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Background: The role of global initiatives in catalyzing change within national contexts is complex and less understood. Addressing adolescent sexual and reproductive health in Kenya requires concerted efforts of both state and non-state actors and more importantly, a supportive environment. This paper deconstructs the moral and social narratives of adolescents' and young people's sexual and reproductive health (AYSRH) in Kenya as driven by the powerful discourse and ideologies pre- and within the Millennium Development Goal (MDG) era. Methods: Literature was systematically searched in PubMed and Medline with policy documents obtained from government agencies from the pre-MDG period (2000 and earlier) and within the MDG period (2001–2015). Literature with a substantial focus on SRH were eligible if they captured the different facets of ASRH in Kenya and sub-Saharan Africa (SSA). The results were reviewed and synthesized to disentangle the moral and social narratives of AYSRH in Kenya with an MDG lens. Results: The evolution of AYSRH policies and programmes in Kenya was gradual and largely shaped by prevailing development threats and moral and social narratives. Pre-MDG period was dominated by issue-based policies of population growth and high fertility rates, with a focus on married population with strong cultural and religious barriers to AYSRH; early to mid-MDG was mainly influenced by the threat of HIV/AIDS, culminating in the first Adolescent Reproductive Health and Development Policy in 2003. However, the policies and subsequent programmes focused on abstinence only and medical narratives, with persistent religious and cultural opposition to AYSRH. Late-MDG saw more progressive policies (these are policies that refer to those that tends towards acceptance of liberal social reforms and which sometimes are contrary to entrenched social norms, beliefs and practices), high government commitment and a refocus on SRH issues due to sustained early childbearing, culminating in the revised Adolescent Sexual and Reproductive Health Policy of 2015. Conclusion: Debates in the translation of global goals and commitments to policy and practice at country level need to account for national level realities in AYSRH reforms. The findings contribute to critical evidence for strategic policy and programming approaches for AYSRH in Kenya and in SSA and for the realization of their rights within the context of sustainable development goals. [ABSTRACT FROM AUTHOR]

Since access to HIV testing, counselling, and drug therapy has improved so dramatically, scholars have investigated ways this ‘scale-up’ has interacted with HIV/AIDS-related stigma in sub-Saharan Africa. Drawing on data collected during ethnographic research in a trading centre in western Kenya, this paper critically analyses two violent and localised case studies of panic over the ill health of particular community residents as a nuanced lens through which to explore the dynamic interplay of gender politics and processes of HIV/AIDS-related stigma in the aftershocks of the AIDS crisis. Gaining theoretical momentum from literatures focusing on stigma, gender, witchcraft, gossip, and accusation, we argue that the cases highlight collective anxieties, as well as local critiques of shifting gender roles and the strain of globalisation and legacies of uneven development on myriad forms of relationships. We further contend that these heightened moments of panic and accusation were deployments of power that ultimately sharpened local gender politics and conflicts on the ground in ways that complicated the social solidarity necessary to tackle social and health inequalities. The paper highlights one community’s challenge to eradicate the stigma associated with HIV/AIDS during a period of increased access to HIV services. [ABSTRACT FROM PUBLISHER]

Background: In Kenya, infant mortality rate increased from 59 deaths per 1000 live births in 1988 to 78 deaths per 1000 live births by 2003. This was an increase of about 32 percent in 15 years. The reasons behind this upturn are poorly understood. This paper investigates the probable factors behind the upsurge in infant mortality in Kenya during the 1988-2003 period. Understanding the causes behind the upsurge is critical in designing high impact public health strategies for the acceleration of national and international public health goals such as the Millennium Development Goals (MDGs). The reversals in early child mortality is also regarded as one of the most important topics in contemporary demography. Methods: A merged dataset drawn from the Kenya Demographic and Health Surveys of 1993, 1998 and 2003 was used. The merged KDHS included a total of 5265 singletons. Permission to use the KDHS data was obtained from ICF international on the following website: http://www.measuredhs.com. Stata version 11.0 was used for data analysis. The paper used regression decomposition techniques as the main method for analysing the contribution of the selected covariates on the upsurge in infant mortality. Results: The duration of breastfeeding; maternal education, regional HIV prevalence and malaria endemicity were the factors that appeared to have contributed much to the observed rise in infant mortality in Kenya over the period. If all the live births that occurred in the 1996/03 period had the same mean values of all explanatory variables as those of live births that occurred in the 1988/95 period, then infant mortality would have increased by a massive 14 deaths per 1000 live births. However, if the live births that occurred in the 1988/95 period had the same mean values of all explanatory variables as those that occurred in the 1996/03 period, the upsurge in infant mortality would have been negligible. While the role of HIV in the upturn in infant mortality in Kenya and other sub Saharan African countries is indisputable, this study demonstrates that it is the duration of breastfeeding and Malaria endemicity that played a more significant role in Kenya's upsurge in infant mortality during the 1988-2003 period. Conclusions: Efforts aimed at controlling and preventing malaria and HIV should be stepped up to avert an upsurge in infant mortality. There is need to step up alternative baby feeding practices among mothers who are HIV positive especially after the first six months of breastfeeding. Owing to the widely known inverse relationship between maternal education and infant mortality, there is need for concerted efforts to promote girl child education. Owing to the important role played by the short preceding birth interval to the upsurge in infant mortality, there is need to promote family planning methods in Kenya. [ABSTRACT FROM AUTHOR]

Information and communication technology (ICT) has been recognized as a key enabler of Millennium Development Goals (MDGs). This paper will address one aspect of the relationship between ICT and MDGs by focussing on the way ICT has been employed for monitoring HIV/AIDS initiatives in Kenya. The objective of the paper is to better understand how a donor multi-agency presence has influenced the strengthening of HIV/AIDS monitoring and evaluation as set in international policies. Based on the case study of the Kenya National HIV/AIDS Programme, the paper takes an institutional theory perspective to identify the main competing logics producing misalignment between policy discourses and their enactments by different policy actors engaged in the restructuring of HIV/AIDS monitoring and evaluation systems. Poor donor-aid coordination has been recognized as one of the major sources of discrepancies between restructuring plans and their enactments. This has caused verticalization and centralization of monitoring systems and poor local ownership of HIV/AIDS information hampering improved design and implementation of HIV/AIDS programs. The paper concludes by highlighting implications for a more effective usage of ICT in monitoring MDGs and their integration into local contexts. [ABSTRACT FROM AUTHOR]

Kenya has the twelfth largest HIV/AIDS epidemic in the world. In 2016, there was an estimated 1.6 million people living with HIV in Kenya. Youth ages 15–24 accounted for over half (51%) of the HIV incidence reported in 2015, a significant increase from 2013 where youth accounted for 29% of all new cases. The purpose of this paper is to review HIV prevalence and incidence among youth and other key populations in Kenya and to discuss the cultural attitudes and practices that impact the HIV epidemic including relevant laws, policies, and initiatives with a focus on the role of school psychologists in neuropsychological interventions for children and adolescents living with HIV. A broad range of biomedical, behavioral, and structural approaches for addressing the HIV-related needs among youth in Kenya are discussed as is the importance of addressing the psychosocial needs of youth living with HIV by acknowledging the relationship between physical health, mental health, and academic outcomes. The critical role of school psychologists and other school professionals in implementing these strategies is highlighted. [ABSTRACT FROM AUTHOR]

