blood in the
prior 12 months. Sixty-four per cent were voluntary donors, and the rest were
FRD. Compared to FRD, the majority of voluntary donors were <25 years old (59%
versus 18%), from the highest wealth quintile (57% versus 42%) and single (64%
versus 23%). In addition, voluntary donors were less likely to have been sexually
active than replacement donors (43% versus 13%). HIV prevalence was lower among
voluntary donors than among FRD (2·6% versus 7·4%, P-value=0·07).
CONCLUSIONS: The majority of blood donors in Kenya are voluntary with lower
potential risk of TTI.
PMID: 20738836 [PubMed - indexed for MEDLINE]
99. Am J Hum Biol. 2010 Nov-Dec;22(6):768-74.
Maternal hemoglobin depletion in a settled northern Kenyan pastoral population.
Miller EM.
Department of Anthropology, University of Michigan, Ann Arbor, Michigan 48109,
USA. [email protected]
OBJECTIVES: This study examines maternal hemoglobin depletion in a
cross-sectional sample of Ariaal women living in northern Kenya. Maternal
hemoglobin depletion occurs when women do not have enough dietary iron to replace
the high levels of iron allocated to the fetus during pregnancy.
METHODS: To study this phenomenon, reproductive histories, socioeconomic status,
anthropometry, and hemoglobin levels were collected from a cross-section of 200
lactating Ariaal women in northern Kenya.
RESULTS: Ariaal women show increasing levels of hemoglobin with increasing time
since birth and lower hemoglobin levels with increasing parity, indicating an
incomplete repletion of dietary iron over women's reproductive lifetime. Women
who lived in a more livestock-dependent village had higher hemoglobin levels and
lower prevalence of clinical anemia than women who lived in villages more
dependent on agriculture, indicating that differences in diet may alleviate the
effects of iron depletion.
CONCLUSIONS: These data demonstrate that Ariaal women are iron depleted due to
pregnancy, incompletely replete hemoglobin during the course of lactation, and
show depletion of hemoglobin with increasing parity. Women in this community may
be able to improve their iron status through a greater reliance on food sources
rich in dietary iron.
PMID: 20721981 [PubMed - indexed for MEDLINE]
100. Am J Clin Pathol. 2010 Sep;134(3):410-8.
Field experience in implementing ISO 15189 in Kisumu, Kenya.
Zeh CE, Inzaule SC, Magero VO, Thomas TK, Laserson KF, Hart CE, Nkengasong JN;
KEMRI/CDC HIV Research Laboratory.
US Centers for Disease Control and Prevention, Kenya, Kisumu, Kenya.
Quality medical laboratory services are an integral part of routine health care,
medical research, and public health systems. Despite this vital role, quality
laboratory services in Africa are scarce. The crucial need for expanding quality
laboratory services throughout sub-Saharan Africa is especially critical because
of the region's burden of disease. Fortunately, several plans from supporting
international partners are underway to help strengthen laboratory infrastructure
in this region. A key component of these initiatives is the enforcement of
quality assurance services through accreditation by international standards such
as the International Organization for Standardization (ISO) 15189. However,
acquisition and maintenance of these standards are a significant challenge,
especially in resource-limited settings. The most common limiting factors can
include funding, government support, equipment, training opportunities, and poor
procurement infrastructure. In this article, we discuss the challenges and
benefits accrued in pursuing and sustaining ISO 15189 accreditation for the Kenya
Medical Research Institute/Centre for Disease Control HIV-Research Laboratory in
Kisumu, Kenya.
PMID: 20716797 [PubMed - indexed for MEDLINE]
101. J Acquir Immune Defic Syndr. 2010 Oct 1;55(2):e3-10.
Acceptance of HIV testing for children ages 18 months to 13 years identified
through voluntary, home-based HIV counseling and testing in western Kenya.
Vreeman RC, Nyandiko WM, Braitstein P, Were MC, Ayaya SO, Ndege SK, Wiehe SE.
Department of Pediatrics, Children's Health Services Research, Indiana University
School of Medicine, Indianapolis, IN, USA. [email protected]
BACKGROUND: Home-based voluntary counseling and testing (HCT) presents a novel
approach to early diagnosis. We sought to describe uptake of pediatric HIV
testing, associated factors, and HIV prevalence among children offered HCT in
METHODS: The USAID-Academic Model Providing Access to Healthcare Partnership
conducted HCT in western Kenya in 2008. Children 18 months to 13 years were
offered HCT if their mother was known to be dead, her living status was unknown,
mother was HIV infected, or of unknown HIV status. This retrospective analysis
describes the cohort of children encountered and tested.
RESULTS: HCT was offered to 2289 children and accepted for 1294 (57%). Children
were more likely to be tested if more information was available about a suspected
or confirmed maternal HIV infection [for HIV-infected living mothers odds ratio
(OR) = 3.20, 95% confidence interval (CI): 1.64 to 6.23), if parents were not in
household (OR = 1.50, 95% CI: 1.40 to 1.63), if they were grandchildren of head
of household (OR = 4.02, 95% CI: 3.06 to 5.28), or if their father was not in
household (OR = 1.41, 95% CI: 1.24 to 1.56). Of the eligible children tested, 60
(4.6%) were HIV infected.
CONCLUSIONS: HCT provides an opportunity to identify HIV among high-risk
children; however, acceptance of HCT for children was limited. Further
investigation is needed to identify and overcome barriers to testing uptake.
PMID: 20714272 [PubMed - indexed for MEDLINE]
102. AIDS Care. 2010 Nov;22(11):1323-31.
How late is too late? Timeliness to scheduled visits as an antiretroviral therapy
adherence measure in Nairobi, Kenya and Lusaka, Zambia.
Blacher RJ, Muiruri P, Njobvu L, Mutsotso W, Potter D, Ong'ech J, Mwai P, Degroot
A, Zulu I, Bolu O, Stringer J, Kiarie J, Weidle PJ.
Centers for Disease Control and Prevention, Atlanta, GA, USA.
[email protected]
Collecting self-reported data on adherence to highly active antiretroviral
therapy (HAART) can be complicated by patients' reluctance to report poor
adherence. The timeliness with which patients attend visits might be a useful
alternative to estimate medication adherence. Among Kenyan and Zambian women
receiving twice daily HAART, we examined the relationship between self-reported
pill taking and timeliness attending scheduled visits. We analyzed data from 566
Kenyan and Zambian women enrolled in a prospective 48-week HAART-response study.
At each scheduled clinic visit, women reported doses missed over the preceding
week. Self-reported adherence was calculated by summing the total number of doses
reported taken and dividing by the total number of doses asked about at the visit
attended. A participant's adherence to scheduled study visits was defined as "on
time" if she arrived early or within three days, "moderately late" if she was
four-seven days late, and "extremely late/missed" if she was more than eight days
late or missed the visit altogether. Self-reported adherence was <95% for 29
(10%) of 288 women who were late for at least one study visit vs. 3 (1%) of 278
who were never late for a study visit (odds ratios [OR] 10.3; 95% confidence
intervals [95% CI] 2.9, 42.8). Fifty-one (18%) of 285 women who were ever late
for a study visit experienced virologic failure vs. 32 (12%) of 278 women who
were never late for a study visit (OR 1.7; 95% CI 1.01, 2.8). A multivariate
logistic regression model controlling for self-reported adherence found that
being extremely late for a visit was associated with virologic failure (OR 2.0;
95% CI 1.2, 3.4). Timeliness to scheduled visits was associated with
self-reported adherence to HAART and with risk for virologic failure. Timeliness
to scheduled clinic visits can be used as an objective proxy for self-reported
adherence and ultimately for risk of virologic failure.
PMID: 20711886 [PubMed - indexed for MEDLINE]
103. AIDS Educ Prev. 2010 Aug;22(4):328-43.
Evaluation of a U.S. evidence-based parenting intervention in rural Western
Kenya: from parents matter! To families matter!
Vandenhoudt H, Miller KS, Ochura J, Wyckoff SC, Obong'o CO, Otwoma NJ, Poulsen
MN, Menten J, Marum E, Buvé A.
Institute of Tropical Medicine, Antwerp, Belgium. [email protected]
We evaluated Families Matter! Program (FMP), an intervention designed to improve
parent-child communication about sexual risk reduction and parenting skills.
Parents of 10- to 12-year-olds were recruited in western Kenya. We aimed to
assess community acceptability and FMP's effect on parenting practices and
effective parent-child communication. Data were collected from parents and their
children at baseline and 1 year postintervention. The intervention's effect was
measured on six parenting and parent-child communication composite scores
reported separately for parents and children. Of 375 parents, 351 (94%) attended
all five intervention sessions. Parents' attitudes regarding sexuality education
changed positively. Five of the six composite parenting scores reported by
parents, and six of six reported by children, increased significantly at 1 year
postintervention. Through careful adaptation of this U.S. intervention, FMP was
well accepted in rural Kenya and enhanced parenting skills and parent-child
sexuality communication. Parents are in a unique position to deliver primary
prevention to youth before their sexual debut as shown in this Kenyan program.
PMID: 20707693 [PubMed - indexed for MEDLINE]
104. AIDS Educ Prev. 2010 Aug;22(4):273-85.
Cultural adaptation of a U.S. evidence-based parenting intervention for rural
Western Kenya: from parents matter! To families matter!
Poulsen MN, Vandenhoudt H, Wyckoff SC, Obong'o CO, Ochura J, Njika G, Otwoma NJ,
Miller KS.
Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta,
GA 30333, USA. [email protected]
Evidence-based interventions (EBIs) are critical for effective HIV prevention,
but time and resources required to develop and evaluate new interventions are
limited. Alternatively, existing EBIs can be adapted for new settings if core
elements remain intact. We describe the process of adapting the Parents Matter!
Program, an EBI originally developed for African American parents to promote
effective parent-child communication about sexual risk reduction and parenting
skills, for use in rural Kenya. A systematic process was used to assess the
community's needs, identify potential EBIs, identify and make adaptations,
pilot-test the adapted intervention, and implement and monitor the adapted EBI.
Evaluation results showed the adapted EBI retained its effectiveness,
successfully increasing parent-child sexual communication and parenting skills.
Our experience suggests an EBI can be successfully adapted for a new context if
it is relevant to local needs, the process is led by a multidisciplinary team
with community representation, and pilot-testing and early implementation are
well monitored.
PMID: 20707689 [PubMed - indexed for MEDLINE]
105. Trop Anim Health Prod. 2011 Jan;43(1):199-207. Epub 2010 Aug 12.
Factors that determine use of breeding services by smallholder dairy farmers in
Central Kenya.
Murage AW, Ilatsia ED.
Kenya Agricultural Research Institute, National Animal Husbandry Research Centre,
Naivasha Kenya, P.O. Box 25, 20117, Naivasha. [email protected]
This study examined the determinants of smallholder dairy farmers' use of
breeding services in Nyandarua and Kiambu districts, Central Kenya. Data was
collected through semi-structured interviews with 140 randomly selected
respondents. The breeding services considered were artificial insemination (AI),
natural bull service, or a combination of AI and bull services. A multinomial
logit econometric model was used fitting AI as the base category. There was a
negative relationship between higher levels of education, herd size, and location
and the use of bull service. However, education, herd size, and credit were
positively related to the combined option. The results indicate that uptake of AI
services after the liberalization of the sector is influenced by other factors
besides cost-related factors. Factors such as accessibility to breeding services
and product markets had influence on the farmer decision to choose among the
available breeding services. The effectiveness of the breeding services in terms
of successful conception also plays a big role in the choice. A need for
concerted efforts to increase farmer's knowledge base on utilization and
effectiveness of available breeding services is imperative. Furthermore,
smallholder dairy farming could be made more sustainable and economically viable
by implementing initiatives geared towards enhancing access to breeding services
that would guarantee access to quality genetic material.
PMID: 20703810 [PubMed - indexed for MEDLINE]
106. Afr J Reprod Health. 2010 Mar;14(1):33-41.
The attitudes of Kenyan in-school adolescents toward sexual autonomy.
Adaji SE, Warenius LU, Ong'any AA, Faxelid EA.
Division of International Health, IHCAR, Department of Public Health Sciences,
Karolinska Institutet, Stockholm, Sweden. [email protected]
This was a cross-sectional study to examine the attitudes of Kenyan in-school
adolescents towards premarital sex, unwanted pregnancies/abortions and
contraception. Data collection was undertaken using a structured questionnaire.
Kenyan in-school adolescents have conservative attitudes toward premarital sex,
disagreeing that adolescent boy and girls should be left alone to satisfy their
sexual needs. The girls had the view that boys have uncontrollable sexual
appetites. With regards to unwanted pregnancies, the majority of the respondents
disagreed with allowing abortions for pregnant school girls while they agreed
that a pregnant school girl should be allowed to return to school. However, the
majority of the girls held the view that a school boy who had impregnated a
school girl should be expelled from school. The attitudes of the respondents to
contraception were also largely conservative. The conservative attitudes of the
respondents conflicts with the findings of high levels of unsafe sex and
reproductive ill-health among Kenyan adolescents. There is need to help Kenyan
in-school adolescents to develop more realistic attitudes toward sexuality in
order to improve their reproductive health.
PMID: 20695137 [PubMed - indexed for MEDLINE]
107. J Acquir Immune Defic Syndr. 2010 Dec 1;55(4):483-90.
Task-shifting of antiretroviral delivery from health care workers to persons
living with HIV/AIDS: clinical outcomes of a community-based program in Kenya.
Selke HM, Kimaiyo S, Sidle JE, Vedanthan R, Tierney WM, Shen C, Denski CD,
Katschke AR, Wools-Kaloustian K.
Department of Medicine, Indiana University School of Medicine, Indianapolis, IN,
OBJECTIVES: To assess whether community-based care delivered by people living
with HIV/AIDS (PLWAs) could replace clinic-based HIV care.
DESIGN: Prospective cluster randomized controlled clinical trial.
SETTING: Villages surrounding 1 rural clinic in western Kenya.
SUBJECTS: HIV-infected adults clinically stable on antiretroviral therapy (ART).
INTERVENTION: The intervention group received monthly Personal Digital Assistant
supported home assessments by PLWAs with clinic appointments every 3 months. The
control group received standard of care monthly clinic visits.
MAIN OUTCOMES MEASURED: Viral load, CD4 count, Karnofsky score, stability of ART
regimen, opportunistic infections, pregnancies, and number of clinic visits.
RESULTS: After 1 year, there were no significant intervention-control differences
with regard to detectable viral load, mean CD4 count, decline in Karnofsky score,
change in ART regimen, new opportunistic infection, or pregnancy rate.
Intervention patients made half as many clinic visits as did controls (P <
CONCLUSIONS: Community-based care by PLWAs resulted in similar clinical outcomes
as usual care but with half the number of clinic visits. This pilot study
suggests that task-shifting and mobile technologies can deliver safe and
effective community-based care to PLWAs, expediting ART rollout and increasing
access to treatment while expanding the capacity of health care institutions in
resource-constrained environments.
PMID: 20683336 [PubMed - indexed for MEDLINE]
108. Am J Epidemiol. 2010 Sep 1;172(5):606-12. Epub 2010 Jul 26.
Assessment of changes in condom use among female sex workers in a prospective
cohort study introducing diaphragm use for disease prevention.
Gallo MF, Warner L, Bell AJ, Wiener J, Eschenbach DA, Bukusi EA, Sharma A,
Njoroge B, Ngugi E, Jamieson DJ.
Division of Reproductive Health, National Center for Chronic Disease Prevention
and Health Promotion, Centers for Disease Control and Prevention, Atlanta,
Georgia 30341-3724, USA. [email protected]
Changes in the rates of condom use and number of sexual partners were evaluated
among 140 female sex workers in Kibera, Kenya, participating in a 6-month study
of diaphragm safety and acceptability for prevention of sexually transmitted
infections conducted in 2004-2005. Analyses were stratified by partner type.
Multivariable Tobit regression modeling was used to assess the association
between study visit and proportion of acts protected. Participants completed 140
baseline visits and 390 bimonthly follow-up visits. The mean percentage of coital
acts reported as protected by a condom increased from 56% at baseline to 68% at
the 6-month visit (P < 0.01). Similar increases were observed for condom use by
all partner types. Additionally, the mean number of sexual partners decreased
over the study. Furthermore, consistent (i.e., 100%) diaphragm use during
follow-up was associated with a higher proportion of coital acts protected by a
condom in analyses adjusted for study visit and coital frequency. These findings
suggest that, despite concerns that introduction of the diaphragm would result in
more risky sexual behaviors, reported condom use increased and number of partners
PMID: 20660519 [PubMed - indexed for MEDLINE]
109. HIV Med. 2010 Nov;11(10):650-60. doi: 10.1111/j.1468-1293.2010.00873.x.
Nevirapine-associated hepatotoxicity was not predicted by CD4 count ≥250 cells/μL
among women in Zambia, Thailand and Kenya.
Peters PJ, Stringer J, McConnell MS, Kiarie J, Ratanasuwan W, Intalapaporn P,
Potter D, Mutsotso W, Zulu I, Borkowf CB, Bolu O, Brooks JT, Weidle PJ.
Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD,
and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention, Atlanta,
GA 30333, USA. [email protected]
OBJECTIVE: The aim of the study was to determine risk factors for developing
severe hepatotoxicity (grade 3 or 4 hepatotoxicity) and rash-associated
hepatotoxicity (rash with ≥ grade 2 hepatotoxicity) among women initiating
nevirapine-based antiretroviral therapy (ART).
METHODS: The Non-Nucleoside Reverse Transcriptase Inhibitor Response Study was a
prospective cohort study carried out in Zambia, Thailand and Kenya. Between May
2005 and January 2007, we enrolled antiretroviral-naïve HIV-infected women
initiating nevirapine-based ART. At enrollment and at weeks 2, 4, 8, 16 and 24,
participants had serum alanine transferase (ALT) and aspartate transaminase (AST)
measured and were evaluated clinically for hepatitis and rash.
RESULTS: Nevirapine-based ART was initiated in 820 women and baseline ALT or AST
results were abnormal (≥ grade 1) in 113 (14%) women. After initiating
nevirapine-based ART, severe hepatotoxicity occurred in 41 (5%) women and
rash-associated hepatotoxicity occurred in 27 (3%) women. In a multivariate
logistic regression model, severe hepatotoxicity and rash-associated
hepatotoxicity were both associated with baseline abnormal (≥ grade 1) ALT or AST
results, but not with a baseline CD4 cell count ≥250 cells/μL. Three participants
(0.4%) died with symptoms suggestive of fatal hepatotoxicity; all three women had
baseline CD4 count <100 cells/μL and were receiving anti-tuberculosis therapy.
CONCLUSION: Among women taking nevirapine-based ART, severe hepatotoxicity and
rash-associated hepatotoxicity were predicted by abnormal baseline ALT or AST
results, but not by a CD4 count ≥250 cells/μL. In resource-limited settings where
transaminase testing is available, testing should focus on early time-points and
on women with abnormal baseline ALT or AST results.
PMID: 20659176 [PubMed - indexed for MEDLINE]
110. Sex Transm Infect. 2010 Nov;86(6):440-1. Epub 2010 Jul 23.
High prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae infections
among HIV-1 negative men who have sex with men in coastal Kenya.
Sanders EJ, Thiong'o AN, Okuku HS, Mwambi J, Priddy F, Shafi J, de Vries H,
McClelland RS, Graham SM.
Kenya Medical Research Institute, Centre for Geographic Medicine Research Coast, PO Box 230, Kilifi, Kenya. [email protected]
OBJECTIVES: To assess the burden of Chlamydia trachomatis (CT) and Neisseria
gonorrhoeae (NG) in high-risk HIV-1 negative men who have sex with men (MSM) in
METHODS: Before the start of a pre-exposure prophylaxis trial, HIV-1 negative
volunteers were screened for sexually transmitted infection (STI) including CT
and NG, using a highly sensitive and specific nucleic acid amplification test.