Infants with HIV-infection have longevity due to improved Highly Active Antiretroviral Therapy (HAART), making many realise their developmental progression which includes access to schooling. However, there is scant information that focuses on disclosure of their positive sero-status to schools and how these children understand and communicate their illnesses. This paper reports on a study of experiences of children affected by HIV and AIDS in Kenya. Qualitative phenomenological data from children aged between 5 and 7 years and their teachers in Early Childhood Development and Education (ECDE) centres were collected using multiple methods. Thematic content analysis was utilised with several themes emerging from findings. Obstacles to disclosure, anticipation of exceptional care, accidental disclosures, lack of psychosocial structures, a need for specialised skills training for teachers, and lack of clear guidelines to assist in disclosure processes emerged as some of the challenges faced. The findings also provide insights into teachers' scaffolding efforts to educate children in understanding and communicating their illnesses, and forging support structures through relationships with their siblings and peers for care and management. [ABSTRACT FROM AUTHOR]

The availability of free antiretroviral treatment in public health facilities since 2004 has contributed to the increasing biomedicalization of AIDS care in Kenya. This has been accompanied by a reduction of funding for community-based care and support organizations since the 2008 global economic crisis and a consequent donor divestment from HIV projects in Africa. This paper explores the ways that HIV interventions, including support groups, home-based care and antiretroviral treatments have shaped expectations regarding relations of care in the low-income area of Kibera in Nairobi, Kenya, over the last decade. Findings are based on 20 months of ethnographic research conducted in Nairobi between January 2011 and August 2013. By focusing on three eras of HIV treatment – pre-treatment, treatment scale-up, and post-crisis – the authors illustrate how family and community-based care have changed with shifts in funding. Many support groups that previously provided HIV care in Kibera, where the state is largely absent and family networks are thin, have been forced to cut services. Large-scale HIV treatment programmes may allow the urban poor in Nairobi to survive, but they are unlikely to thrive. Many care needs continue to go unmet in the age of treatment, and many economically marginal people who had found work in care-oriented community-based organizations now find themselves jobless or engaged in work not related to HIV. [ABSTRACT FROM AUTHOR]

Differentiated care delivery aims to simplify care of people living with HIV, reflect their preferences, reduce burdens on the healthcare system, maintain care quality and preserve resources. However, assessing program effectiveness using observational data is difficult due to confounding by indication and randomized trials may be infeasible. Also, benefits can reach patients directly, through enrollment in the program, and indirectly, by increasing quality of and accessibility to care. Low-risk express care (LREC), the program under evaluation, is a nurse-centered model which assigns patients stable on ART to a nurse every two months and a clinician every third visit, reducing annual clinician visits by two thirds. Study population is comprised of 16,832 subjects from 15 clinics in Kenya. We focus on patient retention in care based on whether the LREC program is available at a clinic and whether the patient is enrolled in LREC. We use G-estimation to assess the effect on retention of two "strategies": (i) program availability but no enrollment; (ii) enrollment at an available program; versus no program availability. Compared to no availability, LREC results in a non-significant increase in patient retention, among patients not enrolled in the program (indirect effect), while enrollment in LREC is associated with a significant extension of the time retained in care (direct effect). G-estimation provides an analytical framework useful to the assessment of similar programs using observational data. [ABSTRACT FROM AUTHOR]

Purpose – The ethicality of using audience segmentation in social marketing contexts has typically been framed within either a consequentialist or non-consequentialist perspective, leading to a hitherto intractable debate. This paper seeks to shed new light on this debate using two alternative ethical frameworks: the theory of just health care (TJHC) and integrative social contracts theory (ISCT). Design/methodology/approach – The paper uses cross-sectional survey data from a Kenyan social marketing campaign that aimed to increase awareness and support for the use of anti-retroviral therapy (ART), a class of drugs that inhibit the development of HIV. Findings – Application of the TJHC and ISCT to the Kenyan social marketing campaign revealed the use of audience segmentation to be ethically justified. Moreover, the TJHC provided a useful framework for guiding decisions about the selection of target audience(s) in health-related contexts. Practical implications – In situations where there are known asymmetries in exposure to mass media channels, adopting a non-segmented mass-media approach may unintentionally entrench pre-existing disparities in health knowledge. Originality/value – The application of the TJHC and ISCT to health-related social marketing contexts offers a means of resolving the longstanding debate about the ethicality of audience segmentation. The ethical principles underpinning the TJHC also provide a decision-making framework to guide discussions about whether audience segmentation should be based on cost-effectiveness (consequentialism) or need (non-consequentialism). This is particularly relevant in social marketing settings, where the resources available for conducting campaigns are often limited and segmentation decisions about the groups that are targeted or excluded can have important health-related implications. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM PUBLISHER]

While generic programmes have been created to raise sexual health awareness, these cannot always be applied to communities whose cultures and circumstances make them especially vulnerable to infection. Taking a phenomenological approach, this paper examines the circumstances of the Gusii people of Kisii, Kenya, and examines the specific challenges of providing sexual health education to the community as experienced by an ethnic Gusii woman, Joyce Ombasa. Joyce's story reveals that the Gusii living in and around rural villages have several cultural characteristics that make them susceptible to HIV/AIDS and that render community health education problematic, especially if offered by a female educator of the same ethnicity. Women cannot teach men. Discussions of sex and condom use, and viewing the naked bodies of the opposite sex are taboo. Promiscuity is commonplace and there is a reluctance to use condoms and to undergo HIV testing. Female circumcision persists and there is a high rate of sexual violence, incest and intergenerational sexual intercourse. In addition, government policies and legislation threaten to exacerbate some of the sexually risky behaviours. Bringing HIV education and female empowerment to the rural Gusii requires a culturally sensitive approach, discarding sexual abstinence messages in favour of harm minimisation, including the promotion of condom use, regular HIV testing and the rejection of female circumcision and intergenerational sex. Trust needs to be built through tactics such as adopting a complex and fluid outsider identity and replacing formal sex education with training in income generating skills and casual discussions regarding condoms and sexual health. [ABSTRACT FROM PUBLISHER]

Background: Carefully planned research is critical to developing policies and interventions that counter physical, psychological and social challenges faced by young people living with HIV/AIDS, without increasing burdens. Such studies, however, must navigate a 'vulnerability paradox', since including potentially vulnerable groups also risks unintentionally worsening their situation. Through embedded social science research, linked to a cohort study involving Adolescents Living with HIV/AIDS (ALH) in Kenya, we develop an account of researchers' responsibilities towards young people, incorporating concepts of vulnerability, resilience, and agency as 'interacting layers'. Methods: Using a qualitative, iterative approach across three linked data collection phases including interviews, group discussions, observations and a participatory workshop, we explored stakeholders' perspectives on vulnerability and resilience of young people living with HIV/AIDS, in relation to home and community, school, health care and health research participation. A total of 62 policy, provider, research, and community-based stakeholders were involved, including 27 ALH participating in a longitudinal cohort study. Data analysis drew on a Framework Analysis approach; ethical analysis adapts Luna's layered account of vulnerability. Results: ALH experienced forms of vulnerability and resilience in their daily lives in which socioeconomic context, institutional policies, organisational systems and interpersonal relations were key, interrelated influences. Anticipated and experienced forms of stigma and discrimination in schools, health clinics and communities were linked to actions undermining ART adherence, worsening physical and mental health, and poor educational outcomes, indicating cascading forms of vulnerability, resulting in worsened vulnerabilities. Positive inputs within and across sectors could build resilience, improve outcomes, and support positive research experiences. Conclusions: The most serious forms of vulnerability faced by ALH in the cohort study were related to structural, inter-sectoral influences, unrelated to study participation and underscored by constraints to their agency. Vulnerabilities, including cascading forms, were potentially responsive to policy-based and interpersonal actions. Stakeholder engagement supported cohort design and implementation, building privacy, stakeholder understanding, interpersonal relations and ancillary care policies. Structural forms of vulnerability underscore researchers' responsibilities to work within multi-sectoral partnerships to plan and implement studies involving ALH, share findings in a timely way and contribute to policies addressing known causes of vulnerabilities. [ABSTRACT FROM AUTHOR]

Little is known about migration during pregnancy related to intimate partner violence (IPV). In this paper, we examine issues of agency in relation to pregnant women's migrations in a high HIV prevalence area of Kenya. We qualitatively explored forced migration among pregnant women, using data from in-depth interviews, focus groups and IPV screening forms. To quantitatively examine migration during pregnancy, we analysed data from a prospective study of 614 pregnant women. The qualitative data revealed that women had varied responses to violence in pregnancy, with some being able to leave the marital home voluntarily as a strategy to escape violence. Others were ‘sent packing’ from their marital homes when they dared to exercise autonomy, in some cases related to HIV status. Quantitative analyses revealed that pregnant women who migrated were more educated, less likely to be living with a partner and had fewer children than other women. Migration among pregnant women in Kenya illustrates the complexity of understanding women's agency in the context of IPV. The findings indicate that there is not a dichotomy between ‘victim’ and ‘agent’, but rather a complex dynamic between and within pregnant women, who may sequentially or simultaneously experience aspects of victimhood and/or agentic response. [ABSTRACT FROM AUTHOR]

Cultural rites can be a panacea when the immense social capital embedded in them is taken stock of as well as they can be a perfidy when all the retrogressive aspects they constitute are taken into consideration. The aim and objective of this article is to generate debate and discourse on panacea and perfidy of cultural rites with particular focus on circumcision. The article used eclectic data sources. Cultural rite of circumcision is a panacea due to an array of factors: it marks entry into adulthood from childhood; it is a mark of cultural social identity in many societies of the world; it constitutes immense social capital and, currently, it serves as a platform for mitigating the effects of HIV/AIDS. Cultural rite of circumcision is also a perfidy due to: its violation of human rights to health; because it undermines boys' and girls' access to school; and because it is usually a leeway to early sexual overtures. The paper recommends to governments to: hold on their responsibilities to safeguard their citizens' rights to health; ensure that male circumcision is surgically safe and done in a hygienic environment; and, alongside NGOs and civil society, educate communities to balance between the human rights pertaining to circumcision and cultural rights. [ABSTRACT FROM AUTHOR]

Copyright of Culture, Health & Sexuality is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

This paper reports findings of a qualitative study on how a university in Kenya has developed a curriculum for preparing teacher trainees to teach about HIV/AIDS. The aim of the study was to understand the process of developing a standalone HIV/AIDS curriculum, the preparedness of both lecturers and trainee teachers to teach about the pandemic to young people who are seen as on HIV high-risk group. The study was conducted by carrying out individual interviews with lecturers, a group interview with trainees, document review and observation. Data gathered were analysed inductively and then literature was used to summarise the findings. The study established that there was awareness among the trainee teachers, dedication and enthusiasm among the lecturers. A number of the trainees who had taken an extra course as peer educators were confident about their preparedness to teach about the pandemic. The other trainees, who had only studied the HIV/AIDS curriculum, felt that they needed more hands-on activities to provide them with greater experiential knowledge about HIV/AIDS. The university's approach is an example that needs to be emulated by other teacher preparation institutions. However, further research is needed to establish how graduates are teaching about HIV/AIDS to the target group of adolescents in their schools. [ABSTRACT FROM AUTHOR]

The promotion and support of urban agriculture (UA) has the potential to contribute to efforts to address pressing challenges of poverty, under nutrition and sustainability among vulnerable populations in the growing cities of sub- Saharan Africa (SSA). This may be especially relevant for HIV/AIDS-affected individuals in SSA whose agricultural livelihoods are severely disrupted by the devastating effects of the disease on physical productivity and nutritional well- being. This paper outlines the process involved in the conception, design and implementation of a project to strengthen technical, environmental, financial and social capacity for UA among HIV-affected households in Nakuru, Kenya. Key lessons learned are also discussed. The first has been the value of multi-stakeholder partnerships, representing a broad range of relevant experience, knowledge and perspectives in order to address the complex set of issues facing agriculture for social purposes in urban settings. A second is the key role of self-help group organizations, and the securing of institutional commitments to support farming by vulnerable persons affected by HIV-AIDS is also apparent. Finally, the usefulness of evaluative tools using mixed methods to monitor progress towards goals and identify supports and barriers to success are highlighted. [ABSTRACT FROM AUTHOR]

A large portion of HIV transmission in sub-Saharan Africa occurs among married couples, yet the majority of research on safer-sex communication has focused on communication between couples in casual relationships. This paper explores how committed Kamba couples in Machakos District, Kenya, communicate about sensitive relational issues. The findings from focus group discussions with five groups of males and five groups of females are presented. The couples freely shared their thoughts about daily and economic issues and certain aspects of family planning and sexuality. Methods for raising sensitive issues with partners included monitoring the spouse's mood, gradual or indirect revelation, mentioning topics during sex, and use of third-party intermediaries. Interference by extended family members, especially husbands' mothers, and male authoritarian roles emerged as hindrances to effective communication between couples. The implications for HIV prevention regarding gender differences and the role of families in couples' communication are discussed. [ABSTRACT FROM AUTHOR]

Abstract: This paper is based on the experiences drawn from a long-term social science research programme on the impact of the AIDS pandemic on orphanhood in western Kenya. It discusses the ethical dilemma of maintaining a delicate balance between research ethics, the expectations of the study population and negotiating the community''s vested interests in a health related research project in a low-income society. I argue that informed consent and the intended benefits of the study to the participants continue to be major challenges facing the justification of social research with people affected by or living with AIDS in low-income societies. The paper underscores the importance of community feedback sessions as a way of enhancing chances of acceptability of research efforts and obtaining informed consent. It further shows how community feedback sessions contribute to local knowledge of the problem being studied, creating opportunities for advocacy. This discussion adds to the existing ethical debate on the wider contexts within which research on vulnerable people affected by AIDS is conducted by arguing that research practice is inseparable from epistemological concerns of knowledge production. I suggest that ethnographers should enhance efforts to innovatively design action research projects to serve the twin purposes of data collection and deal with ethical challenges that are experienced when doing long-term research on vulnerable groups. [Copyright &y& Elsevier]