Samples positive for CT by Aptima testing, were evaluated for the presence of
lymphogranuloma venereum (LGV) serovars using an in-house PCR assay. All men were
asked to submit a urine specimen, and all had a rectal swab collected by a
clinician. Men were asked if they had dysuria, urethral or rectal discharge, or
rectal pain.
RESULTS: 43 HIV-1 negative MSM were screened, of whom 13 reported sex with men
only; the majority (27/43) reported sex work. One volunteer had dysuria and
another, rectal pain. Eleven MSM (26%, 95% CI 14% to 41%) had infections with
either or both pathogens. Homosexual men had a higher prevalence of any infection
than bisexual men (46% vs 17%, p=0.04), and all cases of rectal infections,
including one with CT, two with NG and two with CT/NG co-infection. All patients
with CT were negative for LGV. One patient with a rectal NG infection reported
rectal pain.
CONCLUSIONS: A remarkably high burden of STI infection was found among HIV-1
negative MSM. Most (12/13) infections, including three of four rectal NG
infections, were subclinical. These findings suggest that high-risk MSM will
benefit from effective STI screening in Kenya.
PMID: 20656722 [PubMed - indexed for MEDLINE]
111. Int J Infect Dis. 2010 Sep;14(9):e810-4. Epub 2010 Jul 22.
Prevalence of human papillomavirus genotypes in HIV-1-infected women in Seattle,
USA and Nairobi, Kenya: results from the Women's HIV Interdisciplinary Network
Luque AE, Hitti J, Mwachari C, Lane C, Messing S, Cohn SE, Adler D, Rose R,
Coombs R.
Infectious Diseases Division, Department of Medicine, University of Rochester
School of Medicine and Dentistry, Box 689, 601 Elmwood Avenue, Rochester, NY
14642, USA. [email protected]
BACKGROUND: HIV-infected women have a high prevalence of human papillomavirus
(HPV) infection and are more likely to be infected with HPV genotypes that are
considered high-risk and have the potential for progressing to cervical cancer.
The currently available HPV vaccines protect against specific HPV genotypes that
may not be the most important causes of dysplasia and potentially of cervical
cancer in HIV-1-infected women. African women have been underrepresented in the
studies of global prevalence of HPV genotypes.
METHODS: We compared the HPV genotype distribution in HIV-1-infected women from
Seattle, Washington, USA and Nairobi, Kenya. The reverse line blot assay and DNA
sequencing on cervicovaginal lavage (CVL) specimens were carried out.
RESULTS: The most commonly detected HPV types among the women from Seattle were
HPV 56, 66, MM8, and 81; in contrast HPV 53, 33, and 58 were the most common HPV
genotypes detected in the CVL specimens from the women in the Nairobi cohort. The
HPV types associated with low-grade squamous intraepithelial lesions (LSIL) were
HPV 53 and HPV 56. HPV types 58, 52, and 16 were associated with high-grade
squamous intraepithelial lesions (HSIL).
CONCLUSIONS: A better understanding of HPV genotype distribution in the most
affected regions of the world is essential to planning effective vaccine
strategies if we are unable to demonstrate cross-protection between HPV genotypes
included in the present vaccines and those prevalent in the different
PMCID: PMC2951008 [Available on 2011/9/1]
PMID: 20655263 [PubMed - indexed for MEDLINE]
112. Lancet. 2010 Jul 24;376(9737):268-84.
HIV and risk environment for injecting drug users: the past, present, and future.
Strathdee SA, Hallett TB, Bobrova N, Rhodes T, Booth R, Abdool R, Hankins CA.
University of California, San Diego, Division of Global Public Health, Department
of Medicine, CA 92093-0507, USA. [email protected]
Comment in
Lancet. 2010 Aug 7;376(9739):398-400.
We systematically reviewed reports about determinants of HIV infection in
injecting drug users from 2000 to 2009, classifying findings by type of
environmental influence. We then modelled changes in risk environments in regions
with severe HIV epidemics associated with injecting drug use. Of 94 studies
identified, 25 intentionally examined risk environments. Modelling of HIV
epidemics showed substantial heterogeneity in the number of HIV infections that
are attributed to injecting drug use and unprotected sex. We estimate that,
during 2010-15, HIV prevalence could be reduced by 41% in Odessa (Ukraine), 43%
in Karachi (Pakistan), and 30% in Nairobi (Kenya) through a 60% reduction of the
unmet need of programmes for opioid substitution, needle exchange, and
antiretroviral therapy. Mitigation of patient transition to injecting drugs from
non-injecting forms could avert a 98% increase in HIV infections in Karachi;
whereas elimination of laws prohibiting opioid substitution with concomitant
scale-up could prevent 14% of HIV infections in Nairobi. Optimisation of
effectiveness and coverage of interventions is crucial for regions with rapidly
growing epidemics. Delineation of environmental risk factors provides a crucial
insight into HIV prevention. Evidence-informed, rights-based, combination
interventions protecting IDUs' access to HIV prevention and treatment could
substantially curtail HIV epidemics.
PMID: 20650523 [PubMed - indexed for MEDLINE]
113. J Acquir Immune Defic Syndr. 2010 Oct 1;55(2):239-44.
High rates of AIDS-related mortality among older adults in rural Kenya.
Negin J, Wariero J, Cumming RG, Mutuo P, Pronyk PM.
Sydney School of Public Health, University of Sydney, Sydney, New South Wales,
Australia. [email protected]
BACKGROUND: Health challenges faced by older people in developing countries are
often neglected amidst a wide range of competing priorities. This is evident in
the HIV field where the upper age limit for reporting HIV prevalence remains 49
years. However, the long latency period for HIV infection, and the fact that
older people continue to be sexually active, suggests that HIV and AIDS are
likely to affect older people. To better understand this, we studied mortality
due to AIDS in people aged 50 and older in an area of rural Kenya with high rates
of HIV infection.
METHODS: A community health worker-administered verbal autopsy system was
introduced in Nyanza Province, encompassing 63,500 people. Algorithms were used
to determine cause of death.
RESULTS: A total of 1228 deaths were recorded during the study period; 368 deaths
occurred in people aged 50 years and older. AIDS was the single most common cause
of death, causing 27% of all deaths. AIDS continued to be the main cause of death
up to age 70 years, causing 34% of deaths in people aged 50-59 years and 23% of
deaths in people aged 60-69 years.
CONCLUSIONS: AIDS remains the principle cause of death among older people in
Nyanza Province in western Kenya up until the age of 70 years. Greater efforts
are needed to integrate older people into the HIV response and to better
understand the specific vulnerabilities and challenges faced by this group.
PMID: 20639764 [PubMed - indexed for MEDLINE]
114. JAMA. 2010 Jul 21;304(3):250-1.
A piece of my mind. Vaccine, please.
Scurlock D.
[email protected]
PMID: 20639552 [PubMed - indexed for MEDLINE]
115. AIDS Care. 2010 Jul;22(7):866-73.
Factors affecting breastfeeding cessation after discontinuation of antiretroviral
therapy to prevent mother-to-child transmission of HIV.
Morgan MC, Masaba RO, Nyikuri M, Thomas TK.
Department of Public Health, University of Oxford, Oxford, UK.
[email protected]
In the Kisumu Breastfeeding Study (KiBS), prevention of mother-to-child HIV
transmission study, highly active antiretroviral therapy (HAART) is provided from
34 weeks gestation, through delivery to six months postpartum. The study
recommends that women practice exclusive breastfeeding for six months, then wean
abruptly. We sought to explore factors such as, education, family support,
cultural norms, and sources of information about perinatal HIV transmission,
which may influence a mother's decision to comply or not comply with the study's
recommendation to stop breastfeeding when HAART is discontinued. We used
semi-structured interviews of a purposive sample of 18 mothers participating in
the KiBS. By interviewing 10 mothers who stopped breastfeeding and eight mothers
who continued, it was possible to examine how different factors may have affected
the groups of participants. All participants stated that it was not traditional
to stop breastfeeding at six months. Participants who stopped breastfeeding
reported more family support, were more educated, and were more likely to
disclose their HIV status. Participants who continued breastfeeding more often
expressed concern about stigma. Participants learned about mother-to-child
transmission from clinics, churches, community groups, and other HIV-positive
mothers. This substudy suggests that family support, education, and cultural
norms are important factors that may influence a mother's decision regarding
breastfeeding cessation. Thus, counseling and family support may play integral
roles in the promotion of early breastfeeding cessation.
PMID: 20635251 [PubMed - indexed for MEDLINE]
116. Int J Gynaecol Obstet. 2010 Oct;111(1):89-90. Epub 2010 Jul 13.
Safety of the loop electrosurgical excision procedure performed by clinical
officers in an HIV primary care setting.
Huchko MJ, Maloba M, Bukusi EA.
Department of Obstetrics, Gynecology and Reproductive Sciences, University of
California, San Francisco, CA 94105, USA. [email protected]
PMCID: PMC2937079 [Available on 2011/10/1]
PMID: 20630528 [PubMed - indexed for MEDLINE]
117. PLoS One. 2010 Jul 2;5(7):e11434.
Effect of baseline HIV disease parameters on CD4+ T cell recovery after
antiretroviral therapy initiation in Kenyan women.
McKinnon LR, Kimani M, Wachihi C, Nagelkerke NJ, Muriuki FK, Kariri A, Lester RT,
Gelmon L, Ball TB, Plummer FA, Kaul R, Kimani J.
Department of Medicine, University of Toronto, Toronto, Canada.
[email protected]
BACKGROUND: Antiretroviral therapy (ART) for HIV infection reconstitutes the
immune system and improves survival. However, the rate and extent of CD4+ T cell
recovery varies widely. We assessed the impact of several factors on immune
reconstitution in a large Kenyan cohort.
METHODOLOGY/PRINCIPAL FINDINGS: HIV-infected female sex workers from a
longitudinal cohort, with at least 1 year of pre-ART and 6 months of post-ART
follow-up (n = 79), were enrolled in the current study. The median pre-ART
follow-up was 4,040 days. CD4 counts were measured biannually and viral loads
where available. The median CD4 count at ART initiation was 180 cells/ul, which
increased to 339 cells/ul at the most recent study visit. The rate of CD4+ T cell
increase on ART was 7.91 cells/month (mean = 13, range -25.92 to 169.4). LTNP
status prior to ART initiation did not associate with the rate of CD4 recovery on
ART. In univariate analyses, associations were observed for CD4 recovery rate and
duration of pre-ART immunosuppression (r = -0.326, p = 0.004) and CD4 nadir (r =
0.284, p = 0.012). In multivariate analysis including age, CD4 nadir, duration of
HIV infection, duration of pre-ART immunosuppression, and baseline viral load,
only CD4 nadir (p = 0.007) and not duration of immunosuppression (p = 0.87)
remained significantly associated with the rate of CD4 recovery.
CONCLUSIONS/SIGNIFICANCE: These data suggest that prior duration of immune
suppression does not predict subsequent recovery once ART is initiated and
confirm the previous observation that the degree of CD4 depletion prior to ART
initiation is the most important determinant of subsequent immune reconstitution.
PMCID: PMC2896395
PMID: 20625393 [PubMed - indexed for MEDLINE]
118. AIDS Res Hum Retroviruses. 2010 Jul;26(7):833-8.
Genetic characterization of HIV type 1 among patients with suspected immune
reconstitution inflammatory syndrome after initiation of antiretroviral therapy
in Kenya.
Lihana RW, Khamadi SA, Lubano K, Mwangi J, Kinyua JG, Okoth VO, Lagat NJ, Okoth
FA, Songok EM, Makokha EP.
Center for Virus Research, Kenya Medical Research Institute, Nairobi, Kenya.
[email protected]
Antiretroviral therapy (ART) has improved the survival of HIV patients but is
also associated with unique manifestations of disease in some subjects during the
initial months of therapy. Immune reconstitution inflammatory syndrome (IRIS) is
a disorder among individuals starting ART, with no evidence-based treatment and
management guidelines. We characterized HIV-1 and determined drug resistance
among 14 Kenyan patients with suspected IRIS after ART initiation in 2005.
Polymerase chain reaction, sequencing, and phylogenetic analysis of viral pol and
env showed the following HIV-1 subtypes: A1/A1/A1 (pol-RT/gp41/C2V3), 5; A1/C/A1,
1; A1/D/A1, 2; D/A1/A1, 1; D/C/A1, 1; D/D/A1, 2; D/D/D, 1; and D/A1/A2, 1. Three
patients had viruses with major drug resistance-associated mutations. These
included nucleoside reverse transcriptase inhibitor (RTI) mutations: M41L, K65R,
D67N, K70R, M184V, and K219Q, and nonnucleoside RTI mutations: K101P, L100I,
K103N, and Y181C. Twelve patients harbored viruses that are predicted to use
chemokine coreceptor 5 (CCR5) whereas two had variant viruses predicted to use
the CXCR4 coreceptor. Drug resistance may not be the only cause of ART adverse
events. HIV-1 characterization would be important before and during HIV therapy
to avoid treatment failure.
PMID: 20624074 [PubMed - indexed for MEDLINE]
119. Int J STD AIDS. 2010 Jun;21(6):435-40.
Genital hygiene practices of fishermen targeted for a topical microbicide
intervention against sexually transmitted infections in Kisumu, Kenya.
Kwena ZA, Bukusi EA, Gorbach P, Sharma A, Sang NM, Holmes KK.
Center for Microbiology Research, Kenya Medical Research Institute, Nairobi,
Kenya. [email protected]
Research on hygiene has been relatively limited in the current era of rigorous
observational studies and clinical trials. We set out to investigate the
perception and practices of genital hygiene among fishermen working on the
beaches along Lake Victoria, targeted for a topical male microbicide hygiene
intervention. We conducted 12 focus group discussions involving fishermen (n =
130), recording the discussions in Dholuo (the local language) and transcribing
them verbatim before translating into English. Transcripts were double-coded and
analysed using constant comparative analysis. Despite easy access to lake water
and recognition of a link that may exist between poor genital hygiene and the
risk of penile infection and poor sexual relationships, few fishermen regularly
washed their genitalia due to fear/embarrassment from cleaning their genitalia in
public, traditional Luo beliefs such as that washing with soap would reduce the
fish catch, lack of time because of their busy schedules, laziness and lack of
responsibility, and excessive consumption of alcohol and illicit drugs. Hygiene
practices of the fishermen were poor and could contribute to genital infections
including sexually transmitted infections. Given the fishermen's poor genital
hygiene practices, they may benefit from hygiene intervention, including that
provided by penile microbicides, which can be applied in the privacy of their
PMID: 20606226 [PubMed - indexed for MEDLINE]
120. BMC Public Health. 2010 Jun 30;10:384.
'Relief of oppression': an organizing principle for researchers' obligations to
participants in observational studies in the developing world.
Lavery JV, Bandewar SV, Kimani J, Upshur RE, Plummer FA, Singer PA.
Centre for Research on Inner City Health & Centre for Global Health Research,
Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital,
Toronto, Canada. [email protected]
BACKGROUND: A central question in the debate about exploitation in international
research is whether investigators and sponsors from high-income countries (HIC)
have obligations to address background conditions of injustice in the communities
in which they conduct their research, beyond the healthcare and other
research-related needs of participants, to aspects of their basic life
DISCUSSION: In this paper, we describe the Majengo sexually transmitted disease
(STD) Cohort study, a long-term prospective, observational cohort of sex workers
in Nairobi, Kenya. Despite important scientific contributions and a wide range of
benefits to the women of the cohort, most of the women have remained in the sex
trade during their long-standing participation in the cohort, prompting
allegations of exploitation. The Majengo STD cohort case extends the debate about
justice in international research ethics beyond clinical trials into long-term
observational research. We sketch the basic features of a new approach to
understanding and operationalizing obligations of observational researchers,
which we call 'relief of oppression'. 'Relief of oppression' is an organizing
principle, analogous to the principle of harm reduction that is now widely
applied in public health practice. Relief of oppression aims to help
observational researchers working in conditions of injustice and deprivation to
clarify their ethical obligations to participants. It aims to bridge the gap
between a narrow, transaction-oriented account of avoiding exploitation and a
broad account emphasizing obligations of reparation for historic injustices. We
propose that relief of oppression might focus researchers' consideration of
benefits on those that have some relevance to background conditions of injustice,
and so elevate the priority of these benefits, in relation to others that might
be considered and negotiated with participants, according to the degree to which
the participating communities are constrained in their realization of fundamental
SUMMARY: The over-arching aim of relief of oppression is that, within the range
of benefits negotiated over time with the local communities and organizations, an
increasing proportion reflects a shared interest in improving participants'
fundamental freedoms. We describe how harm reduction serves as a useful analogy
for how we envision relief of oppression functioning in international research.
PMCID: PMC3091550
PMID: 20591194 [PubMed - in process]
121. AIDS. 2010 Jul 31;24(12):1813-21.
A TRIM5alpha exon 2 polymorphism is associated with protection from HIV-1
infection in the Pumwani sex worker cohort.
Price H, Lacap P, Tuff J, Wachihi C, Kimani J, Ball TB, Luo M, Plummer FA.
Public Health Agency of Canada, National Microbiology Laboratory, Winnipeg,
Manitoba, Canada.
OBJECTIVE: The innate immune component TRIM5alpha has the ability to restrict
retrovirus infection in a species-specific manner. TRIM5alpha of some primate
species restricts infection by HIV-1, whereas human TRIM5alpha lacks this
specificity. Previous studies have suggested that certain polymorphisms in human
TRIM5alpha may enhance or impair the proteins affinity for HIV-1. This study
investigates the role of TRIM5alpha polymorphisms in resistance/susceptibility to
HIV-1 within the Pumwani sex worker cohort in Nairobi, Kenya. A group of women
within this cohort remain HIV-1-seronegative and PCR-negative despite repeated
exposure to HIV-1 through active sex work.
DESIGN: A 1 kb fragment of the TRIM5alpha gene, including exon 2, from 1032 women
enrolled in the Pumwani sex worker cohort was amplified and sequenced.
Single-nucleotide polymorphisms (SNPs) and haplotypes were compared between
HIV-1-positive and resistant women.
METHODS: The TRIM5alpha exon 2 genomic fragment was amplified, sequenced and
genotyped. Pypop32-0.6.0 was used to determine SNP and haplotype frequencies and
statistical analysis was carried out using SPSS-13.0 for Windows.
RESULTS: A TRIM5alpha SNP (rs10838525) resulting in the amino acid change from
arginine to glutamine at codon 136, was enriched in HIV-1-resistant individuals
[P = 1.104E-05; odds ratio (OR) 2.991; 95% confidence interval (CI) 1.806-4.953]
and women with 136Q were less likely to seroconvert (P = 0.002; log-rank 12.799).
Wild-type TRIM5alpha exon 2 was associated with susceptibility to HIV-1 (P =
0.006; OR 0.279; 95% CI 0.105-0.740) and rapid seroconversion (P = 0.001;
log-rank 14.475).
CONCLUSIONS: Our findings suggest that a shift from arginine to glutamine at
codon 136 in the coiled-coil region of TRIM5alpha confers protection against
HIV-1 in the Pumwani sex worker cohort.
PMCID: PMC2921035 [Available on 2011/7/1]
PMID: 20588169 [PubMed - indexed for MEDLINE]
122. AIDS. 2010 Aug 24;24(13):2069-74.
Increased levels of immune activation in the genital tract of healthy young women
from sub-Saharan Africa.
Cohen CR, Moscicki AB, Scott ME, Ma Y, Shiboski S, Bukusi E, Daud I, Rebbapragada
A, Brown J, Kaul R.
Department of Obstetrics, Gynecology and Reproductive Sciences, University of
California, San Francisco, California 94117, USA. [email protected]
OBJECTIVES: To determine whether healthy, young women in sub-Saharan Africa have
a more activated immune milieu in the genital tract (i.e. activated CD4 T cells)
than a similar population in the United States.