Copyright of Culture, Health & Sexuality is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Twenty-five years since the onset of HIV/AIDS, young people aged 15–24 now make up half of new HIV infections. This paper advocates for comprehensive sexuality education as an effective panacea to reverse this, with teachers stepping up and embracing their role as sexuality educators. The exploration of this challenge is informed by a small-scale participatory study of teacher responses in a rural primary school in Nakuru district, Kenya. Dialogue was held with 18 teachers (11 females, seven males) on the challenges they faced in teaching sexuality education and teachers emerged as disorientated and embarrassed in conversations about sexuality issues with the pupils. Because sexuality education lacks a curriculum, teachers have found it challenging to integrate it into regular subjects; they also observed that parents seem resistant to addressing this at home, and thus this task falls to them. In the study, a process of self-awareness of the need for them to step up and teach sexuality education emerges among the participants. A key finding is that participatory and dialectical interventions that can prepare teachers and develop their confidence in teaching sexuality education are required. [ABSTRACT FROM AUTHOR]

Because the HIV/AIDS crisis in Kenya is causing the death and disablement of so many prime- aged adults, households are increasingly being headed by adolescents and the elderly. The purpose of this paper is to examine the health status of one of the most vulnerable groups in Kenyan society - adolescent women - and to explore how the type of household head impacts on their health status. Using data from the 2003 Kenya Demographic and Health Survey (KDHS), an indicator of illness signs was used as the dependent variable for health status. Significant differences were found in the health status of adolescent women in households headed by adolescents, prime-aged adults, and the elderly. Even when controlling for demographic factors, residing in an adolescent headed household increased the odds that an adolescent woman would have recently experienced some signs of illness. Other factors which also increased the odds of illness were being married and being in the older age group (20-24). Wealth barely had any impact on illness. Service providers need to pay special attention to the needs of adolescents in non-adult headed households. [ABSTRACT FROM AUTHOR]

This paper examined the everyday challenges, stressors and coping strategies of orphans affected by HIV/AIDS in Nyanza, Kenya. A thematic analysis of six focus group discussions with orphans was guided by Stress and Coping Theoretical Framework. The orphans reported intense stress at the time of their parents' death with their immediate concern being who would care for them. Most orphans were separated from their siblings, and this separation only compounded the stressors and difficulties encountered by orphans. Orphans reported having problems with schooling and being treated differently as compared with the children of their caregivers. Orphans adopted various emotion-foused and problem-focused coping strategies, which were reinforced by financial and social support provided by their caregivers and community-based organizations. [ABSTRACT FROM AUTHOR]

This paper describes the experiences of physicians-in-training at a public hospital in Nairobi, Kenya, where medical professionals practice in an environment characterized by both significant lack of resources and patients with HIV/AIDS in historically unprecedented numbers. The data reported here are part of a larger study examining ethical dilemmas in medical education and practice among physicians in East Africa. A questionnaire and semi-structured interview were completed by fifty residents in four medical specialties, examining social and emotional supports, personal and professional sources of stress, emotional numbing and disengagement from patients and peers, and symptoms of post-traumatic stress and depression. The factors affecting resident well-being are found in this study to be more complex than previous interviews suggested. This study highlights the fact that as a result of working in an environment characterized by poor communication among hospital staff as well as a lack of resources and high numbers of patients with HIV/AIDS, residents' perceptions of themselves--their technical proficiency, their ability to care and feel for others and themselves, and for some their entire sense of self--are significantly affected. Also affected are the patients they work to treat. [ABSTRACT FROM AUTHOR]

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

Highlights • Education policy makers and practitioners can use this analysis as a source of information and application. • Demonstrates a comprehensive application of education cost-effectiveness analysis to high-quality interventions. • Assesses the cost-effectiveness of two education interventions, ex post facto. • Highlights a sound and disciplined cost-analysis method for use when cost details are both available and unavailable. Abstract This paper demonstrates a comprehensive and thorough application of an education cost-effectiveness analysis. Two interventions implemented in Western Kenya aimed to reduce the incidence of HIV/AIDS contraction in middle school girls. The cost-effectiveness of each intervention is assessed, ex post facto, by combining the results of the two programs’ evaluations with their costs. As few education evaluations consider cost, this article highlights a sound and disciplined method to use when detailed cost information is both readily available and unavailable. An analysis such as this has policy implications for a more efficient use of educational resources, reduction in the costs of achieving specific objectives, and expansion on what can be accomplished for a budget or another type of constraint, especially in a low-income to lower-middle income economy context. [ABSTRACT FROM AUTHOR]

Background: We performed an economic analysis of a new technology used in antenatal care (ANC) clinics, the ANC panel. Introduced in 2019–2020 in five Rwandan districts, the ANC panel screens for four infections [hepatitis B virus (HBV), human immunodeficiency virus (HIV), malaria, and syphilis] using blood from a single fingerstick. It increases the scope and sensitivity of screening over conventional testing. Methods: We developed and applied an Excel-based economic and epidemiologic model to perform cost-effectiveness and cost-benefit analyses of this technology in Kenya, Rwanda, and Uganda. Costs include the ANC panel itself, its administration, and follow-up treatment. Effectiveness models predicted impacts on maternal and infant mortality and other outcomes. Key parameters are the baseline prevalence of each infection and the effectiveness of early treatment using observations from the Rwanda pilot, national and international literature, and expert opinion. For each parameter, we found the best estimate (with 95% confidence bound). Results: The ANC panel averted 92 (69–115) disability-adjusted life years (DALYs) per 1,000 pregnant women in ANC in Kenya, 54 (52–57) in Rwanda, and 258 (156–360) in Uganda. Net healthcare costs per woman ranged from $0.53 ($0.02-$4.21) in Kenya, $1.77 ($1.23-$5.60) in Rwanda, and negative $5.01 (-$6.45 to $0.48) in Uganda. Incremental cost-effectiveness ratios (ICERs) in dollars per DALY averted were $5.76 (-$3.50-$11.13) in Kenya, $32.62 ($17.54-$46.70) in Rwanda, and negative $19.40 (-$24.18 to -$15.42) in Uganda. Benefit-cost ratios were $17.48 ($15.90-$23.71) in Kenya, $6.20 ($5.91-$6.45) in Rwanda, and $25.36 ($16.88-$33.14) in Uganda. All results appear very favorable and cost-saving in Uganda. Conclusion: Though subject to uncertainty, even our lowest estimates were still favorable. By combining field data and literature, the ANC model could be applied to other countries. [ABSTRACT FROM AUTHOR]

Sexuality education in African contexts is riddled with socio-cultural complexity, tension and taboo. Such tensions are compounded when the focus of intervention is primary school children who are presumed ‘innocent’. However, sub-Saharan Africa remains the region of the world most severely impacted upon by the human immunodeficiency virus and the acquired immunodeficiency syndrome, thus heightening the need to talk to children about sex and sexuality. This paper explores the role of consulting pupils, participation and dialogue as methodological innovations that have the potential to enable new ways of thinking about sex and sexuality and the transcendence of ‘dead end debates’ about what should and should not be taught. The paper is based on data from an action research project in Kenya, Ghana and Swaziland. The data show that the desire to create a space characterised by consultation, listening and dialogue in which adults and children could participate ‘as if’ they were social equals was inevitably not straightforward or ever fully realised. Nevertheless, pupils were able to make their voices heard at many points in these spaces and powerful moments of dialogue did exist with some of the adults undergoing significant changes of opinion throughout the process. [ABSTRACT FROM PUBLISHER]

Background: This study evaluated the effect of revisions to existing peer-counselor services, called Mentor Mothers (MM), at maternal and child health clinics on medication adherence for women living with HIV (WLWH) in Kenya and on early infant HIV testing. Methods: The Enhanced Mentor Mother Program study was a 12-site, two-arm cluster-randomized trial enrolling pregnant WLWH from March 2017 to June 2018 (with data collection through September 2020). Six clinics were randomized to continued MM-supported standard care (SC). Six clinics were randomized to the intervention arm (INT = SC plus revised MM services to include more one-on-one interactions). Primary outcomes for mothers were defined as: (PO1) the proportion of days covered (PDC) with antiretroviral therapy (ART) ≥ 0.90 during the last 24-weeks of pregnancy; and (PO2) ≥ 0.90 PDC during the first 24-weeks postpartum. Secondary outcomes were infant HIV testing according to national guidelines (at 6, 24, and 48 weeks). Crude and adjusted risk differences between study arms are reported. Results: We enrolled 363 pregnant WLHV. After excluding known transfers and subjects with incomplete data extraction, data were analyzed for 309 WLWH (151 SC, 158 INT). A small share achieved high PDC during the prenatal and postnatal periods (0.33 SC/0.24 INT achieved PO1; 0.30 SC/0.31 INT achieved PO2; crude or adjusted risk differences were not statistically significant). In addition, ~ 75% in both study arms completed viral load testing during year two after enrollment, with > 90% suppressed in both arms. For infants, ≥ 90% in both arms had at least one HIV test through study follow up (76 weeks) but testing on schedule according to PMTCT guidelines was uncommon. Conclusions: While national guidelines in Kenya recommended that all HIV-infected pregnant women take a daily antiretroviral regimen for life following a HIV diagnosis, results presented here indicate that a minor share achieved high medication coverage during the prenatal and postnatal periods analyzed. In addition, adjustments to Mentor-Mother services showed no improvement in study outcomes. The lack of effect for this behavioral intervention is relatively consistent with the existing literature to improve mother-infant outcomes along the PMTCT care cascade. Clinical Trial Number: NCT02848235. Date of first trial registration 28/07/2016. [ABSTRACT FROM AUTHOR]

Depression is common during pregnancy and is associated with reduced adherence to HIV-related care, though little is known about perinatal trajectories of depression and viral suppression among women living with HIV (WLHV) in sub-Saharan Africa. We sought to assess any association between perinatal depressive symptoms and viral non-suppression among WLWH. Depressive symptomatology and viral load data were collected every 6 months from WLWH enrolled in the African Cohort Study (AFRICOS; January 2013–February 2020). Generalized estimating equations modeled associations between depressive symptoms [Center for Epidemiological Studies Depression (CES-D) ≥ 16] and viral non-suppression. Of 1722 WLWH, 248 (14.4%) had at least one pregnancy (291 total) and for 61 pregnancies (21.0%), women reported depressive symptoms (13.4% pre-conception, 7.6% pregnancy, 5.5% one-year postpartum). Depressive symptomatology was associated with increased odds of viral non-suppression (aOR 2.2; 95% CI 1.2–4.0, p = 0.011). Identification and treatment of depression among women with HIV may improve HIV outcomes for mothers. [ABSTRACT FROM AUTHOR]

Introduction: Healthcare worker training is essential to successful implementation of assisted partner services (aPS), which aims to improve HIV testing and linkage‐to‐care outcomes for previously unidentified HIV‐positive individuals. Cameroon, Kenya and Mozambique are three African countries that have implemented aPS programmes and are working to bring those programmes to scale. In this paper, we present and compare different aPS training strategies implemented by these three countries, and discuss facilitators and barriers associated with implementation of aPS training in sub‐Saharan Africa. Discussion: aPS training programmes in Cameroon, Kenya and Mozambique share the following components: the development of comprehensive and interactive training curricula, recruitment of qualified trainees and trainers with intimate knowledge of the community served, continuous training, and rigorous monitoring and evaluation activities. Cameroon and Kenya were able to engage various stakeholders early on, establishing multilateral coalitions that facilitated attainment of long‐term buy‐in from the local governments. Ministries of Health and various implementing partners are often included in strategic planning and delivery of training curricula to ensure sustainability of the training programmes. Kenya and Mozambique have integrated aPS training into the national HTS guidelines, which are being rolled out nationwide by the Ministries of Health and implementing partners. Continual revision of training curricula to reflect the country context, as well as ongoing monitoring and evaluation, have also been identified as key facilitators to sustain aPS training programmes. Some of the barriers to scale‐up and sustainability of aPS training include limited funding and resources for training and scale‐up and shortage of aPS providers to facilitate on‐the‐job mentorship. Conclusions: These three programmes demonstrate that aPS training can be implemented and scaled up in sub‐Saharan Africa. As countries plan for initial implementation or national scale‐up of aPS services, they will need to establish government buy‐in, expand funding sources, address the shortage of staff and resources to provide aPS and on‐the‐job mentorship, and continuously collect data to evaluate and improve aPS training plans. Development of national standards for aPS training, empowered healthcare providers, increased government commitment, and sustained funding for aPS services and training will be crucial for successful aPS implementation. [ABSTRACT FROM AUTHOR]

The twofold function of condom use - contraception and sexually transmitted disease protection - should be taken into account when understanding attitudes towards this practice. Emphasis on the interpretation of condom use as a protective practice conflicts with the norms of fidelity and trust, which regulate marriage. The alternative interpretation of condom use as a contraceptive method may be less problematic. This paper analyzes the extent to which the attitude of married men and women towards condom use with their spouses, and their actual use of condoms within marriage, are affected by their expectations about the dominant attitudes and behaviors in their peer group. I expect that a social consensus on understanding condom use as an HIV-preventive behavior will not make this practice more acceptable within marriage, while social acceptance of modern contraception and, more specifically, of the use of condoms for contraceptive purposes will. Two waves of a longitudinal survey from 1996 to 1999 in rural Kenya are analyzed using fixed-effects regression. Social support for each function of condom use is measured with indicators of the proportion of individuals in the peer group that use condoms for a particular purpose or have a positive attitude towards each of the uses, according to the respondent. The results support the hypothesis for men, but are inconclusive for women. [ABSTRACT FROM AUTHOR]