DESIGN: A cross-sectional study nested in a phase 1 microbicide trial.
METHODS: Cervical cytobrushes were collected from 18 to 24-year-old women in San
Francisco, California, USA (n = 18) and Kisumu, Kenya (n = 36) at enrollment into
a phase 1 microbicide trial. All participants tested negative for HIV, herpes
simplex virus 2, gonorrhea, chlamydia, and trichomonas, and had abstained from
sex for at least 7 days prior to enrollment. Cryopreserved T-cell populations
were assayed by flow cytometry in a central laboratory. Secretory leukocyte
protease inhibitor levels were assayed in cervicovaginal lavage samples. The
Wilcoxon rank-sum test was used to compare immune parameters between sites.
RESULTS: The total number of endocervical CD4(+) T cells was slightly higher in
participants from San Francisco, but participants from Kisumu had a substantially
higher number and proportion of CD4(+) T cells expressing the early activation
marker CD69, with and without the HIV coreceptor C-C chemokine receptor type 5,
and a greater proportion of activated CD8(+) T cells. Median (interquartile
range) genital levels of secretory leukocyte protease inhibitor were lower in
participants from Kisumu compared with those from San Francisco [190 (96-519) vs.
474 (206 817) pg/ml, P < 0.03].
CONCLUSION: Activated mucosal T cells were increased in the genital tract of
young, sexually transmitted infection/HIV-free Kenyan women, independent of
common genital coinfections, and secretory leukocyte protease inhibitor levels
were reduced. The cause of these mucosal immune differences is not known, but
could partly explain the high HIV incidence in young women from sub-Saharan
PMCID: PMC2914808 [Available on 2011/8/1]
PMID: 20588163 [PubMed - indexed for MEDLINE]
123. Popul Health Metr. 2010 Jun 29;8:21.
Verbal autopsy interpretation: a comparative analysis of the InterVA model versus
physician review in determining causes of death in the Nairobi DSS.
Oti SO, Kyobutungi C.
African Population and Health Research Center, P,O, Box 10787 GPO-00100, Nairobi,
Kenya. [email protected]
ABSTRACT:BACKGROUND: Developing countries generally lack complete vital
registration systems that can produce cause of death information for health
planning in their populations. As an alternative, verbal autopsy (VA) - the
process of interviewing family members or caregivers on the circumstances leading
to death - is often used by Demographic Surveillance Systems to generate cause of
death data. Physician review (PR) is the most common method of interpreting VA,
but this method is a time- and resource-intensive process and is liable to
produce inconsistent results. The aim of this paper is to explore how a
computer-based probabilistic model, InterVA, performs in comparison with PR in
interpreting VA data in the Nairobi Urban Health and Demographic Surveillance
System (NUHDSS).
METHODS: Between August 2002 and December 2008, a total of 1,823 VA interviews
were reviewed by physicians in the NUHDSS. Data on these interviews were entered
into the InterVA model for interpretation. Cause-specific mortality fractions
were then derived from the cause of death data generated by the physicians and by
the model. We then estimated the level of agreement between both methods using
Kappa statistics.
RESULTS: The level of agreement between individual causes of death assigned by
both methods was only 35% (kappa = 0.27, 95% CI: 0.25 - 0.30). However, the
patterns of mortality as determined by both methods showed a high burden of
infectious diseases, including HIV/AIDS, tuberculosis, and pneumonia, in the
study population. These mortality patterns are consistent with existing knowledge
on the burden of disease in underdeveloped communities in Africa.
CONCLUSIONS: The InterVA model showed promising results as a community-level tool
for generating cause of death data from VAs. We recommend further refinement to
the model, its adaptation to suit local contexts, and its continued validation
with more extensive data from different settings.
PMCID: PMC2902422
PMID: 20587026 [PubMed - in process]
124. Dermatol Online J. 2010 Jun 15;16(6):8.
Extensive hypertrophic lichen planus in an HIV positive patient.
Emadi SN, Akhavan-Mogaddam J, Yousefi M, Sobhani B, Moshkforoush A, Emadi SE.
Red Crescent Society of the Islamic Republic of Iran Research and Medical Center,
Nairobi, Kenya. [email protected]
Individuals who are infected with Human Immunodeficiency Virus (HIV) suffer from
numerous dermatoses. These disorders are often more severe than those observed in
non HIV-infected persons afflicted with the same diseases. Lichen planus (LP) is
a chronic inflammatory papulosquamous skin disorder. Herein, the diagnosis and
treatment of a 40-year-old HIV+ Kenyan man afflicted with hypertrophic lichen
planus (HLP) is described. In this case, lesions of HLP were widely distributed
across the trunk and extremities, having become of such thickness on the dorsal
surfaces of the hands and fingers as to make normal use of hands impossible. A
significant distinguishing feature of this patient is prior history of
tuberculosis, which is a known trigger for lichenoid skin lesions.
PMID: 20579463 [PubMed - indexed for MEDLINE]
125. East Afr Med J. 2009 Aug;86(8):378-86.
Intermittent presumptive treatment of malaria to prevent low birth weight in
newborns in a cohort of pregnant women from a malaria endemic area.
Alusala DN, Estambale BB.
Division of Malaria Control, Ministry of Public Health and Sanitation, Nairobi,
OBJECTIVE: To determine and describe the patterns of low birth weight in newborns
of a cohort of mothers given intermittent presumptive treatment (IPT) for malaria
prevention in a malaria endemic area of Kenya.
DESIGN: A longitudinal prospective cohort study.
SETTING: Got Agulu Health Centre in Usigu Division, Bondo District, Nyanza
SUBJECTS: Pregnant women of all parities attending antenatal care services. Only
women who gave informed consent for themselves and their newborns after birth
were eligible to participate in the study.
RESULTS: Parity was highly predictive of birth weight in the study subjects.
Primigravidae and secondigravidae had a significantly lower mean birth weight
(2952g) than women of higher gravidity (3214g) p-value <0.0001. Regardless of IPT
administration, women who became positive for malaria infection at any point
during pregnancy delivered 73.7% of the LBW infants. There was no significant
difference in mean birth weights between primigravidae and multigravidae who had
parasitaemia at baseline and at delivery (means 2906g and 3062g respectively,
p=0.11). However, there was a significant difference between the parasitaemia
negative primigravidae and multigravidae at baseline and at delivery (means 2952g
and 3204g respectively, p=0.006). Infection with helminths did not have an effect
on birth weight. Overall, low birth weight was observed in 9% of the newborns and
was most commonly found in primigravidae and secondigravidae (14.8% and 13.1%
CONCLUSION: Although many factors have been known to play a role in the causation
of low birth weight (LBW <2500g), parity status and malaria infection in malaria
endemic areas still play a major role regardless of IPT administration.
PMID: 20575312 [PubMed - indexed for MEDLINE]
126. East Afr Med J. 2009 Aug;86(8):374-7.
The contribution of very low birth weight deaths to infant mortality.
Were FN, Bwibo NO.
Department of Paediatrics and Child Health, College of Health Sciences,
University of Nairobi, P.O. Box 19676-00200, Nairobi, Kenya.
BACKGROUND: Infant mortality remains high in many developing countries in which
the contribution of deaths among infants born very low birth weight (VLBW) may be
considerable. This contribution has however not been quantified in most such
countries. This paper explores a model that can be used in this respect.
OBJECTIVE: To determine the contribution of very low birth weight infants towards
the overall infants deaths in Kenya.
DESIGN: Prospective cohort study.
SETTING: Kenyatta National Hospital, Pumwani Maternity Hospital and Kilifi
District Hospital.
SUBJECTS: Very low birth weight infants followed up for a period of one year.
RESULTS: The neonatal, post-neonatal and infant mortalities for the cohort were
442, 139 and 581/1000 respectively. These were thirteen, three and seven times
higher than the national averages respectively. Of the national birth cohort of
1,300,000 during that year, it was estimated that between 15,600 (1.2%) and
24,700 (1.9%) were born VLBW. Given this VLBW infant burden and extrapolating the
infant mortality observed in this study to the general population, between 9,064
(8.9%) and 14,351(14.2%) of the 101,400 (78/1000) infants who die during infancy
in the country are born VLBW.
CONCLUSION: The cohort reports very high infant mortality for VLBW infants when
compared to the general population. Despite constituting less than 2% of the
birth cohort, these infants contribute between 8.9% and 14.2% of all infant
PMID: 20575311 [PubMed - indexed for MEDLINE]
127. East Afr Med J. 2009 Aug;86(8):364-73.
Characteristics of HIV-infected children seen in Western Kenya.
Nyandiko WM, Mwangi A, Ayaya SO, Nabakwe EC, Tenge CN, Gisore PM, Vreeman RC.
Department of Child Health and Paediatrics, School of Medicine, Moi University,
Eldoret, Kenya.
OBJECTIVES: To describe the characteristics and outcomes of children registered
for care in a large HIV care programme in Western Kenya.
DESIGN: A retrospective descriptive study.
SETTING: USAID-AMPATH HIV clinics in health centres; district and sub-district
hospitals; Moi Teaching and Referral Hospital in Western Kenya.
SUBJECTS: HIV-infected children below age of 15 years seen in a network of 18
clinics in Western Kenya.
INTERVENTIONS: Paediatric HIV diagnosis and care including treatment and
prevention of opportunistic infections and provision of combination
antiretroviral therapy (CART).
MAIN OUTCOME MEASURES: Diagnosis, clinical stage and immune status at enrollment
and follow-up; hospitalisation and death. Descriptive statistical analyses and
chi square tests were performed.
RESULTS: Four thousand and seventeen HIV-infected children seen between June 2002
and April 2008. Median age at enrollment was four years (0-14.2 years), 51%
girls, 25% paternal orphans, 10% total orphans and 13% maternal orphans. At
enrollment, 25% had weight-for-Age Z scores (WAZ) > or = -1 and 21% had WAZ
scores < or = 3. Orphaned children had worse WAZ scores (p=0.0001). Twenty five
per cent of children were classified as WHO clinical stage 3 and 4, 56% were WHO
clinical stages 1 and 2 with 19% missing clinical staging at enrollment. Cough
(25%), gastroenteritis (21%), fever (15%), pneumonia (10%) were the commonest
presenting features. Twenty six per cent had been diagnosed with tuberculosis and
only 25% started on cotrimoxazole preventive therapy (CPT). Median CD4% at
enrollment was 16% (0-64%); latest recorded values were 22% (0-64). Sixty four
per cent were on cART (cART+), median age at start was 5.4 (014.4 years). The
median initial CD4% among cART+ was 13 (0-62) compared to 24 (0-64) for those not
on ART (cART-). Median CD4% for cART+ improved to 22% (0-59); whereas cART- was
23% (0-64) at last appointment. During the period of follow-up, one fifth (19%)
of children on cART were lost to follow-up compared to slightly over one third
(37%) for those not on cART. Thirty four percent were hospitalised; 41% diagnosed
with pneumonia. Six per cent of 4017 were confirmed dead.
CONCLUSIONS: HIV-infected children were enrolled in care early in childhood.
Orphanhood was prevalent in these children as were gastroenteritis, fever,
pneumonia and advanced immuno-suppression. Orphans were more likely to be
severely malnourished. Only a quarter of children were put on cotrimoxazole
preventive therapy. Children commenced on cART late but responded well to
treatment. Loss to follow-up was less prevalent among those on cART.
PMID: 20575310 [PubMed - indexed for MEDLINE]
128. Epidemiol Rev. 2010 Apr;32(1):137-51. Epub 2010 Jun 23.
The expanding epidemics of HIV type 1 among men who have sex with men in low- and
middle-income countries: diversity and consistency.
Beyrer C, Baral SD, Walker D, Wirtz AL, Johns B, Sifakis F.
Center for Public Health and Human Rights, Bloomberg School of Public Health,
Johns Hopkins University, Baltimore, Maryland 20205, USA.
Men who have sex with men (MSM) have borne a disproportionate burden of human
immunodeficiency virus (HIV) infection and remain a markedly underresourced
population globally. To better describe HIV epidemics among MSM in low- and
middle-income countries, the authors conducted a systematic review of published
and unpublished literature available after January 1, 2000 (2000-2009). A total
of 133 HIV prevalence studies from 50 countries met the search criteria. Data
were used to develop an algorithmic approach to categorize these epidemics. The
authors found that the HIV epidemic in low- and middle-income countries may be
described using the following 4 scenarios: 1) settings where MSM are the
predominant contributor to HIV cases; 2) settings where HIV transmission among
MSM occurs in the context of epidemics driven by injection drug users; 3)
settings where HIV transmission among MSM occurs in the context of
well-established HIV transmission among heterosexuals; and 4) settings where both
sexual and parenteral modes contribute significantly to HIV transmission. The
authors focused on Peru, Ukraine, Kenya, and Thailand to describe the diversity
across and similarities between proposed epidemic scenarios. This scenario-based
categorization of HIV epidemics among MSM may assist public health agencies and
civil societies to develop and implement better-targeted HIV prevention programs
and interventions.
PMID: 20573756 [PubMed - indexed for MEDLINE]
129. BMC Infect Dis. 2010 Jun 23;10:186.
High rate of pneumococcal bacteremia in a prospective cohort of older children
and adults in an area of high HIV prevalence in rural western Kenya.
Feikin DR, Jagero G, Aura B, Bigogo GM, Oundo J, Beall BW, Karani A, Morpeth S,
Njenga MK, Breiman RF.
International Emerging Infections Program, Centers for Disease Control and
Prevention, Mbagathi Road, off Mbagathi Way, Nairobi, Kenya. [email protected]
BACKGROUND: Although causing substantial morbidity, the burden of pneumococcal
disease among older children and adults in Africa, particularly in rural
settings, is not well-characterized. We evaluated pneumococcal bacteremia among
21,000 persons > or =5 years old in a prospective cohort as part of
population-based infectious disease surveillance in rural western Kenya from
October 2006-September 2008.
METHODS: Blood cultures were done on patients meeting pre-defined
criteria--severe acute respiratory illness (SARI), fever, and admission for any
reason at a referral health facility within 5 kilometers of all 33 villages where
surveillance took place. Serotyping of Streptococcus pneumoniae was done by latex
agglutination and quellung reaction and antibiotic susceptibility testing was
done using broth microdilution. We extrapolated incidence rates based on persons
with compatible illnesses in the surveillance population who were not cultured.
We estimated rates among HIV-infected persons based on community HIV prevalence.
We projected the national burden of pneumococcal bacteremia cases based on these
RESULTS: Among 1,301 blood cultures among persons > or =5 years, 52 (4%) yielded
pneumococcus, which was the most common bacteria isolated. The yield was higher
among those > or =18 years than 5-17 years (6.9% versus 1.6%, p < 0.001). The
highest yield was for inpatients with SARI (10%), compared with SARI outpatients
(3%) and acute febrile outpatients (1%). Serotype 1 pneumococcus was most common
(42% isolates) and 71% were serotypes included in the 10-valent pneumococcal
conjugate vaccine (PCV10). Non-susceptibility to beta-lactam antibiotics was low
(<5%), but to trimethoprim-sulfamethoxazole was high (>95%). The crude rate of
pneumococcal bacteremia was 129/100,000 person-years, and the adjusted rate was
419/100,000 person-years. Nineteen (61%) of 31 patients with HIV results were
HIV-positive. The adjusted rate among HIV-infected persons was 2,399/100,000
person-years (Rate ratio versus HIV-negative adults, 19.7, 95% CI 12.4-31.1). We
project 58,483 cases of pneumococcal bacteremia will occur in Kenyan adults in
CONCLUSIONS: Pneumococcal bacteremia rates were high among persons > or =5 years
old, particularly among HIV-infected persons. Ongoing surveillance will document
if expanded use of highly-active antiretroviral treatment for HIV and
introduction of PCV10 for Kenyan children (anticipated in late 2010) result in
substantial secondary benefits by reducing pneumococcal disease in adults.
PMCID: PMC2901359
PMID: 20573224 [PubMed - indexed for MEDLINE]
130. Soc Sci Med. 2010 Aug;71(3):616-25. Epub 2010 May 5.
A multi-level model of condom use among male and female upper primary school
students in Nyanza, Kenya.
Maticka-Tyndale E, Tenkorang EY.
University of Windsor, Department of Sociology, Anthropology & Criminology,
Windsor, Ontario, N9B 3P4 Canada. [email protected]
Although several studies have emphasized the relevance of community level
variables to AIDS prevention among young people in sub-Saharan Africa, few have
tested the empirical connections between such variables and sexual behaviors.
Using data from 3645 sexually experienced grade 6 and 7 students from 160
schools, modeled on Fisher and Fisher's information-motivation-behavioral skills
(IMB) model (2000, 1993) and Campbell's identification of community influences
(2003), this study applies hierarchical linear models to estimate the effects of
individual and community level variables on condom use among youth in Nyanza
Province, Kenya. Four separate models were fit for both males and females.
Results show significant differences across schools and communities regarding
condom use. The predictors of reported condom use at last intercourse for both
males and females were ethnicity, pressure to engage in sexual intercourse, and
condom self efficacy. While age, religion, rejecting myths about the spread of
HIV, and talking to male relatives about HIV/AIDS were all positively related to
condom use for males, risk perception, socio-economic status of the school and
school sponsorship by a religious group were negatively related to the outcome
variable. For females, abstinence self efficacy and HIV prevention programming in
community festivals were additional significant predictors, both increasing the
odds of condom use. Our results suggest that there are marked differences in
factors influencing reported condom use among males and females in Nyanza, Kenya.
While some of these factors exist at the individual level, others exist at the
school/community level. Based on our findings, we recommend that AIDS prevention
interventions take account not only of individual-level factors, but also
school/community influences on the sexual behaviors of youth.
PMID: 20570426 [PubMed - indexed for MEDLINE]
131. Reprod Health. 2010 Jun 19;7:11.
Community-level intimate partner violence and the circumstances of first sex
among young women from five African countries.
Gómez AM, Speizer IS.
Department of Maternal and Child Health, Gillings School of Global Public Health,
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
[email protected]
ABSTRACT:BACKGROUND: Gender-based violence is an important risk factor for
adverse reproductive health (RH). Community-level violence may inhibit young
women's ability to engage in safer sexual behaviors due to a lack of control over
sexual encounters. Few studies examine violence as a contextual risk factor.
METHODS: Using nationally representative data from five African countries, the
association between community-level physical or sexual intimate partner violence
(IPV) and the circumstances of first sex (premarital or marital) among young
women (ages 20-29) was examined.
RESULTS: In Mali, and Kenya bivariate analyses showed that young women who had
premarital first sex were from communities where a significantly higher
percentage of women reported IPV experience compared to young women who had
marital first sex. Multivariate analyses confirmed the findings for these two
countries; young women from communities with higher IPV were significantly more
likely to have had premarital first sex compared to first sex in union. In
Liberia, community-level IPV was associated with a lower risk of premarital sex
as compared to first sex in union at a marginal significance level. There was no
significant relationship between community-level IPV and the circumstances of
first sex in the Democratic Republic of Congo or Zimbabwe.
CONCLUSION: These findings indicate that context matters for RH. Individualized
efforts to improve RH may be limited in their effectiveness if they do not
acknowledge the context of young women's lives. Programs should target prevention
of violence to improve RH outcomes of youth.
PMCID: PMC2904724
PMID: 20565896 [PubMed - in process]
132. Croat Med J. 2010 Jun;51(3):271-3.
HIV prevalence and associated behavioral factors in Lesotho, Kenya, Malawi, and
Muula AS.
[email protected]
PMCID: PMC2897087
PMID: 20564772 [PubMed - indexed for MEDLINE]
133. AIDS Care. 2010 Aug;22(8):1012-20.
HIV prevention through sport: the case of the Mathare Youth Sport Association in
Delva W, Michielsen K, Meulders B, Groeninck S, Wasonga E, Ajwang P, Temmerman M,
Vanreusel B.
International Centre for Reproductive Health, Faculty of Medicine and Health
Sciences, Ghent University, Ghent, Belgium. [email protected]
Sport has become a popular tool for HIV prevention, based on claims that it can
foster life skills that are necessary to translate knowledge, attitudes and
behavioural intentions into actual behaviour. Empirical evidence of the
effectiveness of sport-based HIV prevention programmes is, however, sorely
lacking. We therefore conducted a cross-sectional survey assessing sexual
behaviour and the determinants thereof among 454 youth of the Mathare Youth Sport
Association (MYSA) in Kenya and a control group of 318 non-MYSA members. Multiple
(ordinal) logistic regression models were applied to measure the association
between MYSA membership and attitudes, subjective norms and self-efficacy related
to condom use as well as sexual experience, age at sexual debut, condom use,
history of concurrent relationships and number of partners in the last year. MYSA
members were more likely to use condoms during the first sex act (odds ratio
(OR)=2.10; 95% CI: 1.10-3.99). Consistent condom use with the current/last
partner was 23.2% (36/155) among MYSA members vs. 17.2% (17/99) among the control
group. Even after adjusting for media exposure - a factor associated with both
MYSA membership and higher frequency of condom use - MYSA members were still
found to use condoms more frequently with their current/last partner (adjusted
OR=1.64; 95% CI: 1.01-2.68). Nevertheless, levels of condom use remain
disturbingly low. More rigorous evaluations of sport programmes for HIV
prevention are needed. When possible, programmes should be preceded by baseline
assessments, trends in risk behaviour of the intervention group should be
compared with those of a control group, and protocols for data collection and
analysis should include measuring of and adjusting for potentially confounding
PMID: 20552463 [PubMed - indexed for MEDLINE]
134. AIDS. 2010 Jun 19;24(10):1449-54.
HIV viral set point and host immune control in individuals with HIV-specific CD8+
T-cell responses prior to HIV acquisition.
Kaul R, MacDonald KS, Nagelkerke NJ, Kimani J, Fowke K, Ball TB, Luo M, Kariri A,
Jaoko W, Moses S, Rowland-Jones S, Plummer FA.
Department of Medicine, University of Toronto, Toronto, ON, Canada.
[email protected]
OBJECTIVE: Vaccine-induced CD8(+) T-cell responses in primates have been
associated with a reduced simian immunodeficiency virus plasma viral load and
enhanced T-cell responses, but cellular vaccines have shown limited success in
human trials. We previously described HIV-specific T-cell responses in two groups
of highly exposed, persistently seronegative Kenyan female sex workers, and a
subset of these participants have subsequently acquired HIV. We examined the
impact of pre-existing CD8(+) T-cell responses on post-acquisition outcomes.
DESIGN AND METHODS: HIV-specific CD8(+) T-cell responses had been examined in
highly exposed, persistently seronegative participants from the Pumwani and
Kibera cohorts, using a combination of virus-specific lysis, proliferation,
interferon-gamma production, or all. Plasma viral load set point and HIV-specific
T-cell proliferation and cytokine production were now examined post hoc by
blinded investigators in the subset of participants who acquired HIV.
RESULTS: Pre-acquisition cellular immune assays and post-infection viral load
were available for 46 participants, and HIV-specific CD8(+) T-cell responses had
been detected in 25 of 46 (54%) participants. Pre-acquisition CD8(+) T-cell
responses were associated with a lower post-acquisition HIV viral load set point
in both cohorts (pooled analysis, 3.1 vs. 4.1 log(10) RNA copies/ml; P=0.0002)
and with enhanced post-acquisition HIV-specific CD8(+) T-cell proliferation (3.8
vs. 1.0%, P=0.03), but with a trend to reduced post-acquisition CD8(+) T-cell
interferon-gamma responses. Conclusion: HIV-specific CD8(+) T-cell responses
prior to HIV acquisition were associated with a lower HIV viral load and an
altered functional profile of post-acquisition CD8(+) T-cell responses.
PMID: 20549840 [PubMed - indexed for MEDLINE]
135. Lancet. 2010 Jun 5;375(9730):1988-2008. Epub 2010 May 27.
Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries,
1970-2010: a systematic analysis of progress towards Millennium Development Goal
Rajaratnam JK, Marcus JR, Flaxman AD, Wang H, Levin-Rector A, Dwyer L, Costa M,
Lopez AD, Murray CJ.
Institute for Health Metrics and Evaluation, University of Washington, Seattle,
WA 98121, USA.
Erratum in
Lancet. 2010 Aug 28;376(9742):686.
Lancet. 2010 Jun 19;375(9732):2142.
Comment in
Lancet. 2010 Jun 5;375(9730):1941-3.
Lancet. 2010 Oct 9;376(9748):1223-4.
BACKGROUND: Previous assessments have highlighted that less than a quarter of
countries are on track to achieve Millennium Development Goal 4 (MDG 4), which
calls for a two-thirds reduction in mortality in children younger than 5 years
between 1990 and 2015. In view of policy initiatives and investments made since
2000, it is important to see if there is acceleration towards the MDG 4 target.
We assessed levels and trends in child mortality for 187 countries from 1970 to
METHODS: We compiled a database of 16 174 measurements of mortality in children
younger than 5 years for 187 countries from 1970 to 2009, by use of data from all
available sources, including vital registration systems, summary birth histories
in censuses and surveys, and complete birth histories. We used Gaussian process
regression to generate estimates of the probability of death between birth and
age 5 years. This is the first study that uses Gaussian process regression to
estimate child mortality, and this technique has better out-of-sample predictive
validity than do previous methods and captures uncertainty caused by sampling and
non-sampling error across data types. Neonatal, postneonatal, and childhood
mortality was estimated from mortality in children younger than 5 years by use of
the 1760 measurements from vital registration systems and complete birth
histories that contained specific information about neonatal and postneonatal
FINDINGS: Worldwide mortality in children younger than 5 years has dropped from
11.9 million deaths in 1990 to 7.7 million deaths in 2010, consisting of 3.1
million neonatal deaths, 2.3 million postneonatal deaths, and 2.3 million
childhood deaths (deaths in children aged 1-4 years). 33.0% of deaths in children
younger than 5 years occur in south Asia and 49.6% occur in sub-Saharan Africa,
with less than 1% of deaths occurring in high-income countries. Across 21 regions
of the world, rates of neonatal, postneonatal, and childhood mortality are
declining. The global decline from 1990 to 2010 is 2.1% per year for neonatal
mortality, 2.3% for postneonatal mortality, and 2.2% for childhood mortality. In
13 regions of the world, including all regions in sub-Saharan Africa, there is
evidence of accelerating declines from 2000 to 2010 compared with 1990 to 2000.
Within sub-Saharan Africa, rates of decline have increased by more than 1% in
Angola, Botswana, Cameroon, Congo, Democratic Republic of the Congo, Kenya,
Lesotho, Liberia, Rwanda, Senegal, Sierra Leone, Swaziland, and The Gambia.
INTERPRETATION: Robust measurement of mortality in children younger than 5 years
shows that accelerating declines are occurring in several low-income countries.
These positive developments deserve attention and might need enhanced policy
attention and resources.
FUNDING: Bill & Melinda Gates Foundation.
PMID: 20546887 [PubMed - indexed for MEDLINE]
136. AIDS Behav. 2010 Oct;14(5):1066-71.
Predicting pregnancy in HIV-1-discordant couples.
Guthrie BL, Choi RY, Bosire R, Kiarie JN, Mackelprang RD, Gatuguta A,
John-Stewart GC, Farquhar C.
Department of Epidemiology, University of Washington, Seattle, WA 98104-2499,
USA. [email protected]
This study examines the incidence and predictors of pregnancy in HIV-1-discordant
couples from Nairobi, Kenya. Women from 454 discordant couples were followed for
up to 2 years. One-year cumulative incidence of pregnancy was 9.7%. Pregnancy
rates did not differ significantly between HIV-1-infected and uninfected women
(HR = 1.46). The majority of pregnancies occurred among women < 30 years old
reporting a desire for future children (1-year incidence 22.2%). Pregnancy rates
may be high among discordant couples, indicating desire for children may override
concerns of HIV-1 transmission and increase unprotected sex, and highlighting the
need to make conception safer.
PMCID: PMC3051103 [Available on 2011/10/1]
PMID: 20544384 [PubMed - indexed for MEDLINE]
137. J Acquir Immune Defic Syndr. 2010 Aug 15;54(5):533-41.
Eighteen-month follow-up of HIV-1-infected mothers and their children enrolled in
the Kesho Bora study observational cohorts.
Kesho Bora Study Group.
Collaborators: Meda N, Fao P, Ky-Zerbo O, Gouem C, Somda P, Hien H, Ouedraogo PE,
Kania D, Sanou A, Kossiwavi IA, Sanogo B, Ouedraogo M, Siribie I, Valéa D,
Ouedraogo S, Somé R, Rouet F, Luchters S, Reyners M, Irungu E, Katingima C,
Mwaura M, Ouattara G, Mandaliya K, Wambua S, Thiongo M, Nduati R, Kose J, Njagi
E, Mwaura P, Bazin B, Rekacewicz C, Taylor A, Flowers N, Thigpen M, Fowler MG,
Jamieson D, Read JS, Bork-Simondon K, Cames C, Cournil A, Claeys P, Temmerman M,
Van de Perre P, Becquart P, Foulongne V, Segondy M, de Vincenzi I, Gaillard P,
Farley T, Habib N, Landoulsi S.
OBJECTIVE: To assess the effectiveness and safety of antiretrovirals (ARVs) used
for treatment or prophylaxis in a breastfeeding population of HIV-1-infected
women (Burkina-Faso, Kenya, South Africa).
METHODS: HIV-1-infected pregnant women with <200 CD4 cells per cubic millimeter
or with World Health Organization stage 4 disease (cohort A) and asymptomatic
women with >500 CD4 cells per cubic millimeter (cohort B) were enrolled into 2
prospective cohorts. Women with 200-500 CD4 cells per cubic millimeter were
enrolled in a parallel randomized trial. Women in cohort A initiated
antiretroviral therapy. Women in cohort B received zidovudine from 34 to 36 weeks
gestation until delivery, with single-dose nevirapine in labor (cohort B). All
children received single-dose nevirapine.
RESULTS: Of 248 women enrolled, 111 (cohort A) and 125 (cohort B) infants alive
at 24 hours after birth were analyzed. Sixty-nine percent and 42% of women had
undetectable viral load at delivery, respectively. Ten children in each cohort
died. The 18-month cumulative incidences of HIV-1 infection were 7.5% (95%
confidence interval: 3.8% to 14.5%) (cohort A) and 5.8% (2.8% to 11.8%) (cohort
B). Sixty-one percent (cohort A) and 78% (cohort B) were breastfed for a median
duration of 20 weeks. Four children in cohort A and only 1 in cohort B became
HIV-1 infected after 6 weeks of age.
CONCLUSIONS: Antiretroviral therapy initiated a median of 7 weeks before delivery
in women with advanced HIV-1 disease was associated with a significant residual
risk of HIV-1 transmission due to insufficient decrease in viral load by the time
of delivery. Among women with >500 CD4 cells per cubic millimeter, the risk of
breast-milk transmission was very low despite lack of postnatal prophylaxis.
PMID: 20543706 [PubMed - indexed for MEDLINE]
138. Sex Transm Dis. 2010 Aug;37(8):488-93.
Genital ulcer disease treatment policies and access to acyclovir in eight
sub-Saharan African countries.
Corbell C, Stergachis A, Ndowa F, Ndase P, Barnes L, Celum C.
Department of Pharmacy, University of Washington, Seattle, WA 98195, USA.
Comment in
Sex Transm Dis. 2011 Feb;38(2):150.
Sex Transm Dis. 2010 Aug;37(8):494-6.
BACKGROUND: Herpes simplex virus-2, the most common cause of genital ulcer
disease (GUD) globally, is a cofactor in human immunodeficiency virus type-1
(HIV-1) acquisition and transmission. Current World Health Organization
guidelines for sexually transmitted infections recommend acyclovir as first-line
syndromic treatment of GUD in countries with high herpes simplex virus-2
prevalence (> or =30%).
OBJECTIVE: To assess the extent of adoption of acyclovir as syndromic treatment
for GUD, and describe procurement, distribution, and cost of acyclovir in the
public and private sectors of 8 sub-Saharan African countries.
METHODS: We conducted standardized interviews with Ministry of Health (MoH)
officials, pharmacists, and other pharmacy workers based in the public and
private sectors. Interviews were conducted in Botswana, Kenya, Malawi, South
Africa, Tanzania, Uganda, Zambia, and Zimbabwe. Price comparisons were conducted
using the 2007 median international reference price (IRP) for acyclovir.
RESULTS: Of the 8 African countries, 4 surveyed had adopted acyclovir as
first-line syndromic GUD treatment in both their essential medical lists and
sexually transmitted infection guidelines. Country-specific acquisition prices
for acyclovir 200 mg were comparable to the median IRP and ranged from 0.74 to
1.95 times the median IRP. The median retail cost of acyclovir in the private
sector ranged from 5.85 to 9.76 times the median IRP. Public health facilities
faced cost and regulatory barriers that impeded the requisitioning of acyclovir
from the central medical stores.
CONCLUSIONS: Systems for drug procurement, distribution, and access in
sub-Saharan African countries need strengthening for a GUD treatment policy using
acyclovir to be effective.
PMID: 20539260 [PubMed - indexed for MEDLINE]
139. J Int Assoc Physicians AIDS Care (Chic). 2010 May-Jun;9(3):162-9.
A cross-cultural comparison of psychological distress among individuals living
with HIV in Atlanta, Georgia, and Eldoret, Kenya.
Shacham E, Reece M, Ong'or WO, Omollo O, Basta TB.
Health Communication Research Laboratory, Brown School of Social Work, Washington
University, St. Louis, MO, USA. [email protected]
Elevated psychological distress during HIV infection has been consistently
correlated with negative HIV-related health outcomes in studies conducted in
various regions of the world. This study was conducted to compare the nature and
range of psychological distress among HIV-infected individuals who had sought
mental health care as part of their HIV care in Kenya and the United States. The
Brief Symptom Inventory (BSI) was completed by 234 individuals with HIV in
Atlanta, Georgia, USA, and 284 in Eldoret, Kenya. The US-based sample expressed
markedly higher levels of psychological distress symptoms on the anxiety,
depression, interpersonal sensitivity, obsessive-compulsive, and psychoticism
dimensions, as well as the overall global severity index. Substantial proportions
of both the US and Kenya cohorts expressed higher levels of somatization and
paranoid ideation that suggested further psychological evaluation. This study
revealed psychological distress expression varied drastically among individuals
who self-enrolled into HIV-related mental health care within two different care
PMID: 20530470 [PubMed - indexed for MEDLINE]
140. Int J Immunogenet. 2010 Aug;37(4):301-5. Epub 2010 May 27.
CCR5, RANTES and SDF-1 polymorphisms and mother-to-child HIV-1 transmission.
Katz DA, John-Stewart GC, Richardson BA, Majiwa M, Mabuka JM, Lohman-Payne B,
Farquhar C.
Department of Epidemiology, University of Washington, Seattle, WA 98104, USA.
[email protected]
Summary Among 288 HIV-1-infected, breastfeeding women who received zidovudine
prophylaxis and were followed with their infants in Nairobi, we found no
associations between maternal genetic polymorphisms in CCR5 (59029G/A, 59353T/C,
59356T/C, 59402G/A), RANTES (-403G/A) and SDF-1 (3'801G/A) and mother-to-child
HIV-1 transmission; plasma, cervical and breastmilk viral loads; or breastmilk
chemokine concentrations.
PMCID: PMC2922909 [Available on 2011/8/1]
PMID: 20518834 [PubMed - indexed for MEDLINE]
141. J Neurovirol. 2010 May;16(3):189-202.
NeuroAIDS in Africa.
Robertson K, Liner J, Hakim J, Sankalé JL, Grant I, Letendre S, Clifford D, Diop
AG, Jaye A, Kanmogne G, Njamnshi A, Langford TD, Weyessa TG, Wood C, Banda M,
Hosseinipour M, Sacktor N, Nakasuja N, Bangirana P, Paul R, Joska J, Wong J,
Boivin M, Holding P, Kammerer B, Van Rie A, Ive P, Nath A, Lawler K, Adebamowo C,
Royal W 3rd, Joseph J; NeuroAIDS in Africa Conference Participants.
Collaborators: Adebamowo C, Banda M, Bangirana P, Boivin M, Clifford D, Diop AG,
Fieggen G, Grant I, Hakim J, Heckmann J, Holding P, Hosseinipour M, Ive P, Jaye
A, Joseph J, Joska J, Kammerer B, Kanmogne G, Langford TD, Lawler K, Letendre S,
McDermott J, Mendelson M, Nakasujja N, Nath A, Njamnshi A, Paul R, Robertson K,
Royal W 3rd, Sacktor N, Sankalé JL, Seedat S, Van Rie A, Weyessa TG, Wong J, Wood
C, Bao J, Bateman K, Cherner M, Collman R, Combrinck M, Ene L, Escobar EG, Geffen
N, Goodkin K, Gouse H, Hardy WD, Hoare J, Jardine J, Kanyama C, Kumwenda J,
Laughton B, Liner J, Marais S, Meintjes EM, Mngqibisa R, Moses A, Radebe D, Sanne
I, Shumbusho F, Soon-U LL, Ssebulime S, Stoloff K, Struthers H, Turate I, Valcour
VG, Waison M.
Department of Neurology, University of North Carolina, Chapel Hill, North
Carolina 27599-7025, USA. [email protected]
In July 2009, the Center for Mental Health Research on AIDS at the National
Institute of Mental Health organized and supported the meeting "NeuroAIDS in
Africa." This meeting was held in Cape Town, South Africa, and was affiliated
with the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention.
Presentations began with an overview of the epidemiology of HIV in sub-Saharan
Africa, the molecular epidemiology of HIV, HIV-associated neurocognitive
disorders (HANDs), and HAND treatment. These introductory talks were followed by
presentations on HAND research and clinical care in Botswana, Cameroon, Ethiopia,
The Gambia, Kenya, Malawi, Nigeria, Senegal, South Africa, Uganda, and Zambia.
Topics discussed included best practices for assessing neurocognitive disorders,
patterns of central nervous system (CNS) involvement in the region,
subtype-associated risk for HAND, pediatric HIV assessments and neurodevelopment,
HIV-associated CNS opportunistic infections and immune reconstitution syndrome,
the evolving changes in treatment implementation, and various opportunities and
strategies for NeuroAIDS research and capacity building in the region.
PMID: 20500018 [PubMed - indexed for MEDLINE]
142. East Afr Med J. 2009 Jul;86(7):314-22.
Use of insecticide treated bed nets among pregnant women in Kilifi District,
Njoroge FK, Kimani VN, Ongore D, Akwale WS.
Department of Community Health, College of Health Sciences, University of
Nairobi, P.O. Box 19676-0202 Nairobi, Kenya.
BACKGROUND: Malaria is one of the most serious public health problems in Kenya.
Pregnant women are among the groups with the highest risk of malaria. Use of
insecticide treated bed nets (ITNs) is a cost-effective method of controlling
malaria. Despite this, there is low utilisation of ITNs among pregnant women in
Kilifi district which is an endemic malaria zone.
OBJECTIVE: To determine knowledge, attitude and practice on the use of ITNs in
the prevention of malaria among pregnant women in Kilifi district.
DESIGN: A descriptive cross-sectional study.
SETTING: The district hospital and the five health centres in Kilifi district
SUBJECTS: Two hundred and twenty pregnant women attending antenatal clinics (ANC)
between October and December 2007.
RESULTS: Knowledge on malaria illness and ITNs was high with majority of pregnant
women having adequate level of knowledge (86.9%). There was significant
association between level of education and adequate knowledge (P-value = 0.010).