Abstract: Research on caregiving children tends to be limited to children''s caregiving experiences of parents with a specific disease or disability. This has led to a common perception that children''s caregiving is a single, uniform and often long-term experience. Whilst this is most certainly the case for many children in economically more advanced countries, this may not hold true in rural Africa, where poverty and AIDS can have significant knock-on effects on entire families and communities. This paper seeks to develop a more complex understanding of children''s caring experiences by asking children whom they have cared for over time and explore the different pathways that lead to their caregiving at different stages of their lives. The study reports on qualitative data collected from 48 caregiving children and 10 adults in the Bondo district of western Kenya in 2007. A multi-method approach was adapted, with historical profiles, Photovoice and draw-and-write essays complementing 34 individual interviews and 2 group discussions. A thematic network analysis revealed that children''s caregiving was not confined to a single experience. Children were observed to provide care for a number of different family and community members for varying periods of time and intensities. Although their living arrangements and life circumstances often gave them little choice but to care, a social recognition of children''s capacity to provide care for fragile adults, helped the children construct an identity, which both children and adults drew on to rationalise children''s continued and multiple caring experiences. The study concludes that agencies and community members looking to support caregiving children need to consider their care trajectories — including whom they care for as well as the order, intensity, location and duration of their past and likely future caring responsibilities. [Copyright &y& Elsevier]

Abstract: Despite what is currently the most rapid urbanization on the globe, an alarming growth of impoverished urban slum settlements in Africa, and the highest rates of HIV in the world – with greater prevalence in urban than rural areas – insufficient attention has been paid to the relationship between urban poverty and risky sexual behavior. Although emerging research has focused on how slum residence is linked to risky behavior, there is a paucity of work on how migration to slums is related to risky sex. Using a sample of sexually active women from the 2000 Nairobi Cross-Sectional Slum Survey (NCSS), this paper demonstrates that the relationship between slum residence and risky behavior is a multifaceted one. Beyond the effect of current residence in slums migratory factors, specifically previous place of residence and length of time since arrival, prove to be significant cofactors, with the effect of the former conditioned by the latter. Perhaps more importantly, where migrants moved from appears to influence risky behavior in a non-uniform manner. [ABSTRACT FROM AUTHOR]

This paper emerged from a lack of literature on women's vulnerability to HIV/AIDS in AIDS discourses. Women have been vulnerable to HIV/AIDS since the epidemic emerged but not much research has been done specifically on Kenyan women. The ways in which women are vulnerable to HIV infection were explored by examining social, economic, and cultural identities that affect women's sexual relations using a feminist lens. In this research, it is postulated that HIV vulnerability has to be studied in the context of patriarchy and cultural constraints. To address women's vulnerability to HIV/AIDS, secondary analysis of data from the 2003 Kenya Demographic and Health Survey was utilized. Hence, demographic variables of age, education, religion, ethnicity, region of residence, marital status, and employment were the independent variables that were used to discern the factors associated with HIV vulnerability among women. A dependent variable, HIV vulnerability which I constructed from the 2003 Health and Demographic Survey was conceived of as a larger concept comprised of powerlessness in basic decision-making processes within the household, AIDS-related knowledge on transmission and prevention, cultural practices which encompassed polygamy, wife inheritance, and sexual behavior, and perceived risk of contracting the HIV/AIDS disease. In this study, the data strongly suggested that women in Kenya are more vulnerable to HIV/AIDS when they are younger, have low levels of education, are from different ethnicities and from certain regions, are unmarried, and not employed. The findings supported the literature that women's vulnerability is strongly influenced and tied by broader forces present in the society. Women's vulnerability to HIV/AIDS is real and needs to be tackled for any progress to occur in the fight against AIDS. HIV/AIDS is a very expensive disease that totally drains economies of households, communities, and countries. Until HIV vulnerability is acknowledged and fought, women will continue to succumb to the disease overwhelmingly and Kenya will eventually disintegrate as it will be full of sick people intensifying underdevelopment. Women's vulnerability to HIV/AIDS is an urgent issue that needs dire attention for Kenya to prosper. A healthy population fosters development and stability. However HIV/AIDS produces instability, suffering, extreme poverty, and underdevelopment. [ABSTRACT FROM AUTHOR]

Six sub-Saharan African countries currently have laws on sexual violence, including Kenya, and eight others have provisions on sexual violence in other legislation. Effective legislation requires functioning medico-legal linkages to enable both justice to be done in cases of sexual violence and the provision of health services for survivors of sexual violence. The health sector also needs to provide post-rape care services and collect and deliver evidence to the criminal justice system. This paper reviews existing data on sexual violence in sub-Saharan Africa, and summarises the content of sexual violence legislation in the region and the strengths and weaknesses of existing medico-legal linkages, using Kenya as a case study. Many sub-Saharan African countries do not yet have comprehensive post-rape care services, nor substantial co-ordination between HIV and sexual and reproductive health services, the legal and judicial systems, and sexual violence legislation. These need to be integrated by cross-referrals, using standardised referral guidelines and pathways, treatment protocols, and medico-legal procedures. Common training approaches and harmonised information across sectors, and common indicators, would facilitate government accountability. Joint and collaborative planning and working at country level, through sharing of information and data between the different systems remain key to achieving this. Six pays d'Afrique subsaharienne ont actuellement des lois sur la violence sexuelle, notamment le Kenya, et huit autres des dispositions sur la violence sexuelle dans une autre législation. Une législation efficace exige des liens médico-légaux pour permettre à la justice de s'exercer en cas de violence sexuelle et aux victimes de recevoir des soins de santé. Le secteur de la santé doit aussi assurer des soins après un viol, recueillir et transmettre les indices au système de justice pénale. Cet article examine les données sur la violence sexuelle en Afrique subsaharienne, et résume le contenu de la législation s'y rapportant dans la région ainsi que les forces et les faiblesses des liaisons médico-légales existantes, en utilisant le Kenya comme étude de cas. Beaucoup de pays d'Afrique subsaharienne n'ont pas de services complets de soins après un viol, ni de coordination substantielle entre les services de santé génésique et de traitement du VIH, les systèmes juridique et judiciaire et la législation sur la violence sexuelle. Ils doivent être reliés par des références croisées, au moyen de directives standard d'aiguillage et de passerelles, de protocoles de traitement et de procédures médico-légales. Des approches communes de formation et une information harmonisée entre secteurs, ainsi que des indicateurs communs, aideraient les autorités à se responsabiliser. Une planification et des activités conjointes et concertées au niveau national, par le partage d'informations et de données entre différents systèmes, demeurent essentielles pour y parvenir. En seis países de Ãfrica subsahariana, contando a Kenia, existen leyes sobre la violencia sexual, y en ocho más existen disposiciones al respecto en otra legislación. La legislación eficaz requiere enlaces médico-jurídicos que funcionen para permitir el cumplimiento de la justicia en casos de violencia sexual y la prestación de servicios de salud para las sobrevivientes. El sector salud debe proporcionar servicios de atención post-violación y recolectar y entregar evidencias al sistema de justicia penal. En este artículo se analizan los datos sobre la violencia sexual en Ãfrica subsahariana y se resume el contenido de la legislación sobre la violencia sexual en la región y las fortalezas y debilidades de los enlaces médico-jurídicos, usando a Kenia como un estudio de caso. En muchos países de Ãfrica subsahariana aún no existen servicios de atención integral post-violación, o coordinación entre los servicios de VIH y los de salud sexual y reproductiva, los sistemas jurídico y judicial y la legislación sobre la violencia sexual. Estos deben integrarse mediante referencias, usando directrices y vías de consulta, protocolos de tratamiento y procedimientos médico-jurídicos estandarizados. Enfoques comunes de capacitación e información armonizada en todos los sectores, e indicadores comunes, facilitarían la responsabilidad del gobierno. Una planificación conjunta y colaborativa, así como trabajar a nivel nacional, mediante el intercambio de información y datos entre los diferentes sistemas, continúan siendo esenciales para lograrlo. [ABSTRACT FROM AUTHOR]