Good attitude on ITNs use was low. There was no association between good attitude
and any of the socio-demographic variables. The majority of pregnant women
attending ANC owned ITNs (75.4%). ITNs usage was high (70.5%). There was
significant association between religion and good practice (p-value = 0.050).
Although adequate level of knowledge on malaria and protective role of ITNs was
high, there was no association between knowledge with practice and attitude.
CONCLUSION: Before any malaria preventive intervention is implemented in an area,
different socio-cultural factors must be considered when behavioural
interventions for malaria control are designed and implemented. Targeted health
education should be disseminated to the community to remove stigma and
misconceptions associated with ITNs. Community concerns and fears should be
PMID: 20499780 [PubMed - indexed for MEDLINE]
143. Vox Sang. 2010 Oct;99(3):212-9. doi: 10.1111/j.1423-0410.2010.01340.x.
Reduced risk of transfusion-transmitted HIV in Kenya through centrally
co-ordinated blood centres, stringent donor selection and effective p24
antigen-HIV antibody screening.
Basavaraju SV, Mwangi J, Nyamongo J, Zeh C, Kimani D, Shiraishi RW, Madoda R,
Okonji JA, Sugut W, Ongwae S, Pitman JP, Marum LH.
HIV Prevention Branch, Global AIDS Program, National Center for HIV/AIDS, viral
Hepatitis, STD and TB Prevention, US Centers for Disease Control and Prevention,
Atlanta, GA 30341, USA. [email protected]
Comment in
Vox Sang. 2011 May;100(4):434-5; author reply 436-7.
BACKGROUND: Following a 1994 study showing a high rate of transfusion-associated
HIV, Kenya implemented WHO blood safety recommendations including: organizing the
Kenya National Blood Transfusion Service (NBTS), stringent blood donor selection,
and universal screening with fourth-generation p24 antigen and HIV antibody
assays. Here, we estimate the risk of transfusion-associated HIV transmission in
Kenya resulting from NBTS laboratory error and consider the potential safety
benefit of instituting pooled nucleic acid testing (NAT) to reduce window period
METHODS: From November to December 2008 in one NBTS regional centre, and from
March to June 2009 in all six NBTS regional centres, every third unit of blood
screened negative for HIV by the national algorithm was selected. Dried blood
spots were prepared and sent to a reference laboratory for further testing,
including NAT. Test results from the reference laboratory and NBTS were compared.
Risk of transfusion-associated HIV transmission owing to laboratory error and the
estimated yield of implementing NAT were calculated.
FINDINGS: No cases of laboratory error were detected in 12,435 units tested. We
estimate that during the study period, the percentage of units reactive for HIV
by NAT but non-reactive by the national algorithm was 0·0% (95% exact binomial
confidence interval, 0·00-0·024%).
INTERPRETATION: By adopting WHO blood safety strategies for resource-limited
settings, Kenya has substantially reduced the risk of transfusion-associated HIV
infection. As the national testing and donor selection algorithm is effective,
implementing NAT is unlikely to add a significant safety benefit. These findings
should encourage other countries in the region to fully adopt the WHO strategies.
PMID: 20497410 [PubMed - indexed for MEDLINE]
144. Soc Sci Med. 2010 Jul;71(2):335-44. Epub 2010 Apr 24.
Investigating the association between HIV/AIDS and recent fertility patterns in
Magadi MA, Agwanda AO.
Sociology, City University, London, United Kingdom. [email protected]
Findings from previous studies linking the HIV/AIDS epidemic and fertility of
populations have remained inconclusive. In sub-Saharan Africa, demographic
patterns point to the epidemic resulting in fertility reduction. However,
evidence from the 2003 Kenya Demographic and Health Survey (KDHS) has revealed
interesting patterns, with regions most adversely affected with HIV/AIDS showing
the clearest reversal trend in fertility decline. While there is suggestive
evidence that fertility behaviour in some parts of sub-Saharan Africa has changed
in relation to the HIV/AIDS epidemic, more rigorous empirical analysis is
necessary to better understand this relationship. In this paper, we examine
individual and contextual community HIV/AIDS factors associated with fertility
patterns in Kenya, paying particular attention to possible mechanisms of the
association. Multilevel models are applied to the 2003 KDHS, introducing various
proximate fertility determinants in successive stages, to explore possible
mechanisms through which HIV/AIDS may be associated with fertility. The results
corroborate findings from earlier studies of the fertility inhibiting effect of
HIV among infected women. HIV-infected women have 40 percent lower odds of having
had a recent birth than their uninfected counterparts of similar background
characteristics. Further analysis suggests an association between HIV/AIDS and
fertility that exists through proximate fertility determinants relating to sexual
exposure, breastfeeding duration, and foetal loss. While HIV/AIDS may have
contributed to reduced fertility, mainly through reduced sexual exposure, there
is evidence that it has contributed to increased fertility, through reduced
breastfeeding and increased desire for more children resulting from increased
infant/child mortality (i.e. a replacement phenomenon). In communities at
advanced stages of the HIV/AIDS epidemic, it is possible that infant/child
mortality has reached appreciably high levels where the impact of replacement and
reduced breastfeeding duration is substantial enough to result in a reversal of
fertility decline. This provides a plausible explanation for the patterns
observed in regions with particularly high HIV prevalence in Kenya.
PMID: 20494502 [PubMed - indexed for MEDLINE]
145. Int J Health Geogr. 2010 May 22;9:24.
Spatial distribution and cluster analysis of sexual risk behaviors reported by
young men in Kisumu, Kenya.
Westercamp N, Moses S, Agot K, Ndinya-Achola JO, Parker C, Amolloh KO, Bailey RC.
School of Public Health, University of Illinois at Chicago, 1603 W Taylor Street,
(MC 923), Chicago, IL 60612-4394, USA. [email protected]
BACKGROUND: The well-established connection between HIV risk behavior and place
of residence points to the importance of geographic clustering in the potential
transmission of HIV and other sexually transmitted infections (STI).
METHODS: To investigate the geospatial distribution of prevalent sexually
transmitted infections and sexual behaviors in a sample of 18-24 year-old
sexually active men in urban and rural areas of Kisumu, Kenya, we mapped the
residences of 649 men and conducted spatial cluster analysis. Spatial
distribution of the study participants was assessed in terms of the demographic,
behavioral, and sexual dysfunction variables, as well as laboratory diagnosed
STIs. To test for the presence and location of clusters we used Kulldorff's
spatial scan statistic as implemented in the Satscan program.
RESULTS: The results of this study suggest that sexual risk behaviors and STIs
are evenly distributed in our sample throughout the Kisumu district. No
behavioral or STI clusters were detected, except for condom use. Neither urban
nor rural residence significantly impacted risk behavior or STI prevalence.
CONCLUSION: We found no association between place of residence and sexual risk
behaviors in our sample. While our results can not be generalized to other
populations, the study shows that geospatial analysis can be an important tool
for investigating study sample characteristics; for evaluating HIV/STI risk
factors; and for development and implementation of targeted HIV and STI control
programs in specifically defined populations and in areas where the underlying
population dynamic is poorly understood.
PMCID: PMC2881901
PMID: 20492703 [PubMed - indexed for MEDLINE]
146. Trop Med Int Health. 2010 Jul;15(7):833-41. Epub 2010 May 14.
Retention of HIV-infected and HIV-exposed children in a comprehensive HIV
clinical care programme in Western Kenya.
Braitstein P, Katshcke A, Shen C, Sang E, Nyandiko W, Ochieng VO, Vreeman R,
Yiannoutsos CT, Wools-Kaloustian K, Ayaya S.
Moi University School of Medicine, Eldoret, Kenya. [email protected]
BACKGROUND: To describe incidence rates (IR) and risk factors for
loss-to-follow-up (LTFU) among HIV-infected and HIV-exposed children in a large
HIV treatment programme in Western Kenya.
METHODS: The USAID-AMPATH Partnership has enrolled >100,000 patients (20%
children) at 23 clinic sites throughout western Kenya. LTFU is defined as being
absent from the clinic for >3 months if on combination antiretroviral treatment
(cART) and >6 months if not. Included in this analysis were children aged <14
years, HIV exposed or infected at enrollment, and enrolled between April 2002 and
March 2009. The IR for LTFU are presented per 100 child-years (CY) of follow-up.
Proportional hazards models with time-independent and time-dependent covariates
were used to model factors associated with LTFU. Weight for height Z-scores were
calculated using EpiInfo, with severe malnutrition being defined as a Z-score
<or=-3.0. Immune suppression was defined as per WHO age-specific categories.
RESULTS: There were 13,510 children eligible for analysis, comprising 3106
children who at enrollment were HIV infected and 10,404 children who were HIV
exposed. The overall IR of LTFU was 18.4 (17.8-18.9) per 100 CY. Among
HIV-infected children, 15.2 (13.8-16.7) and 14.1 (13.1-15.8) per 100 CY became
LTFU, pre- and post-cART initiation, respectively. The only independent risk
factor for becoming LTFU among the HIV-infected children was severe immune
suppression (AHR: 2.17, 95% CI: 1.51-3.12). Among the HIV-exposed children, 20.1
per 100 (19.4-20.7) became LTFU. Independent risk factors for LTFU among them
were being severely low weight for height (AHR: 1.69, 95% CI: 1.25-2.28), being
orphaned at enrollment (AHR: 1.57, 95% CI: 1.23-1.64), being CDC Class B or C
(AHR: 1.41, 95% CI: 1.14-1.74), and having received cART (AHR: 1.56, 95% CI:
1.23-1.99). Protective against becoming LTFU among the HIV exposed were testing
HIV positive (AHR: 0.26, 95% CI: 0.21-0.32), older age (AHR: 0.90, 95% CI:
0.85-0.96), enrolling in later time periods, and receiving food supplementation
(AHR: 0.58, 95% CI: 0.32-1.04).
CONCLUSIONS: There is a high rate of LTFU among these highly vulnerable children,
particularly among the HIV exposed. These data suggest that HIV-infected and
HIV-exposed children are at especially high risk for LTFU if they are sick or
PMCID: PMC2929358 [Available on 2011/7/1]
PMID: 20487430 [PubMed - indexed for MEDLINE]
147. SAHARA J. 2009 Dec;6(4):170-8.
Food security in HIV/AIDS response: insights from Homa Bay, Kenya.
Datta D, Njuguna J.
[email protected]
This paper examines the viability and effectiveness of a pilot farming initiative
in reversing impacts of HIV/AIDS on the most affected households in Homa Bay,
Kenya. The paper argues that once patients are stable, they can effectively be
engaged in farming with minimal financial and technical support, resulting in
enhanced food security of the affected households. More importantly, it helps to
reduce HIV/AIDS-related stigma and improve the individual's self-esteem. Some of
the key challenges of the pilot initiative were the limited number of
agricultural extension workers and absence of facilities to enable them to
deliver services to the farmers, the high cost of farm inputs, the unavailability
of farm inputs when they were needed, poorly developed agricultural markets, and
the absence of irrigation facilities. The paper recommends the sensitive
scaling-up of this approach. However, farming initiatives by HIV/AIDS service
NGOs should be linked to at least three key aspects: (a) treatment, care and
support to HIV/AIDS affected households; (b) micro grant schemes or subsidies to
enable farmers to purchase farming tools and farm inputs; and (c) comprehensive
on-farm training support. To ensure effectiveness and wider reach, government
needs to view agriculture through an HIV lens and promote a multisectoral
approach that recognises the relationship between HIV/AIDS and food security. A
number of immediate actions are required to strengthen this relationship, such as
increased public investment to augment extension services, subsidise farm inputs,
and develop infrastructure including agricultural markets.
PMID: 20485856 [PubMed - indexed for MEDLINE]
148. SAHARA J. 2009 Nov;6(3):120-6; quiz 127-33.
Assessment of knowledge, attitudes and practices of infant feeding in the context
of HIV: a case study from western Kenya.
Wachira J, Otieno-Nyunya B, Ballidawa J, Braitstein P.
Moi University School of Public Health, Eldoret, Kenya.
Guidelines for infant feeding options among HIV-positive mothers are changing
with informative research. Cultural factors, socialisation processes, gender
dimensions and socio-economic status within communities should be considered in
recommending feasible and sustainable options. The objective of this study was to
assess the knowledge, attitudes and practices with regards to infant feeding in
the context of HIV. A cross-sectional study was conducted between November 2003
and January 2004. The study was carried out in Kosirai Division, Nandi-North
District, in western Kenya. The target population was community members aged 18 45 years and key informants aged 18 years and above. Structured questionnaires
and in-depth interviews were used to collect data. Multistage and snowball
sampling methods were used to identify study participants. Quantitative data were
analysed using the SPSS statistical package for social scientists (Version 12).
Cross-tabulations were calculated and Pearson's chi-square test used to test
significance of relationships between categorical variables. Recorded qualitative
data were transcribed and coded. Themes were developed and integrated. A
generation of concepts was used to organise the presentation into summaries,
interpretations and text. A total of 385 individuals participated in the survey,
50% of whom were women. There were 30 key informants. Farming was the main source
of income but half of the women (49.7% ) had no income. Most of the respondents
(85.5% ) knew of breastfeeding as a route of HIV transmission with sex (p=0.003)
and age (p=0.000) being highly associated with this knowledge. Breastfeeding was
the norm although exclusive breastfeeding was not practised. Cow's milk, the main
breast milk substitute, was reported as being given to infants as early as two
weeks. It was the most popular (93.5% ) infant feeding option in the context of
HIV/AIDS. Heating expressed milk, wet nursing and milk banks were least
preferred. Thus, the social, cultural and psychological complexity of infant
feeding practices should be taken into account when advocating appropriate infant
feeding options. Further research is required to determine the safety of using
cow's milk as an infant feeding option. Community engagement, including education
and awareness strategies, specific to the benefits of exclusive breastfeeding as
a mechanism to reduce the risk of HIV transmission is urgently needed.
PMID: 20485852 [PubMed - indexed for MEDLINE]
149. SAHARA J. 2009 Nov;6(3):105-14.
'Triangulating' AMPATH: demonstration of a multi-perspective strategic programme
evaluation method.
Inui TS, Sidle JE, Nyandiko WM, Yebei VN, Frankel RM, Mossbarger DL, Ayuku D,
Ballidawa J, Ayikukwei R.
Regenstrief Institute, Inc, the Sam Regenstrief Professor of Health Services
Research, and Health Care Research at Indiana University School of Medicine, USA.
[email protected]
Clinical programmes are typically evaluated on operational performance metrics of
cost, quality and outcomes. Measures of patient satisfaction are used to assess
the experience of receiving care, but other perspectives, including those of
staff and communities, are not often sought or used to assess and improve
programmes. For strategic planning, the Kenyan HIV/AIDS programme AMPATH
(Academic Model Providing Access to Healthcare) sought to evaluate its
performance in 2006. The method used for this evaluation was termed
'triangulation', because it used information from three different
sources--patients, communities, and programme staff. From January to August 2006,
Indiana University external evaluators and AMPATH staff gathered information on
strengths, weaknesses and suggestions for improvement of AMPATH. Activities
included in-depth key-informant semi-structured interviews of 26 AMPATH clinical
and support staff, 56 patients at eight clinic sites, and seven village health
dialogues (mabaraza) at five sublocations within the AMPATH catchment area. Data
sources included field notes and transcripts of translated audio recordings,
which were subjected to qualitative content analysis. Eighteen recommendations
for programme improvement emerged, including ten from all three respondent
perspectives. Three recommendations were cited by patients and in mabaraza, but
not by staff. Triangulation uncovered improvement emphases that an internal
assessment would miss. AMPATH and Kenyan Ministry of Health leadership have
deliberated these recommendations and accelerated strategic change actions,
including rural satellite programmes, collaboration with village-based workers,
and door-to-door village-based screening and counselling.
PMID: 20485850 [PubMed - indexed for MEDLINE]
150. J Urol. 2010 Jul;184(1):203-9. Epub 2010 May 16.
Circumcision and reduced risk of self-reported penile coital injuries: results
from a randomized controlled trial in Kisumu, Kenya.
Mehta SD, Krieger JN, Agot K, Moses S, Ndinya-Achola JO, Parker C, Bailey RC.
Division of Epidemiology and Biostatistics, University of Illinois at Chicago,
Chicago, Illinois, USA. [email protected]
PURPOSE: Injuries to the penis during intercourse represent a hypothesized
mechanism by which uncircumcised men are at increased risk for HIV. There are no
published, systematically collected data regarding mild penile coital trauma to
our knowledge. We identified risks of self-reported penile coital injuries in men
18 to 24 years old in a randomized trial of circumcision to prevent HIV in
Kisumu, Kenya.
MATERIALS AND METHODS: Each participant underwent standardized interview, medical
history and physical examination at baseline, and 6, 12, 18 and 24 months after
enrollment. Self-reported penile coital injuries were assessed at each visit, and
were defined as penis feels sore during sex, penis gets scratches, cuts or
abrasions during sex, and skin of the penis bleeds after sex. Generalized
estimating equation analysis estimated odds ratios for penile coital injuries.
RESULTS: From February 2002 to September 2005, 2,784 participants were
randomized. At baseline 1,775 (64.4%) men reported any coital injury including
1,313 (47.6%) soreness, 1,328 (48.2%) scratches, abrasions or cuts and 461
(16.7%) bleeding. On multivariable analysis coital injury risk was lower for
circumcised than for uncircumcised men with soreness (OR 0.71, 95% CI 0.64-0.80),
scratches/abrasions/cuts (OR 0.52, 95% CI 0.46-0.59), bleeding (OR 0.62, 95% CI
0.51-0.75) and any coital injury (OR 0.61, 95% CI 0.54-0.68). Other significant
risks included increasing age, multiple recent sex partners, HSV-2 seropositivity
and genital ulcers (p <0.05). Condom use, cleaning the penis soon after
intercourse and being married/cohabiting were protective (p <0.05, each).
CONCLUSIONS: Self-reported penile coital injuries were common in these healthy
young men. Circumcised men were at lower risk for coital injuries. Verifying
penile coital injuries, the mechanism of acquisition and the association with HIV
risk is needed.
PMCID: PMC3090633
PMID: 20483156 [PubMed - indexed for MEDLINE]
151. BMC Pediatr. 2010 May 18;10:33.
Predictors of mortality in HIV-1 infected children on antiretroviral therapy in
Kenya: a prospective cohort.
Wamalwa DC, Obimbo EM, Farquhar C, Richardson BA, Mbori-Ngacha DA, Inwani I,
Benki-Nugent S, John-Stewart G.
Department of Paediatrics, University of Nairobi, Box 19676, Nairobi 00202,
Kenya. [email protected]
BACKGROUND: Among children, early mortality following highly active
antiretroviral therapy (HAART) remains high. It is important to define correlates
of mortality in order to improve outcome.
METHODS: HIV-1-infected children aged 18 months-12 years were followed up at
Kenyatta National Hospital, Nairobi after initiating NNRTI-based HAART. Cofactors
for mortality were determined using multivariate Cox regression models.
RESULTS: Between August 2004 and November 2008, 149 children were initiated on
HAART of whom 135 were followed for a total of 238 child-years (median 21 months)
after HAART initiation. Baseline median CD4% was 6.8% and median HIV-1-RNA was
5.98-log10 copies/ml. Twenty children (13.4%) died at a median of 35 days
post-HAART initiation. Mortality during the entire follow-up period was 8.4
deaths per 100 child-years (46 deaths/100 child-years in first 4 months and 1.0
deaths/100 child-years after 4 months post-HAART initiation). On univariate Cox
regression, baseline hemoglobin (Hb) <9 g/dl, weight-for-height z-score (WHZ) <
-2, and WHO clinical stage 4 were associated with increased risk of death (Hb <9
g/dl HR 3.00 [95% C.I. 1.21-7.39], p = 0.02, WHZ < -2 HR 3.41 [95% C.I.