Abstract: The current study investigates the extent to which sexual exclusivity—the restriction of one''s sexual engagements to a single partner—prevails across various marital status, union type, and co-residence categories among Nairobi''s poorest residents, slum dwellers. This question is central to the spread of HIV in the increasingly urban and poor, high prevalence countries of sub-Saharan Africa, where transmission is primarily via heterosexual sex. In many circles, sexual exclusivity is considered a prominent feature of the marriage institution. Yet, marriage and cohabitation are often not easily distinguishable in sub-Saharan Africa, meaning that the frequent use, as a proxy, of the “in union” category, which includes married as well as cohabiting persons can, at best, be considered tenuous. Using the 2000 Nairobi Cross-Sectional Slum Survey (NCSS), this paper confirms that marriage is associated with higher reports of sexual exclusivity even in settings where poverty provokes risky behavior. The finding, here, is of lower risk of HIV infection for married respondents, with a smaller effect observed among non-married cohabiters. Converse to the implied benefits of marriage, though, women with co-wives are more likely to report multiple partners. The implications of these findings are discussed. [Copyright &y& Elsevier]

Introduction: In 2015, the President's Emergency Plan for AIDS Relief undertook policy shifts to increase efficiencies in its programming, including transitioning HIV/AIDS funding away from low burden areas. We examine the impact of these changes on HIV outreach in Kenya and Uganda.Methods: Qualitative data collection was conducted as a part of a broader mixed-methods evaluation. Two rounds of facility-level case studies and national-level interviews were conducted in Kenya and Uganda, with health facility, sub-national and central Ministry of Health staff, HIV clients, and implementing partners.Results: In both countries, the loss of outreach support affected community-based HIV/AIDS education, testing, peer support, and defaulter tracing.Discussion: Loss of external support for outreach raises concerns for countries' ability to reach the 90-90-90 UNAIDS target, as key linkages between vulnerable communities and health systems can be adversely affected.Conclusion: Development partners should consider how to mitigate potential consequences of transition policies to prevent negative effects at the community level. [ABSTRACT FROM AUTHOR]

We formulate an age and sex-structured deterministic model to assess the effect of increasing comprehensive knowledge of HIV/AIDS disease in the infected Adolescent Girls and Young Women (AGYW) and, Adolescent Boys and Young Men (ABYM) populations in Kenya. Mathematical analysis of infection through sub-network analysis was carried out to trace various infection routes and the veracity of various transmission routes as well as the associated probabilities. Using HIV data in Kenya on our model, disproportional effects were observed when dispensation of comprehensive knowledge of HIV/AIDS was preferred in one population over the other. Effective dispensation of comprehensive knowledge of HIV/AIDS in both the infected AGYW and ABYM populations significantly slows down the infection spread but may not eradicate it. [ABSTRACT FROM AUTHOR]

Aim: To test the effectiveness of a motivational interviewing (MI) intervention using the mobile phone among adults with alcohol use problems. Design A randomized clinical trial of mobile MI and standard in‐person MI with 1‐ and 6‐month follow‐up, including a 1‐month waitlist control followed by mobile MI. Setting: A primary health center in rural Kenya. Participants: Three hundred adults screening positive for alcohol use problems were randomized and received immediate mobile MI (n = 89), in‐person MI (n = 65) or delayed mobile MI (n = 76) for waiting‐list controls 1 month after no treatment, with 70 unable to be reached for intervention. Intervention and comparator: One MI session was provided either immediately by mobile phone, in‐person at the health center or delayed by 1 month and then provided by mobile phone. Measurements Alcohol use problems were repeatedly assessed using the Alcohol Use Disorder Identification Test (AUDIT) and the shorter AUDIT‐C. The primary outcome was difference in alcohol score 1 month after no intervention for waiting‐list control versus 1 month after MI for mobile MI. The secondary outcomes were difference in alcohol score for in‐person MI versus mobile MI one and 6 months after MI. Findings For our primary outcome, average AUDIT‐C scores were nearly three points higher (difference = 2.88, 95% confidence interval = 2.11, 3.66) for waiting‐list controls after 1 month of no intervention versus mobile MI 1 month after intervention. Results for secondary outcomes supported the null hypothesis of no difference between in‐person and mobile MI at 1 month (Bayes factor = 0.22), but were inconclusive at 6 months (Bayes factor = 0.41). Conclusion: Mobile phone‐based motivational interviewing may be an effective treatment for alcohol use problems among adults visiting primary care in Kenya. Providing mobile motivational interviewing may help clinicians in rural areas to reach patients needing treatment for alcohol use problems. [ABSTRACT FROM AUTHOR]

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New HIV infections among adolescents continues to be a large public health burden in sub-Saharan Africa, with few adolescents accessing HIV testing and counseling (HTC) services. We evaluated the effect of a peer referral program among adolescents in Kisumu county, Kenya in accessing HTC. Female adolescents aged 15 to 19 years were recruited from three health clinics in Kisumu County. They, in turn, recruited their peers for HTC by handing out referral cards. Referrals would then recruit their peers and this peer-referral repeated for approximately 5 months. The 252 female index seeds showed a relatively higher-risk profile for HIV compared to the 792 referral participants. The referral system yielded an increased proportion of first-time adolescent testers from 13.1% among index seeds to 42.7% among the second wave of referrals. However, the peer referral system ultimately did not increase the absolute number of adolescents Queryaccessing HTC. Future strategies should consider these findings to better target those with undiagnosed HIV infection. [ABSTRACT FROM AUTHOR]