1.28-9.08], p = 0.01, and WHO clinical stage 4, HR 3.08 [1.17-8.12], p = 0.02).
On multivariate analysis Hb < 9 g/dl remained predictive of mortality after
controlling for age, baseline CD4%, WHO clinical stage and weight-for-height
z-score (HR 2.95 (95% C.I. 1.04-8.35) p = 0.04).
CONCLUSION: High early mortality was observed in this cohort of Kenyan children
receiving HAART, and low baseline hemoglobin was an independent risk factor for
PMCID: PMC2887829
PMID: 20482796 [PubMed - indexed for MEDLINE]
152. Sex Transm Dis. 2010 Jun;37(6):382-5.
Diaphragm for STI and HIV prevention: is it a safe method for women at high risk?
Njoroge B, Gallo MF, Sharma A, Bukusi EA, Nguti R, Bell AJ, Jamieson DJ, Williams
D, Eschenbach DA.
Center for Microbiology Research, Kenya Medical Research Institute, Nairobi,
Kenya, Africa.
Female sex workers (n = 140) were enrolled in a 6-month acceptability trial of
the diaphragm. We randomized a subset (n = 40) to receive colposcopies after 1
month of diaphragm use or after 1 month of observation before commencing
diaphragm use. Adverse events were mild in nature. Frequency of colposcopic
findings did not differ between women randomized to immediate versus delayed
diaphragm use (P = 0.25).
PMID: 20473244 [PubMed - indexed for MEDLINE]
153. AIDS Care. 2010 Jun;22(6):729-36.
Determinants of failure to access care in mothers referred to HIV treatment
programs in Nairobi, Kenya.
Otieno PA, Kohler PK, Bosire RK, Brown ER, Macharia SW, John-Stewart GC.
Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya.
BACKGROUND: As prevention of mother-to-child transmission of HIV (PMTCT) programs
and HIV treatment programs rapidly expand in parallel, it is important to
determine factors that influence the transition of HIV-infected women from
maternal to continuing care.
DESIGN: This study aimed to determine rates and co-factors of accessing HIV care
by HIV-infected women exiting maternal care. A cross-sectional survey of women
who had participated in a PMTCT research study and were referred to care programs
in Nairobi, Kenya was conducted.
METHODS: A median of 17 months following referral, women were located by peer
counselors and interviewed to determine whether they accessed HIV care and what
influenced their care decisions. Fisher's exact test was used to assess the
association between client characteristics and access to care.
RESULTS: Peer counselors traced 195 (82%) residences, where they located 116
(59%) participants who provided information on care. Since exit, 50% of
participants had changed residence, and 74% reported going to the referral HIV
program. Reasons for not accessing care included lack of money, confidentiality,
and dislike of the facility. Women who did not access care were less likely to
have informed their partner of the referral (p=0.001), and were less likely
believe that highly active antiretroviral therapy (HAART) is effective (p<0.01).
Among those who accessed care, 33% subsequently discontinued care, most because
they did not qualify for HAART. Factors cited as barriers to access included
stigma, denial, poor services, and lack of money. Factors that were cited as
making care attractive included health education, counseling, free services, and
CONCLUSION: A substantial number of women exiting maternal care do not transit to
HIV care programs. Partner involvement, a standardized referral process and more
comprehensive HIV education for mothers diagnosed with HIV during pregnancy may
facilitate successful transitions between PMTCT and HIV care programs.
PMID: 20467938 [PubMed - indexed for MEDLINE]
154. AIDS Care. 2010 Jun;22(6):743-50.
Assessing male spousal engagement with prevention of mother-to-child transmission
(pMTCT) programs in western Kenya.
Reece M, Hollub A, Nangami M, Lane K.
Center for Sexual Health Promotion, Indiana University, Bloomington, USA.
[email protected] <[email protected]>
The importance of male spousal involvement in the prevention of mother-to-child
transmission (pMTCT) programs is incremental to maintain family health and
adherence to human immunodeficiency virus (HIV) treatment and prevention
regimens. This study examined reasons for men's involvement in pMTCT initiatives
sought by their wives and other HIV-related services in western Kenya. Data were
collected from 146 men and women during 16 focus groups across four different
HIV-related clinics. Four different groups of participants were recruited: (1)
male spouses of women enrolled in pMTCT within the past 12 months; (2) married
men who were participating in support groups of the AMPATH Support Network; (3)
married women living with HIV who were currently enrolled in pMTCT; and (4)
married women who were HIV negative and currently enrolled in pMTCT. Demographic
information was collected from each participant using a written questionnaire.
Focus groups were conducted to determine the factors associated with men's
participation in pMTCT services. From the emergent themes revealed by the focus
groups, several intervention strategies were identified to increase male
involvement in HIV-related services, specifically pMTCT. They include: couple's
counseling, weekend clinic hours or extended weekday hours, community education
regarding HIV-related services offered at clinics, and making clinics more
male-oriented. These findings provide a starting point for the development of
interventions to increase men's involvement in pMTCT programs.
PMID: 20461572 [PubMed - indexed for MEDLINE]
155. BMC Public Health. 2010 May 11;10:245.
Shamba Maisha: a pilot study assessing impacts of a micro-irrigation intervention
on the health and economic wellbeing of HIV patients.
Pandit JA, Sirotin N, Tittle R, Onjolo E, Bukusi EA, Cohen CR.
Department of Obstetrics, Gynecology and Reproductive Sciences, University of
California San Francisco School of Medicine, USA.
BACKGROUND: HIV/AIDS negatively impacts poverty alleviation and food security,
which reciprocally hinder the rapid scale up and effectiveness of HIV care
programs. Nyanza province has the highest HIV prevalence (15.3%), and is the
third highest contributor (2.4 million people) to rural poverty in Kenya. Thus,
we tested the feasibility of providing a micro-irrigation pump to HIV-positive
farmers in order to evaluate its impact on health and economic advancement among
HIV-positive patients and their families.
METHODS: Thirty HIV-positive patients enrolled in the Family AIDS Care and
Education Services (FACES) program in Kisumu, Kenya were provided a
micro-financed loan to receive an irrigation pump and farming guidance from
KickStart, the developer of the pump. Economic data, CD4 counts, household health
and loan repayment history were collected 12 months after the pumps were
RESULTS: Mean annual family income increased by $1,332 over baseline. CD4 counts
did not change significantly. Though income increased, only three (10%)
participants had paid off more than a quarter of the loan.
CONCLUSIONS: We demonstrated the feasibility of an income-generating
micro-irrigation intervention among HIV-positive patients and the collection of
health and economic data. While family income improved significantly, loan
repayment rates were low- likely complicated by the drought that occurred in
Kenya during the intervention period.
PMCID: PMC2877674
PMID: 20459841 [PubMed - indexed for MEDLINE]
156. J Acquir Immune Defic Syndr. 2010 Jul 1;54(3):317-23.
Increasing access to HIV counseling and testing through mobile services in Kenya:
strategies, utilization, and cost-effectiveness.
Grabbe KL, Menzies N, Taegtmeyer M, Emukule G, Angala P, Mwega I, Musango G,
Marum E.
US Centers for Disease Control and Prevention, Global AIDS Program, National
Center for HIV, Viral Hepatitis, STD, and TB Prevention, Atlanta, GA 30333, USA.
[email protected]
INTRODUCTION: This study compares client volume, demographics, testing results,
and costs of 3 "mobile" HIV counseling and testing (HCT) approaches with existing
"stand-alone" HCT in Kenya. A retrospective cohort of 62,173 individuals
receiving HCT between May 2005 and April 2006 was analyzed. Mobile HCT approaches
assessed were community-site mobile HCT, semimobile container HCT, and fully
mobile truck HCT. Data were obtained from project monitoring data, project
accounts, and personnel interviews.
RESULTS: Mobile HCT reported a higher proportion of clients with no prior HIV
test than stand-alone (88% vs. 58%). Stand-alone HCT reported a higher proportion
of couples than mobile HCT (18% vs. 2%) and a higher proportion of discordant
couples (12% vs. 4%). The incremental cost-effectiveness of adding mobile HCT to
stand-alone services was $14.91 per client tested (vs. $26.75 for stand-alone
HCT); $16.58 per previously untested client (vs. $43.69 for stand-alone HCT); and
$157.21 per HIV-positive individual identified (vs. $189.14 for stand-alone HCT).
CONCLUSIONS: Adding mobile HCT to existing stand-alone HCT seems to be a
cost-effective approach for expanding HCT coverage for reaching different target
populations, including women and young people, and for identifying persons with
newly diagnosed HIV infection for referral to treatment and care.
PMID: 20453819 [PubMed - indexed for MEDLINE]
157. J Urban Health. 2010 May 7. [Epub ahead of print]
Menstrual Pattern, Sexual Behaviors, and Contraceptive Use among Postpartum Women
in Nairobi Urban Slums.
Ndugwa RP, Cleland J, Madise NJ, Fotso JC, Zulu EM.
London School of Hygiene and Tropical Medicine, London, UK,
[email protected]
Postpartum months provide a challenging period for poor women. This study
examined patterns of menstrual resumption, sexual behaviors and contraceptive use
among urban poor postpartum women. Women were eligible for this study if they had
a birth after the period September 2006 and were residents of two Nairobi slums
of Korogocho and Viwandani. The two communities are under continuous demographic
surveillance. A monthly calendar type questionnaire was administered
retrospectively to cover the period since birth to the interview date and data on
sexual behavior, menstrual resumption, breastfeeding patterns, and contraception
were collected. The results show that sexual resumption occurs earlier than
menses and postpartum contraceptive use. Out of all postpartum months where women
were exposed to the risk of another pregnancy, about 28% were months where no
contraceptive method was used. Menstrual resumption acts as a trigger for
initiating contraceptive use with a peak of contraceptive initiation occurring
shortly after the first month when menses are reported. There was no variation in
contraceptive method choice between women who initiate use before and after
menstrual resumption. Overall, poor postpartum women in marginalized areas such
as slums experience an appreciable risk of unintended pregnancy. Postnatal visits
and other subsequent health system contacts provide opportunities for reaching
postpartum women with a need for family planning services.
PMID: 20449772 [PubMed - as supplied by publisher]
158. Qual Health Res. 2011 Jan;21(1):14-26. Epub 2010 Apr 30.
Rooting inquiry in tradition: the health baraza as a tool for social research in
Naanyu V, Sidle JE, Frankel RM, Ayuku D, Nyandiko WM, Inui TS.
Moi University, Eldoret, Kenya. [email protected]
The baraza is a customary form of community assembly in East Africa. We examined
the use of the health baraza as a process that can improve data collection and
deepen community understanding of sociocultural issues surrounding HIV/AIDS. In
the evaluation of the United States Agency for International Development
(USAID)-Academic Model for Prevention and Treatment of HIV/AIDS Partnership
(USAID-AMPATH) in Kenya, investigators facilitated mabaraza (the plural of
baraza) to gather information of relevance to program success, improvement, and
community collaboration. Seven mabaraza were held at local health facilities.
Mabaraza rapidly evoked essential information for the USAID-AMPATH program and
facilitated vibrant discussion of themes that were of interest to local
communities. Mabaraza combined individual and community outlooks, producing emic
understanding of the program's meaning to local populations. The baraza
assemblage is a promising technique for applied sociology, participatory
research, and program evaluation.
PMID: 20435788 [PubMed - indexed for MEDLINE]
159. Reprod Health. 2010 Apr 29;7(1):1.
Antenatal and delivery care in rural western Kenya: the effect of training health
care workers to provide "focused antenatal care".
Ouma PO, van Eijk AM, Hamel MJ, Sikuku ES, Odhiambo FO, Munguti KM, Ayisi JG,
Crawford SB, Kager PA, Slutsker L.
Kenya Medical Research Institute, Centre for Global Health Research, Kisumu,
Kenya. [email protected]
ABSTRACT:BACKGROUND: Maternal mortality remains high in developing countries and
data to monitor indicators of progress in maternal care is needed. We examined
the status of maternal care before and after health care worker (HCW) training in
WHO recommended Focused Antenatal Care.
METHODS: An initial cross-sectional survey was conducted in 2002 in Asembo and
Gem in western Kenya among a representative sample of women with a recent birth.
HCW training was performed in 2003 in Asembo, and a repeat survey was conducted
in 2005 in both areas.
RESULTS: Antenatal clinic (ANC) attendance was similar in both areas (86%) in
2005 and not significantly different from 2002 (90%). There was no difference in
place of delivery between the areas or over time. However, in 2005, more women in
Asembo were delivered by a skilled assistant compared to Gem (30% vs.23%, P =
0.04), and this proportion increased compared to 2002 (17.6% and 16.1%,
respectively). Provision of iron (82.4%), folic acid (72.0%),
sulfadoxine-pyrimethamine (61.7%), and anthelminths (12.7%) had increased in
Asembo compared to 2002 (2002: 53.3%, 52.8%, 20.3%, and 4.6%, respectively), and
was significantly higher than in Gem in 2005 (Gem 2005: 69.7%, 47.8%, 19.8%, and
4.1%, respectively) (P < 0.05 for all). Offering of tests for sexually
transmitted diseases and providing information related to maternal health was
overall low (<20%) and did not differ by area. In 2005, more women rated the
quality of the antenatal service in Asembo as very satisfactory compared to Gem
(17% vs. 6.5%, P < 0.05).
CONCLUSIONS: We observed improvements in some ANC services in the area where HCWs
were trained. However, since our evaluation was carried out 2 years after
three-day training, we consider any significant, sustained improvement to be
PMCID: PMC2867783
PMID: 20429906 [PubMed - in process]
160. BMC Womens Health. 2010 Apr 28;10:13.
"I will not let my HIV status stand in the way." Decisions on motherhood among
women on ART in a slum in Kenya- a qualitative study.
Awiti Ujiji O, Ekström AM, Ilako F, Indalo D, Rubenson B.
Karolinska Institute, Department of Public Health Sciences, Division of Global
Health, SE- 171 77 Stockholm, Sweden. [email protected]
BACKGROUND: The African Medical Research Foundation antiretroviral therapy
program at the community health centre in Kibera counsels women to wait with
pregnancy until they reach the acceptable level of 350 cells/ml CD4 count and to
discuss their pregnancy intentions with their health care providers. A 2007
internal assessment showed that women were becoming pregnant before attaining the
350 cells/ml CD4 count and without consulting health care providers. This
qualitative study explored experiences of intentionally becoming pregnant among
women receiving highly active antiretroviral therapy (HAART).
METHODS: Nine pregnant women, six newly delivered mothers and five women wanting
to get pregnant were purposefully selected for in-depth interviews. Content
analysis was used to organize and interpret the women's experiences of becoming
RESULTS: Women's choices for pregnancy could be categorized into one overarching
theme 'strive for motherhood' consisting of three sub-themes. A child is thought
of as a prerequisite for a fulfilled and happy life. The women accepted that good
health was required to bear a pregnancy and thought that feeling well, taking
their antiretroviral treatment and eating nutritious food was enough. Consulting
health care providers was perceived as interfering with the women's decisions to
get pregnant. Becoming pregnant as an HIV-infected woman was, however,
complicated by the dilemmas related to disclosing HIV infection and discussing
pregnancy intentions with their partners.
CONCLUSIONS: Motherhood is important to women on antiretroviral treatment. But
they seemed to lack understanding of the relationship between a high CD4 cell
count and a low chance of transmission of HIV to offspring. Better education
about the relationship of perceived good physical health, low CD4 cell count and
the risk of mother to child transmission is required. Women want to control the
domain of childbearing but need enough information to make healthy choices
without risking transmission.
PMCID: PMC2873237
PMID: 20423528 [PubMed - indexed for MEDLINE]
161. J Infect Dis. 2010 Jun 1;201(11):1677-85.
Increased risk of HIV acquisition among Kenyan men with human papillomavirus
Smith JS, Moses S, Hudgens MG, Parker CB, Agot K, Maclean I, Ndinya-Achola JO,
Snijders PJ, Meijer CJ, Bailey RC.
Gillings School of Global Public Health, Department of Epidemiology, University
of North Carolina, Chapel Hill, North Carolina, USA. [email protected]
BACKGROUND: Few data on the effect of human papillomavirus (HPV) infection on
human immunodeficiency virus (HIV) acquisition are available.
METHODS: HIV-seronegative, sexually active, 18-24-year-old Kenyan men
participating in a randomized trial of male circumcision provided exfoliated
penile cells from 2 anatomical sites (glans/coronal sulcus and shaft) at
baseline. The GP5+/6+ polymerase chain reaction assay ascertained a wide range of
HPV DNA types at the baseline visit. The risk of HIV infection was estimated
using Kaplan-Meier methods and hazard ratios from proportional hazards models.
RESULTS: Of 2168 uncircumcised men with baseline HPV data, 1089 (50%) were
positive for HPV DNA. The cumulative incidence of HIV infection by 42 months was
5.8% (95% confidence interval [CI], 3.6%-7.9%) among men with HPV-positive
glans/coronal sulcus specimens, versus 3.7% [95% CI, 1.8%-5.6%] among men with
HPV-negative glans/coronal sulcus specimens (P = .01). Controlling for subsequent
circumcision status, baseline herpes simplex virus type 2 serostatus, and sexual
and sociodemographic risk factors, the hazard ratio for HIV infection among men
with HPV-positive glans/coronal sulcus specimens was 1.8 (95% CI, 1.1-2.9),
compared with men with HPV-negative glans/coronal sulcus specimens.
CONCLUSION: The results suggest an independent increased risk of HIV
seroconversion among HPV-positive men. If this finding is confirmed in other
studies, HPV prevention could be another tool for HIV prevention.
PMCID: PMC2873838
PMID: 20415595 [PubMed - indexed for MEDLINE]
162. Sex Transm Infect. 2010 Aug;86(4):318-22. Epub 2010 Apr 21.
Intravaginal practices among female sex workers in Kibera, Kenya.
Gallo MF, Sharma A, Bukusi EA, Njoroge B, Nguti R, Jamieson DJ, Bell AJ,
Eschenbach DA.
Division of Reproductive Health, National Center for Chronic Disease Prevention
and Health Promotion, Centers for Disease Control and Prevention, Atlanta,
Georgia 30341-3724, USA. [email protected]
OBJECTIVES: To assess vaginal cleansing and lubricant use among female sex
workers (FSW) in Kenya participating in a 6-month, prospective study of the
acceptability of the use of the diaphragm.
METHODS: The study is based on 140 FSW in Nairobi, who completed 140 baseline
visits and 390 bi-monthly follow-up visits. Participants were instructed to wear
the diaphragm for all coital acts during follow-up and to refrain from vaginal
cleansing while wearing the diaphragm. Logistic regression was used to identify
predictors of recent vaginal cleansing to 'tighten' the vagina reported at
baseline; recent vaginal cleansing to prevent infection reported at baseline;
recent vaginal cleansing with the diaphragm in place reported during follow-up;
and recent use of oil-based lubricant during coitus reported at baseline.
RESULTS: At baseline, 99% of women reported vaginal cleansing in the previous 2
weeks for purposes of hygiene or to remove evidence of past coitus. Approximately
41% of women also reported cleansing in the past 2 weeks to 'tighten' the vagina.
Women reported vaginal cleansing with the diaphragm in place in the past 2 weeks
at 14% of follow-up visits in which the diaphragm was used. Predictors of such
cleansing included young age, 6-month study visit, being divorced or widowed and
higher educational level.
CONCLUSIONS: While vaginal cleansing is a modifiable behaviour, given that
cleansing for hygiene was almost universal among this study population at
baseline and that more women reported cleansing while wearing the diaphragm as
the study progressed, the complete eradication of the practice would probably be
PMID: 20410077 [PubMed - indexed for MEDLINE]
163. Am J Pathol. 2010 Jun;176(6):2798-805. Epub 2010 Apr 15.
Abundant expression of HIV target cells and C-type lectin receptors in the
foreskin tissue of young Kenyan men.
Hirbod T, Bailey RC, Agot K, Moses S, Ndinya-Achola J, Murugu R, Andersson J,
Nilsson J, Broliden K.
Center for Molecular Medicine, Infectious Disease Unit, Department of Medicine,
Solna, Karolinska Institutet, 171 76 Stockholm, Sweden. [email protected]
A biological explanation for the reduction in HIV-1 (HIV) acquisition after male
circumcision may be that removal of the foreskin reduces the number of target
cells for HIV. The expression of potential HIV target cells and C-type lectin
receptors in foreskin tissue of men at risk of HIV infection were thus analyzed.
Thirty-three foreskin tissue samples, stratified by Herpes simplex virus type 2
status, were obtained from a randomized, controlled trial conducted in Kenya. The
samples were analyzed by confocal in situ imaging microscopy and mRNA
quantification by quantitative RT-qPCR. The presence and location of T cells
(CD3(+)CD4(+)), Langerhans cells (CD1a(+)Langerin/CD207(+)), macrophages (CD68(+)
or CD14(+)), and submucosal dendritic cells (CD123(+)BDCA-2(+) or
CD11c(+)DC-SIGN(+)) were defined. C-type lectin receptor expressing cells were
detected in both the epithelium and submucosa, and distinct lymphoid aggregates
densely populated with CD3(+)CD4(+) T cells were identified in the submucosa.
Although the presence of lymphoid aggregates and mRNA expression of selected
markers varied between study subjects, Herpes simplex virus type 2 serostatus was
not the major determinant for the detected differences. The detection of abundant
and superficially present potential HIV target cells and submucosal lymphoid
aggregates in foreskin mucosa from a highly relevant HIV risk group demonstrate a
possible anatomical explanation that may contribute to the protective effect of
male circumcision on HIV transmission.
PMCID: PMC2877841
PMID: 20395432 [PubMed - indexed for MEDLINE]
164. Int J Tuberc Lung Dis. 2010 May;14(5):611-5.
Impact of introducing human immunodeficiency virus testing, treatment and care in
a tuberculosis clinic in rural Kenya.
Huerga H, Spillane H, Guerrero W, Odongo A, Varaine F.
Médecins Sans Frontières, Nairobi, Kenya. [email protected]
SETTING: In July 2005, Médecins Sans Frontières and the Ministry of Health,
Kenya, implemented an integrated tuberculosis-human immunodeficiency virus
(TB-HIV) programme in western Kenya.
OBJECTIVE: To evaluate the impact of an integrated TB-HIV programme on patient
care and TB programme outcomes.
DESIGN: Retrospective evaluation of three time periods: before (January-June
2005), shortly after (January-June 2006) and medium term after (January-December
2007) the implementation of the integrated programme.
RESULTS: Respectively 79% and 91% of TB patients were HIV tested shortly and at
medium term after service integration. The HIV-positive rate varied from 96%
before the intervention to respectively 88% (305/347) and 74% (301/405) after.
The estimated number of HIV-positive cases was respectively 303, 323 and 331 in
the three periods. The proportion of patients receiving cotrimoxazole prophylaxis
increased significantly from 47% (142/303) to 94% (303/323) and 86% (285/331, P <
0.05). Before the intervention, 87% (171/197) of the TB-HIV patients would have
been missed when initiating antiretroviral treatment, compared to respectively
29% (60/210) and 36% (78/215) after the integration. The TB programme success
rate increased from 56% (230/409) to 71% (319/447) in the third period (P <
0.05); however, there was no significant decrease in the default rate: 20% to 22%
(P = 0.66) and 18% (P = 0.37).
CONCLUSION: Integrated TB-HIV care has a very positive impact on the management
of TB-HIV patients and on TB treatment outcomes.
PMID: 20392355 [PubMed - indexed for MEDLINE]
165. AIDS Care. 2010 Feb;22(2):187-94.
Implementation of clinic-based modified-directly observed therapy (m-DOT) for
ART; experiences in Mombasa, Kenya.
Munyao P, Luchters S, Chersich MF, Kaai S, Geibel S, Mandaliya KN, Temmerman M,
Rutenberg N, Sarna A.
International Centre for Reproductive Health, Mombasa, Kenya.
The effectiveness of modified-directly observed therapy (m-DOT), an adherence
support intervention adapted from TB DOTS programmes, has been documented.
Describing the implementation process and acceptability of this intervention is
important for scaling up, replication in other settings and future research. In a
randomised trial in Mombasa, Kenya, patients were assigned to m-DOT or standard
of care for 24 weeks. m-DOT entailed twice weekly visits to a health centre for
medication collection, ongoing adherence counselling and nurse-observed pill
ingestion. Community health workers (CHWs) traced non-attendees, observing pill
taking at participant's home. Using process indicators and a semi-structured
questionnaire, implementation of m-DOT was evaluated among 94 participants who
completed 24 weeks m-DOT (81%; 94/116). Two-thirds of m-DOT recipients were
female (64%; 74/116) and a mean 37 years (SD = 7.8). Selection of the m-DOT
observation site was determined by proximity to home for 73% (69/94), with the
remainder choosing sites near their workplace, or due to perceived high-quality
services. A median 42 of 48 scheduled m-DOT visits (IQR = 28-45) were attended.
Most found m-DOT is very useful (87%; 82/94) and had positive attitudes to the
services. A high proportion received CHWs home visits (96%; 90/94) and looked
forward to these. Use of CHWs and several satellite observation sites facilitated
provision of services closer to patient's homes. A substantial number, however,
thought 24 weeks of m-DOT was too long (43%; 42/94). Our experience suggests that
m-DOT services could be implemented widely and are acceptable if delivered with
adequate attention to coordination, provision of a broad set of interventions,
shifting tasks to less-specialised workers and integration within the health
system. m-DOT programmes should utilise existing resources while simultaneously
expanding capacity within communities and the public sector. These findings could
be used to inform replication of such services and to improve the design of m-DOT
in future studies.
PMID: 20390497 [PubMed - indexed for MEDLINE]
166. AIDS Care. 2010 Feb;22(2):137-45.
Improvements in physical wellbeing over the first two years on antiretroviral
therapy in western Kenya.
Fox MP, McCoy K, Larson BA, Rosen S, Bii M, Sigei C, Shaffer D, Sawe F, Wasunna
M, Simon JL.
Department of International Health, Center for Global Health and Development,
School of Public Health, Boston University, Boston, MA, USA. [email protected]
Improvements in physical wellbeing during the first six months on antiretroviral
therapy (ART) are well known, but little is known regarding long-term follow-up.
We conducted a prospective cohort study among 222 HIV-positive adult tea
plantation workers in western Kenya to assess wellbeing over their first two
years on ART. Study subjects completed a standardized questionnaire during repeat
ART clinic visits. A 30-day recall period was used to elicit the number of days
when subjects experienced poor health and the number of days that pain made it
difficult to complete usual activities at home and work. A seven-day recall
period was used to assess the severity of bodily pain, nausea, fatigue, and rash.
Prevalence of most symptoms declined over time. A median of seven days poor
health during the first month on ART declined to three days in the 24th month
(p=0.043). For pain making usual activities difficult, a median of seven days
during the first month on ART fell to zero by 12 months (p< or =0.0001) but
increased to three days by two years. Any bodily pain (range 59-83%) and fatigue
(range 51-84%) over the past seven days were common through two years. However,
pain and fatigue often over the past seven days declined over two years (from
24-10% (p=0.067) and 41-15% (p=0.002)). Skin rash was rare at all times, though
higher at two years (8.6%) than any other time. Initial improvements in physical
wellbeing were sustained over two years, however, increased pain and skin rash at
year two may indicate problems as treatment programs mature. These improvements
in physical wellbeing will be important in sustaining the long-term success of
HIV treatment programs.
PMCID: PMC2856113
PMID: 20390492 [PubMed - indexed for MEDLINE]
167. AIDS Care. 2010 Jan;22(1):119-25.
Ensuring quality of services in HIV prevention research settings: findings from a
multi-center quality improvement pilot in East Africa.
Ngongo Bahati P, Kidega W, Ogutu H, Odada J, Bender B, Fast P, Becker J, Price M.
International AIDS Vaccine Initiative, Nairobi, Kenya. [email protected]
Quality improvement (QI) has been widely implemented in health services but has
not been widely applied in HIV prevention research. Most prevention research
centers have commonly employed traditional approaches (e.g., checklists) to
quality control that document what has been done but not the quality of what has
been done. Unlike other health settings, prevention research settings have unique
characteristics and ethical requirements that require the development or
adaptation of specific quality indicators. A QI model for health services was
adapted for use in prevention research settings and was piloted between August
2006 and July 2007 at three research centers in East Africa. Four hundred and
twenty-six volunteers exit interviews were administered in two cycles.
Quantitative and qualitative data were analyzed using Excel worksheets. QI
meeting reports and QI plans were used to complement data from exit interviews.
On average, 52% of total enrolled volunteers participated in the exit interview.
The designed QI plans successfully helped reduce volunteers' reported waiting
time to see counselors (p<0.001) and pharmacists (p<0.001). It also increased the
percentage of interviewed volunteers who reported being counseled on family
planning at clinical trials (from 66 to 93%; p=0.02) at follow-up visits, and who
were refreshed on informed consent at follow-up visits (from 90 to 96%; p=0.009).
The percentage of interviewed volunteers that expressed satisfaction with
services received from counselors increased (from 87 to 94%; p=0.009) while the
percentage of volunteer satisfied with services from trial physicians remained
constant (93%). The majority of volunteers interviewed reported satisfaction with
other major components of research such as confidentiality, understanding of
trial objectives, benefits and risks of participation, and risk reduction
counseling. However, satisfaction with services from community outreach workers
and other staff at research centers dropped over the course of the study (from
88% in Cycle 1 to 74% in Cycle 3; p= < 0.001). Increased commitment to QI is
crucial in ensuring quality of services and ethical conduct of HIV prevention
research centers.
PMID: 20390489 [PubMed - indexed for MEDLINE]
168. AIDS Care. 2010 Jan;22(1):96-103.
Children caring for their "caregivers": exploring the caring arrangements in
households affected by AIDS in Western Kenya.
Skovdal M.
Institute of Social Psychology, London, UK. [email protected]
Reflecting dominant understandings of childhood, many researchers describe
orphans as an emotional and financial cost to the households in which they live.
This has created a representation of orphans as a burden, not only to their
fostering household, but also to society. This article seeks to challenge this
representation by exploring children's contributions to their fostering
households. Drawing on research from Bondo District in Kenya, this article brings
together the views of 36 guardians and 69 orphaned children between the ages of
11 and 17, who articulated their circumstances through photography and drawing.
Nearly 300 photos and drawings were selected by the children and subsequently
described in writing. An additional 44 in-depth interviews and three focus group
discussions were conducted to explore findings further. The data suggest that
many fostering households benefit tremendously from absorbing orphaned children.
All orphans were found to contribute to their fostering household's income and
provide valuable care or support to ageing, ailing or young members of their
households. The article concludes that caution should be exercised in using the
term "caregiver" to describe foster parents due to the reciprocity, and indeed at
times a reversal, of caring responsibilities.
PMID: 20390486 [PubMed - indexed for MEDLINE]
169. PLoS Negl Trop Dis. 2010 Mar 30;4(3):e644.
Prevalence and correlates of helminth co-infection in Kenyan HIV-1 infected
Walson JL, Stewart BT, Sangaré L, Mbogo LW, Otieno PA, Piper BK, Richardson BA,
John-Stewart G.
Department of Global Health, University of Washington, Seattle, WA, USA.
[email protected]
BACKGROUND: Deworming HIV-1 infected individuals may delay HIV-1 disease
progression. It is important to determine the prevalence and correlates of
HIV-1/helminth co-infection in helminth-endemic areas.
METHODS: HIV-1 infected individuals (CD4>250 cells/ul) were screened for helminth
infection at ten sites in Kenya. Prevalence and correlates of helminth infection
were determined. A subset of individuals with soil-transmitted helminth infection
was re-evaluated 12 weeks following albendazole therapy.
RESULTS: Of 1,541 HIV-1 seropositive individuals screened, 298 (19.3%) had
detectable helminth infections. Among individuals with helminth infection,
hookworm species were the most prevalent (56.3%), followed by Ascaris
lumbricoides (17.1%), Trichuris trichiura (8.7%), Schistosoma mansoni (7.1%), and
Strongyloides stercoralis (1.3%). Infection with multiple species occurred in
9.4% of infections. After CD4 count was controlled for, rural residence (RR 1.40,
95% CI: 1.08-1.81), having no education (RR 1.57, 95% CI: 1.07-2.30), and higher
CD4 count (RR 1.36, 95% CI: 1.07-1.73) remained independently associated with
risk of helminth infection. Twelve weeks following treatment with albendazole,
32% of helminth-infected individuals had detectable helminths on examination.
Residence, education, and CD4 count were not associated with persistent helminth
CONCLUSIONS: Among HIV-1 seropositive adults with CD4 counts above 250
cells/mm(3) in Kenya, traditional risk factors for helminth infection, including
rural residence and lack of education, were associated with co-infection, while
lower CD4 counts were not.
PMCID: PMC2846937
PMID: 20361031 [PubMed - indexed for MEDLINE]
170. Sex Transm Dis. 2010 May;37(5):290-7.
Population level impact of an imperfect prophylactic vaccine for herpes simplex
Alsallaq RA, Schiffer JT, Longini IM Jr, Wald A, Corey L, Abu-Raddad LJ.
Vaccine and Infectious Disease Institute, Fred Hutchinson Cancer Research Center,
Seattle, WA, USA. [email protected] <[email protected]>
BACKGROUND: The continuation of developing Herpes simplex virus type-2 (HSV-2)
prophylactic vaccines requires parallel mathematical modeling to quantify the
effect on the population of these vaccines.
METHODS: Using mathematical modeling we derived 3 summary measures for the
population effect of imperfect HSV-2 vaccines as a function of their efficacies
in reducing susceptibility (VES), genital shedding (VEP), and infectivity during
shedding (VEI). In addition, we studied the population level effect of vaccine
intervention using representative vaccine efficacies.
RESULTS: A vaccine with limited efficacy of reducing shedding frequency (VEP =
10%) and infectivity (VEI = 0%) would need to reduce susceptibility by 75% (VES =
75%) to substantially reduce the sustainability of HSV-2 infection in a
population. No reduction in susceptibility would be required to reach this target
in a vaccine that decreased shedding by 75% (VES = 0%, VEP = 75%, VEI = 0%). Mass
vaccination using a vaccine with imperfect efficacies (VES = 30%, VEP = 75%, and
VEI = 0%) in Kisumu, Kenya, in 2010 would decrease prevalence and incidence in
2020 by 7% and 30%, respectively. For lower prevalence settings, vaccination is
predicted to have a lower effect on prevalence.
CONCLUSION: A vaccine with substantially high efficacy of reducing HSV-2 shedding
frequency would have a desirable effect at the population level. The vaccine's
short-term impact in a high prevalence setting in Africa would be a substantial
decrease in incidence, whereas its immediate impact on prevalence would be small
and would increase slowly over time.
PMCID: PMC2860045
PMID: 20351622 [PubMed - indexed for MEDLINE]
171. Public Health Rep. 2010 Mar-Apr;125(2):325-36.
Improving the lives of vulnerable children: implications of Horizons research
among orphans and other children affected by AIDS.
Schenk KD, Michaelis A, Sapiano TN, Brown L, Weiss E.
Population Council, Washington, DC 20008, USA. [email protected]
From 1997 through 2007, the Horizons program conducted research to inform the
care and support of children who had been orphaned and rendered vulnerable by
acquired immunodeficiency syndrome in sub-Saharan Africa. Horizons conducted
studies in Kenya, Malawi, Rwanda, South Africa, Uganda, Zambia, and Zimbabwe.
Research included both diagnostic studies exploring the circumstances of families
and communities affected by human immunodeficiency virus (HIV) and evaluations of
pioneering intervention strategies. Interventions found to be supportive of
families included succession planning for families with an HIV-positive parent,
training and supporting youth as caregivers, and youth mentorship for
child-headed households. Horizons researchers developed tools to assess the
psychosocial well-being of children affected by HIV and outlined key ethical
guidelines for conducting research among children. The design, implementation,
and evaluation of community-based interventions for orphans and vulnerable
children continue to be a key gap in the evidence base.
PMCID: PMC2821862
PMID: 20297761 [PubMed - indexed for MEDLINE]
172. Public Health Rep. 2010 Mar-Apr;125(2):316-24.
HIV vulnerability of men who have sex with men in developing countries: Horizons
studies, 2001-2008.
Geibel S, Tun W, Tapsoba P, Kellerman S.
Population Council, Nairobi, Kenya. [email protected]
While male-to-male sexual behavior has been recognized as a primary risk factor
for human immunodeficiency virus (HIV), research targeting men who have sex with
men (MSM) in less-developed countries has been limited due to high levels of
stigma and discrimination. In response, the Population Council's Horizons Program
began implementing research activities in Africa and South America beginning in
2001, with the objectives of gathering information on MSM sexual risk behaviors,
evaluating HIV-prevention programs, and informing HIV policy makers. The results
of this nearly decade-long program are presented in this article as a summary of
the Horizons MSM studies in Africa (Senegal and Kenya) and Latin America (Brazil
and Paraguay), and include research methodologies, study findings, and
interventions evaluated. We also discuss future directions and approaches for HIV
research among MSM in developing countries.
PMCID: PMC2821861
PMID: 20297760 [PubMed - indexed for MEDLINE]
173. Trop Med Int Health. 2010 May;15(5):584-91. Epub 2010 Mar 10.
A Safe Motherhood project in Kenya: assessment of antenatal attendance, service
provision and implications for PMTCT.
Delva W, Yard E, Luchters S, Chersich MF, Muigai E, Oyier V, Temmerman M.
International Centre for Reproductive Health, Department of Obstetrics and
Gynaecology, Ghent University, Ghent, Belgium.
OBJECTIVES: To investigate uptake and provision of antenatal care (ANC) services
in the Uzazi Bora project: a demonstration-intervention project for Safe
Motherhood and prevention of mother-to-child transmission of HIV in Kenya.
METHODS: Data were extracted from antenatal clinic, laboratory and maternity ward
registers of all pregnant women attending ANC from January 2004 until September
2006 at three antenatal clinics in Mombasa and two in rural Kwale district of
Coast Province, Kenya (n = 25 364). Multiple logistic and proportional odds
logistic regression analyses assessed changes over time, and determinants of the
frequency and timing of ANC visits, uptake of HIV testing, and provision of iron
sulphate, folate and single-dose nevirapine (sd-NVP).
RESULTS: About half of women in rural and urban settings (52.2% and 49.2%,
respectively) attended antenatal clinics only once. Lower parity, urban setting,
older age and having received iron sulphate and folate supplements during the
first ANC visit were independent predictors of more frequent visits. The first
ANC visit occurred after 28 weeks of pregnancy for 30% (5894/19 432) of women. By
mid-2006, provision of nevirapine to HIV-positive women had increased from 32.5%
and 11.7% in rural and urban clinics, to 67.0% and 74.6%, respectively. Equally
marked improvements were observed in the uptake of HIV testing and the provision
of iron sulphate and folate.
CONCLUSION: Provision of ANC services, including sd-NVP, increased markedly over
time. While further improvements in quality are necessary, particular attention
is needed to implement evidence-based interventions to alter ANC utilization
patterns. Encouragingly, improved provision of basic essential obstetric care may
increase attendance.
PMID: 20230571 [PubMed - indexed for MEDLINE]
174. AIDS Care. 2010 May;22(5):570-6.
Livelihoods, care and the familial relations of orphans in eastern Africa.
Abebe T, Skovdal M.