Background: Human immunodeficiency virus (HIV) viral failure occurs when antiretroviral therapy fails to suppress and sustain a person's viral load count below 1,000 copies of viral ribonucleic acid per milliliter. For those newly diagnosed with HIV and living in a setting where healthcare resources are limited, such as a low- and middle-income country, the World Health Organization recommends viral load monitoring six months after initiation of antiretroviral treatment and yearly thereafter. Deviations from this schedule are made in cases where viral failure occurs or at the discretion of the clinician. Failure to detect viral failure in a timely fashion can lead to delayed administration of essential interventions. Clinical prediction models based on information available in the patient medical record are increasingly being developed and deployed for decision support in clinical medicine and public health. This raises the possibility that prediction models can be used to detect potential for viral failure in advance of viral measurements, particularly when those measurements occur infrequently. Objective: Our goal is to use electronic health record data from a large HIV care program in Kenya to characterize and compare the predictive accuracy of several statistical machine learning methods for predicting viral failure at the first and second measurements following initiation of antiretroviral therapy. Predictive accuracy is measured in terms of sensitivity, specificity and area under the receiver-operator characteristic curve. Methods: We trained and cross-validated 10 statistical machine learning models and algorithms on data from over 10,000 patients in the Academic Model Providing Access to Healthcare care program in western Kenya. These included parametric, non-parametric, ensemble, and Bayesian methods. The input variables included 50 items from the clinical record, hand picked in consultation with clinician experts. Predictive accuracy measures were calculated using 10-fold cross validation. Results: Viral load failure rate is about 20% in this patient cohort at both the first and second measurements. Ensemble techniques generally outperformed other methods. For predicting viral failure at the first follow up measure, specificity was over 90% for these methods, but sensitivity was typically in the 50–60% range. Predictive accuracy was greater for the second follow up measure, with sensitivities over 80%. Super Learner, gradient boosting and Bayesian additive regression trees consistently outperformed other methods. For a viral failure rate of 20%, the positive predictive value for the top-performing methods is between 75 and 85%, while the negative predictive value is over 95%. Conclusion: Evidence from this study suggests that machine learning techniques have potential to identify patients at risk for viral failure prior to their scheduled measurements. Ultimately, prognostic virologic assessment can help guide the administration of earlier targeted intervention such as enhanced drug resistance monitoring, rigorous adherence counseling, or appropriate next-line therapy switching. External validation studies should be used to confirm the results found here. [ABSTRACT FROM AUTHOR]

New HIV infections in Kenya are concentrated among youth ages 15–24. This study explores the lived experiences of youth newly diagnosed with HIV living in an urban informal settlement in Kenya in order to highlight their resilience processes. Five primary thematic areas of resilience processes emerged (1) changing personal perspectives about health and life; (2) changing personal behaviors to promote health and safety; (3) reaching out to supportive health care providers and organizations; (4) reaching out to family, friends, and partners; and (5) helping other youth. Results are discussed with regard to enhancing care for youth living with HIV in Kenya. [ABSTRACT FROM AUTHOR]

HIV remains a major challenge in many contexts globally, and particularly in Kenya due to the high rates of infections among the youth. One of the challenges facing HIV management is the difficulty of communicating about it, especially among adolescents who face stigma associated with the disease. This phenomenological study examines the communication experiences of adolescents living with HIV/AIDS and their perceptions of these experiences. Data were generated through interviews with six HIV-positive adolescents, two caregivers, one social worker and one doctor, who were all selected purposively. The data were analysed thematically and presented in agreement with the themes. Relevant ethical considerations including confidentiality, protection from harm and informed consent were made. The overall perspective of HIV-positive adolescents is that adults accord them a limited platform to communicate their feelings and experiences. They are bombarded with messages of advice, commands, threats, and continuous lectures—a clear indication that the adults are not in touch with the reality of the life of an HIV-positive adolescent. Therefore, there is need for clear, well thought-out platforms for adolescents living with HIV to address their communicative needs. [ABSTRACT FROM AUTHOR]

We conducted in Kenya a mixed-methods randomised controlled trial (RCT) of a nurse-led palliative care intervention integrated with anti-retroviral therapy (ART) provision for the management of HIV. Here we report qualitative findings showing increased resistance to HIV-associated stigma among trial participants. A mixed method design was chosen to enable identification of the active ingredients of the intervention and exploration of participants’ experiences of receiving the intervention. The RCT was conducted from July 2011 to November 2012 in a community hospital in the city of Mombasa, Kenya, with a sample of 120 adults with HIV on ART. Thirty participants were purposively selected to take part in a qualitative exit interview, based on study arm and mental health outcome. Inductive thematic analysis revealed increased resistance to HIV-associated stigma in both the intervention and control groups. Specifically, patients in both groups described benefit from the social support, compassionate care, and open and respectful communication they received through study participation. Participants described improved self-image, increased access to social agency, and increased resistance to HIV-associated stigma. Our findings suggest that there is potential to increase resistance to stigma through simple mechanisms of support, compassion, and improved communication in routine care. The self-reported impact of trial participation on stigma also has implications for future trials in populations in resource-constrained settings where stigma is common. [ABSTRACT FROM AUTHOR]

Despite recent efforts to supply antiretroviral therapy, many in Africa are not receiving medication, instead relying on self-management in their attempts to remain healthy. In Kenya, the majority of those infected are women who are below the extreme poverty level. Building on research demonstrating a link between knowledge of HIV/AIDS management and the length of time HIV-positive women have lived in Nairobi, this article uses a cognitive anthropological approach that conceives of culture as shared models and explores the relationship between how well women know a cultural model of self-managing HIV/AIDS and health among women who are not receiving biomedical treatment. Outcomes include reported perceived stress, depressive symptoms, and recent illness episodes. Here, this association of competence in the shared cultural model and health among women living in extremely marginal economic conditions is explored from a biocultural perspective to better understand this relationship. Knowledge of the model is a significant predictor of better overall health even after controlling for age, education, income, marital status, internal locus of control, and how long women have known that they are HIV-positive. This article adds to the HIV/AIDS literature by quantitatively linking health to cultural knowledge among an HIV-positive population. It also contributes to the cultural consensus literature by demonstrating health benefits of cultural knowledge. [ABSTRACT FROM AUTHOR]

As human immunodeficiency virus (HIV) treatment programs expand in Africa, delivery systems must be strengthened to support patient retention. Clinic characteristics may affect retention, but a relationship between clinic flow and attrition is not established. This project characterized HIV patient experience and flow in an urban Kenyan clinic to understand how these may affect retention. We used Toyota's lean manufacturing principles to guide data collection and analysis. Clinic flow was evaluated using value stream mapping and time and motion techniques. Clinic register data were analyzed. Two focus group discussions were held to characterize HIV patient experience. Results were shared with clinic staff. Wait times in the clinic were highly variable. We identified four main barriers to patient flow: inconsistent patient arrivals, inconsistent staffing, filing system defects, and serving patients out of order. Focus group participants explained how clinic operations affected their ability to engage in care. Clinic staff were eager to discuss the problems identified and identified numerous low-cost potential solutions. Lean manufacturing methodologies can guide efficiency interventions in low-resource healthcare settings. Using lean techniques, we identified bottlenecks to clinic flow and low-cost solutions to improve wait times. Improving flow may result in increased patient satisfaction and retention. [ABSTRACT FROM AUTHOR]