Norwegian Centre for Child Research, Norwegian University of Science and
Technology, Trondheim 7491, Norway. [email protected]
Although the impact of AIDS-induced mortality and morbidity is well-researched,
few studies explore the interaction and reciprocity of care between children and
their households. Drawing on participatory research methods (interviews, focus
groups, photo-essays, story writing and observations), we bring together the
findings of two qualitative studies from rural communities in Ethiopia and Kenya
involving 94 orphans and their households. We argue that children's contributions
to household livelihoods are pivotal to the coping of households affected by
AIDS. Despite various socio-economic constraints placed on their childhood,
orphans' access to the household-based resources of extended families enhances
their ability to obtain long-term means for their livelihoods. Care for orphaned
children is also influenced by reciprocity in terms of household labour
contributions, the care of sick family members and generating and contributing
income in return for adult protection and provisions. We conclude that a
one-dimensional view of orphans as "burdens" not only overshadows the meaningful
contributions they make to their families, but also diverts attention away from
interventions grounded in their felt needs and capacities.
PMID: 20229373 [PubMed - indexed for MEDLINE]
175. J Acquir Immune Defic Syndr. 2010 May 1;54(1):42-50.
Outcomes of HIV-exposed children in western Kenya: efficacy of prevention of
mother to child transmission in a resource-constrained setting.
Nyandiko WM, Otieno-Nyunya B, Musick B, Bucher-Yiannoutsos S, Akhaabi P, Lane K,
Yiannoutsos CT, Wools-Kaloustian K.
Department of Child Health and Pediatrics, Moi University School of Medicine,
Eldoret, Kenya.
OBJECTIVES: To compare rates of mother to child transmission of HIV and infant
survival in women-infant dyads receiving different interventions in a prevention
of Mother to Child Transmission (pMTCT) program in western Kenya.
DESIGN: Retrospective cohort study using prospectively collected data stored in
an electronic medical record system.
SETTING: Eighteen HIV clinics in western Kenya.
POPULATION: HIV-exposed infants enrolled between February 2002 and July 2007, at
any of the United States Agency for International Development-Academic Model
Providing Access To Healthcare partnership clinics.
MAIN OUTCOME MEASURES: Combined endpoint (CE) of infant HIV status and mortality
at 3 and 18 months.
ANALYSIS: Descriptive statistics, chi Fisher exact test, and multivariable
RESULTS: Between February 2002 and July 2007, 2477 HIV-exposed children were
registered for care by the United States Agency for International
Development-Academic Model Providing Access To Healthcare partnership pMTCT
program before 3 months of age. Median age at enrollment was 6.1 weeks; 50.4%
infants were male. By 3 months, 31 of 2477 infants (1.3%) were dead and 183
(7.4%) were lost to follow-up. One thousand (40%) underwent HIV DNA Polymerase
Chain Reaction virologic test at a median age of 8.3 weeks: 5% were HIV infected,
89% uninfected, and 6% were indeterminate. Of the 968 infants with specific test
results or mortality data at 3 months, the CE of HIV infection or death was
reached in 84 of 968 (8.7%) infants. The 3-month CE was significantly impacted
(A) by maternal prophylaxis [51 of 752 (6.8%) combination antiretroviral therapy
(cART); 8 of 69 (11.6%) single-dose nevirapine (sdNVP); and 25 of 147 (17%) no
prophylaxis (P < 0.001)] and (B) by feeding method for the 889 of 968 (91.8%)
mother-infant pairs for which feeding choice was documented [5 of 29 (17.2%)
exclusive breastfeeding; 13 of 110 (11.8%) mixed feeding; and 54 of 750 (7.2%)
formula feeding (P = 0.041)]. Of the 1201 infants > or = 18 months of age: 41
(3.4%) were deceased and 329 (27.4%) were lost to follow-up. Of 621 of 831
(74.7%) infants tested, 65 (10.5%) were infected resulting in a CE of 103 of 659
(15.6%). CE differed significantly by maternal prophylaxis [52 of 441 (11.8%) for
cART; 13 of 96 (13.5%) for sdNVP; and 38 of 122 (31.2%) no therapy group (P <
0.001)] but not by feeding method for the 638 of 659 (96.8%) children with
documented feeding choice [7 of 35 (20%) exclusive breastfeeding, 14 of 63
(22.2%) mixed, and 74 of 540 (13.7%) formula (P = 0.131)]. On multivariate
analysis, sdNVP (odds ratio: 0.4; 95% confidence interval: 0.2 to 0.8) and cART
(odds ratio: 0.3; 95% confidence interval: 0.2 to 0.6) were associated with fewer
CE. At 18 months, feeding method was not significantly associated with the CE.
CONCLUSIONS: Though ascertainment bias is likely, results strongly suggest a
benefit of antiretroviral prophylaxis in reducing infant death and HIV infection,
but do not show a benefit at 18-months from the use of formula. There was a high
rate of loss to follow up, and adherence to the HIV infant testing protocol was
less than 50% indicating the need to address barriers related to infant HIV
testing, and to improve outreach and follow-up services.
PMID: 20224420 [PubMed - indexed for MEDLINE]
176. Eur J Clin Nutr. 2010 May;64(5):510-7. Epub 2010 Mar 10.
The influence of inflammation on plasma zinc concentration in apparently healthy,
HIV+ Kenyan adults and zinc responses after a multi-micronutrient supplement.
Mburu AS, Thurnham DI, Mwaniki DL, Muniu EM, Alumasa FM.
Kenya Medical Research Institute, Centre for Public Health Research, Nairobi,
BACKGROUND/OBJECTIVES: Plasma zinc is an important biomarker of zinc status, but
the concentration is depressed by inflammation.
SUBJECTS/METHODS: Apparently healthy adults, who tested positive twice for human
immunodeficiency virus (HIV) but who had not reached stage IV or clinical AIDS,
were randomly allocated to receive a food supplement (n=17 and 21) or the food
plus a micronutrient capsule (MN; n=10 men and n=33 women) containing 15 mg
zinc/day. We used the inflammation biomarkers, C-reactive protein (CRP) and
alpha1-acid glycoprotein (AGP), to identify subjects with and without
inflammation and determine the effect of inflammation on the response of plasma
zinc concentrations to the MN and food supplements.
RESULTS: There were no differences between men and women either in plasma zinc or
in the responses to the supplements and their data were combined. Plasma zinc was
lower in those with inflammation than without. Repeated measures analysis of
variance (ANOVA) showed that inflammation blocked increases in plasma zinc, and
there was an approximate 10% increase in plasma zinc concentration in response to
the MN supplement (P=0.023) in those without inflammation. Subgroup analysis
showed mean changes in plasma zinc of 0.95 and -0.83 micromol/l (P=0.031) in
response to the MN and food treatments, respectively, in those without
inflammation at both time points.
CONCLUSIONS: Inflammation seems to block any increase in plasma zinc after MN
supplement and it is important to identify those without inflammation to
determine the effectiveness of a zinc supplementation program.
PMID: 20216563 [PubMed - indexed for MEDLINE]
177. Oncology. 2010;78(1):5-11. Epub 2010 Mar 6.
Retrospective analysis of the efficacy of gemcitabine for previously treated
AIDS-associated Kaposi's sarcoma in western Kenya.
Strother RM, Gregory KM, Pastakia SD, Were P, Tenge C, Busakhala N, Jakait B,
Schellhase EM, Rosmarin AG, Loehrer PJ.
Indiana University School of Medicine, IU Simon Cancer Center, 535 Barnhill
Drive, Indianapolis, IN 46202, USA. [email protected]
OBJECTIVES: Evaluation of outcomes in the use of single-agent gemcitabine for the
treatment of AIDS-associated Kaposi's sarcoma (KS) in a western Kenyan cancer
treatment program.
METHODS: Retrospective chart review of all patients with KS treated with single
agent gemcitabine following failure of first-line Adriamycin, bleomycin, and
vincristine (ABV). Baseline demographics were collected, and clinicians'
assessments of response were utilized to fill out objective criteria for both
response as well as symptom benefit assessment.
RESULTS: Twenty-three patients with KS who had previously failed first-line
therapy with ABV were evaluated. Following treatment, 22 of the 23 patients
responded positively to treatment with stable disease or better. Of the 18
patients who had completed therapy, with a median follow-up of 5 months, 12
patients had no documented progression.
CONCLUSIONS: Treatment options in the resource-constrained setting are limited,
both by financial constraints as well as the need to avoid myelotoxicity, which
is associated with high morbidity in this treatment setting. This work shows that
gemcitabine has promising activity in KS, with both objective responses and
clinical benefit observed in this care setting. Gemcitabine as a single agent
merits further investigation for AIDS-associated KS.
PMID: 20215784 [PubMed - indexed for MEDLINE]
178. Lancet Infect Dis. 2010 Mar;10(3):149.
HIV/AIDS on the rise in young people in Kenya.
Siringi S.
PMID: 20213962 [PubMed - indexed for MEDLINE]
179. BMC Infect Dis. 2010 Mar 5;10:47.
Pattern and determinants of HIV research productivity in sub-Saharan Africa:
bibliometric analysis of 1981 to 2009 PubMed papers.
Uthman OA.
BACKGROUND: Several bibliometric studies have been published on AIDS. The
findings obtained from these studies have provided a general picture of the
history and growth of AIDS literature. However, factors related to variation in
HIV research productivity in sub-Saharan Africa have not been examined.
Therefore, this study aims to fill some of the gap in existing research to
provide insights into factors associated with HIV research productivity in
sub-Saharan Africa.
METHODS: A bibliometric analysis regarding sub-Saharan Africa HIV/AIDS research
was conducted in the PubMed database for the period of 1981 to 2009. The numbers
of HIV research articles indexed in PubMed was used as surrogate for total HIV
research productivity. Series of univariable and multivariable negative binomial
regression models were used to explore factors associated with variation in HIV
research productivity in sub-Saharan Africa.
RESULTS: First authors from South Africa, Uganda and Kenya contributed almost
half of the total number of HIV articles indexed in PubMed between 1981 and 2009.
Uganda, Zimbabwe and Malawi had better records when the total production was
adjusted for gross domestic product (GDP). Comoros, the Gambia and Guinea-Bissau
were the most productive countries when the total products were normalized by
number of people with HIV. There were strong positive and statistically
significant correlation between countries number of indexed journal (Pearson
correlation r = 0.77, p = .001), number of higher institutions (r = 0.60, p =
.001), number of physicians (r = 0.83, p = .001) and absolute numbers of HIV
CONCLUSIONS: HIV research productivity in Africa is highly skewed. To increase
HIV research output, total expenditure on health (% of GDP), private expenditure
on health, and adult literacy rate may be important factors to address.
PMCID: PMC2841182
PMID: 20205717 [PubMed - indexed for MEDLINE]
180. Am J Hematol. 2010 Apr;85(4):227-33.
Hematological predictors of increased severe anemia in Kenyan children coinfected
with Plasmodium falciparum and HIV-1.
Davenport GC, Ouma C, Hittner JB, Were T, Ouma Y, Ong'echa JM, Perkins DJ.
Department of Infectious Diseases and Microbiology, University of Pittsburgh,
Pittsburgh, PA, USA.
Comment in
Am J Hematol. 2010 Apr;85(4):225-6.
Malaria and HIV-1 are coendemic in many developing countries, with anemia being
the most common pediatric hematological manifestation of each disease. Anemia is
also one of the primary causes of mortality in children monoinfected with either
malaria or HIV-1. Although our previous results showed HIV-1(+) children with
acute Plasmodium falciparum malaria [Pf(+)] have more profound anemia, potential
causes of severe anemia in coinfected children remain unknown. As such, children
with P. falciparum malaria (aged 3-36 months, n = 542) from a holoendemic malaria
transmission area of western Kenya were stratified into three groups: HIV-1
negative [HIV-1(-)/Pf(+)]; HIV-1 exposed [HIV-1(exp)/Pf(+)]; and HIV-1 infected
[HIV-1(+)/Pf(+)]. Comprehensive clinical, parasitological, and hematological
measures were determined upon enrollment. Univariate, correlational, and
hierarchical regression analyses were used to determine differences among the
groups and to define predictors of worsening anemia. HIV-1(+)/Pf(+) children had
significantly more malarial pigment-containing neutrophils (PCN), monocytosis,
increased severe anemia (Hb < 6.0 g/dL), and nearly 10-fold greater mortality
within 3 months of enrollment. Common causes of anemia in malaria-infected
children, such as increased parasitemia or reduced erythropoiesis, did not
account for worsening anemia in the HIV-1(+)/Pf(+) group nor did carriage of
sickle cell trait or G6PD deficiency. Hierarchical multiple regression analysis
revealed that more profound anemia was associated with elevated PCM, younger age,
and increasing HIV-1 status ([HIV-1(-) --> HIV-1(exp) --> HIV-1(+)]. Thus,
malaria/HIV-1 coinfection is characterized by more profound anemia and increased
mortality, with acquisition of monocytic pigment having the most detrimental
impact on Hb levels.
PMCID: PMC3095458
PMID: 20196168 [PubMed - indexed for MEDLINE]
181. J Acquir Immune Defic Syndr. 2010 Mar 1;53(3):422-4.
Comparing clinic retention between residents and nonresidents of Kibera, Kenya.
Chung MH, Kohler P, Attwa M, Thiga J, John-Stewart GC.
PMID: 20190592 [PubMed - indexed for MEDLINE]
182. Lancet. 2010 Mar 20;375(9719):1014-28. Epub 2010 Feb 26.
HIV prevention, treatment, and care services for people who inject drugs: a
systematic review of global, regional, and national coverage.
Mathers BM, Degenhardt L, Ali H, Wiessing L, Hickman M, Mattick RP, Myers B,
Ambekar A, Strathdee SA; 2009 Reference Group to the UN on HIV and Injecting Drug
Collaborators: Ambekar A, Azim T, Bastos FI, Guarinieri M, Hickman M, Jianhua L,
Kamarulzaman A, Malinowska-Sempruch K, Maxwell JC, Murthy P, Myers B, Onigbogi
OO, Owiti F, Panda S, Stimson G, Strathdee SA, Sulliman F, Toufik A, Toufiq J,
Tyndall M, Wiessing L, Zabransky T, Zhusupov B, Mattick RP, Degenhardt L, Mathers
B, Wodak A, Howard J, Ali H, Azim T, Bastos FI, Guarinieri M, Kamarulzaman A,
Malinowska-Sempruch K, Maxwell JC, Murthy P, Stimson G, Toufik A, Tyndall M,
Zabransky T, Sigmundsdottir L, Chivers S, Rana MU, Briegleb C, Robins L, Lemon J,
Perkins A, Bucello C.
National Drug and Alcohol Research Centre, University of New South Wales, Sydney,
Australia. [email protected]
Comment in
Lancet. 2010 May 22;375(9728):1782.
Lancet. 2010 Mar 20;375(9719):961-3.
BACKGROUND: Previous reviews have examined the existence of HIV prevention,
treatment, and care services for injecting drug users (IDUs) worldwide, but they
did not quantify the scale of coverage. We undertook a systematic review to
estimate national, regional, and global coverage of HIV services in IDUs.
METHODS: We did a systematic search of peer-reviewed (Medline, BioMed Central),
internet, and grey-literature databases for data published in 2004 or later. A
multistage process of data requests and verification was undertaken, involving UN
agencies and national experts. National data were obtained for the extent of
provision of the following core interventions for IDUs: needle and syringe
programmes (NSPs), opioid substitution therapy (OST) and other drug treatment,
HIV testing and counselling, antiretroviral therapy (ART), and condom programmes.
We calculated national, regional, and global coverage of NSPs, OST, and ART on
the basis of available estimates of IDU population sizes.
FINDINGS: By 2009, NSPs had been implemented in 82 countries and OST in 70
countries; both interventions were available in 66 countries. Regional and
national coverage varied substantially. Australasia (202 needle-syringes per IDU
per year) had by far the greatest rate of needle-syringe distribution; Latin
America and the Caribbean (0.3 needle-syringes per IDU per year), Middle East and
north Africa (0.5 needle-syringes per IDU per year), and sub-Saharan Africa (0.1
needle-syringes per IDU per year) had the lowest rates. OST coverage varied from
less than or equal to one recipient per 100 IDUs in central Asia, Latin America,
and sub-Saharan Africa, to very high levels in western Europe (61 recipients per
100 IDUs). The number of IDUs receiving ART varied from less than one per 100
HIV-positive IDUs (Chile, Kenya, Pakistan, Russia, and Uzbekistan) to more than
100 per 100 HIV-positive IDUs in six European countries. Worldwide, an estimated
two needle-syringes (range 1-4) were distributed per IDU per month, there were
eight recipients (6-12) of OST per 100 IDUs, and four IDUs (range 2-18) received
ART per 100 HIV-positive IDUs.
INTERPRETATION: Worldwide coverage of HIV prevention, treatment, and care
services in IDU populations is very low. There is an urgent need to improve
coverage of these services in this at-risk population.
FUNDING: UN Office on Drugs and Crime; Australian National Drug and Alcohol
Research Centre, University of New South Wales; and Australian National Health
and Medical Research Council.
PMID: 20189638 [PubMed - indexed for MEDLINE]
183. Med Anthropol. 2009 Oct;28(4):397-425.
Men, women, and abortion in central Kenya: a study of lay narratives.
Izugbara CO, Otsola KJ, Ezeh AC.
African Population and Health Research Center, Shelter Afrique Center, Nairobi,
Kenya. [email protected]
This article examines lay narratives about abortion among adult men and women in
Nyeri district, central Kenya. The women studied do not champion or defend
abortion and they do not necessarily condemn it. To them, abortion shields not
merely against the shame of mistimed or socially unviable entry into recognized
motherhood but more importantly against the negative socioeconomic consequences
of mistimed or unnecessary childbearing and inconvenient entry into motherhood.
The men, on the other hand, were generally condemnatory toward abortion, viewing
it as women's strategy for concealing their deviation from culturally acceptable
gender and motherhood standards. Induced abortion will persist in Kenya not
primarily because it protects against the shame associated with mistimed
childbearing and entry into motherhood, but largely because women associate
mistimed childbearing and inconvenient entry into motherhood with poverty and
loss of marital viability. Kenyan women seeking abortion may also continue to
rely on poor quality abortion services because qualified providers who
clandestinely perform abortion charge prohibitively.
PMID: 20182971 [PubMed - indexed for MEDLINE]
184. AIDS. 2010 Mar 27;24(6):891-7.
Treatment with antiretroviral therapy is not associated with increased sexual
risk behavior in Kenyan female sex workers.
McClelland RS, Graham SM, Richardson BA, Peshu N, Masese LN, Wanje GH, Mandaliya
KN, Kurth AE, Jaoko W, Ndinya-Achola JO.
Department of Medicine, University of Washington, Seattle, USA.
[email protected]
OBJECTIVE: The objective of this study was to test the hypothesis that sexual
risk behavior would increase following initiation of antiretroviral therapy (ART)
in Kenyan female sex workers (FSWs).
DESIGN: Prospective cohort study.
SETTING: FSW cohort in Mombasa, Kenya, 1993-2008.
SUBJECTS: Eight hundred and ninety-eight women contributed HIV-1-seropositive
follow-up visits, of whom 129 initiated ART.
INTERVENTION: Beginning in March 2004, ART was provided to women qualifying for
treatment according to Kenyan National Guidelines. Participants received sexual
risk reduction education and free condoms at every visit.
MAIN OUTCOME MEASURES: Main outcome measures included unprotected intercourse,
abstinence, 100% condom use, number of sexual partners, and frequency of sex.
Outcomes were evaluated at monthly follow-up visits using a 1-week recall
RESULTS: Compared with non-ART-exposed follow-up, visits following ART initiation
were not associated with an increase in unprotected sex [adjusted odds ratio
(AOR) 0.86, 95% confidence interval (CI) 0.62-1.19, P = 0.4]. There was a