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Background Existing social relationships are a potential source of “social capital” that can enhance support for sustained retention in HIV care. A previous pilot study of a social network-based ‘microclinic’ intervention, including group health education and facilitated HIV status disclosure, reduced disengagement from HIV care. We conducted a pragmatic randomized trial to evaluate microclinic effectiveness. Methods In nine rural health facilities in western Kenya, we randomized HIV-positive adults with a recent missed clinic visit to either participation in a microclinic or usual care (NCT02474992). We collected visit data at all clinics where participants accessed care and evaluated intervention effect on disengagement from care (≥90-day absence from care after a missed visit) and the proportion of time patients were adherent to clinic visits (‘time-in-care’). We also evaluated changes in social support, HIV status disclosure, and HIV-associated stigma. Results Of 350 eligible patients, 304 (87%) enrolled, with 154 randomized to intervention and 150 to control. Over one year of follow-up, disengagement from care was similar in intervention and control (18% vs 17%, hazard ratio 1.03, 95% CI 0.61–1.75), as was time-in-care (risk difference -2.8%, 95% CI -10.0% to +4.5%). The intervention improved social support for attending clinic appointments (+0.4 units on 5-point scale, 95% CI 0.08–0.63), HIV status disclosure to close social supports (+0.3 persons, 95% CI 0.2–0.5), and reduced stigma (-0.3 units on 5-point scale, 95% CI -0.40 to -0.17). Conclusions The data from our pragmatic randomized trial in rural western Kenya are compatible with the null hypothesis of no difference in HIV care engagement between those who participated in a microclinic intervention and those who did not, despite improvements in proposed intervention mechanisms of action. However, some benefit or harm cannot be ruled out because the confidence intervals were wide. Results differ from a prior quasi-experimental pilot study, highlighting important implementation considerations when evaluating complex social interventions for HIV care. Trial registration Clinical trial number: NCT02474992.

In rural sub-Saharan Africa, preventable delays in accessing emergency care remain a dominant factor in maternal and neonatal deaths. The MOMENTUM study is a pragmatic cohort investigation designed to measure the "Three Delays", i.e. delays in recognizing need for care (Type 1), reaching care (Type 2), and receiving care (Type 3) within a remote island health system on Lake Victoria, Kenya. The study utilizes an adaptive methodology to provide actionable data for a locally-directed "Health Navigation" intervention. We present analysis of 56 maternal and neonatal emergency cases occurring between January 2019 and February 2020. The mean Total Delay Interval (Type 1-3) reported was 39.3 ± 32.3hours. Notably, 18 cases in this cohort resulted in a neonatal (n = 16) or maternal death (n = 2). Sub-analysis indicates significant delay interval reductions associated with involvement of a "Health Navigator" in emergency care coordination for Type 2 Delay Intervals (0.5 ± 0.3 vs. 1.2 ± 1.1 hrs., p = 0.002) and Type 3 Delay Intervals (17.9 ± 14.1 vs. 32.9 ± 33.7 hrs., p = 0.030). Prolonged delays, complex barriers, and high mortality highlight the fraught nature of maternal emergencies in this remote setting. We discuss practical considerations for application of the Three Delays model, and avenues for further investigation.

BACKGROUND In rural sub-Saharan Africa (SSA), the human immunodeficiency virus (HIV)/AIDS pandemic has exerted effects on nearly every aspect of life. Yet despite the pandemic's near ubiquitous impacts, major barriers to HIV care, treatment, and support persist. Compounding the barriers to care is the incredible complexity and diversity of experience across different sociocultural contexts. OBJECTIVES This exploratory community-based participatory study aimed to generate an explanatory model about how geographic and socioeconomic marginalization shape community perception of HIV care, treatment, and support among rural communities of Mfangano Island, Kenya. METHODS Twelve focus groups with a total of 105 participants were conducted as a part of a mixed-methods cross-sectional health study. RESULTS Study findings are organized within an ecological framework with the following themes: readiness at the individual level, social capital at the household level, and collective efficacy at the community level. Potential solutions were also described within this framework; enabling encouragement at the individual level, enhancing productivity at the household level, and addressing underlying socioeconomic inequities at the community level. CONCLUSIONS HIV-related consequences at the individual, household, and community levels have adversely affected how Mfangano communities respond to the HIV/AIDS epidemic. Community-based strategies are needed to address interrelated inequities at multiple levels. Changing community perception may overcome HIV stigma to enable individual readiness to seek care. Access to care and treatment enhances productivity and hence social capital in HIV-affected households. Addressing socioeconomic inequities at the community level increases access to social and instrumental support and, thus, may decrease risk and vulnerability for HIV/AIDS.

Rationale A growing body of research emphasizes the need to engage social networks in maternal and child nutrition interventions. However, an understanding of how interventions functionally engage not only mothers but fathers, grandparents, friends, and other social network members remains limited. Objective This study uses an adaptation of a social-ecological model to analyze the multiple levels at which the Kanyakla Nutrition Program operates to change behavior. Methods This study analyzes focus group data (four groups; n = 35, 7 men and 28 women) following the implementation of the Kanyakla Nutrition Program, a novel nutrition intervention engaging social networks to increase nutrition knowledge, shift perceptions, and promote positive practices for infant and young child feeding and community nutrition in general. Results: Participant perspectives indicate that the Kanyakla Nutrition Program contributed to nutrition knowledge and confidence, changed perceptions, and supported infant and child feeding practices at the individual, interpersonal, and institutional levels. However, many respondents report challenges in transcending barriers at the broader community and systems levels of influence, where environmental and economic constraints continue to affect food access. Conclusion Analysis of the Kanyakla Nutrition Program suggests that for interventions addressing household level determinants of nutrition, simultaneously engaging the household's network of interpersonal and community relationships can play a role in building momentum and consensus to address persistent structural barriers to improved nutrition.

Background In sub-Saharan Africa, failure to initiate and sustain HIV treatment contributes to significant health, psychosocial, and economic impacts that burden not only infected individuals but diverse members of their social networks. Yet, due to intense stigma, the responsibility for managing lifelong HIV treatment rests solely, and often secretly, with infected individuals. We introduce the concept of “HIV risk induction” to suggest that social networks of infected individuals share a vested interest in improving long-term engagement with HIV care, and may represent an underutilized resource for improving HIV/AIDS outcomes within high prevalence populations. Methods In 2012, we implemented a ‘microclinic’ intervention to promote social network engagement in HIV/AIDS care and treatment. A microclinic is a therapy management collective comprised of a small group of neighbors, relatives, and friends who are trained as a team to provide psychosocial and adherence support for HIV-infected members. Our study population included 369 patients on ART and members of their social networks on Mfangano Island, Kenya, where HIV prevalence approaches 30%. Here we report qualitative data from 18 focus group discussions conducted with microclinic participants ( n = 82), community health workers ( n = 40), and local program staff ( n = 39). Results Participants reported widespread acceptability and enthusiasm for the microclinic intervention. Responses highlight four overlapping community transformations regarding HIV care and treatment, namely 1) enhanced HIV treatment literacy 2) reduction in HIV stigma, 3) improved atmosphere for HIV status disclosure and 4) improved material and psychosocial support for HIV-infected patients. Despite challenges, participants describe an emerging sense of “collective responsibility” for treatment among HIV-infected and HIV-uninfected members of social networks. Discussion The lived experiences and community transformations highlighted by participants enrolled in this social network intervention in Western Kenya suggest opportunities to reframe the continuum of HIV care from a secretive individual journey into a network-oriented cycle of engagement.

© 2015 Elsevier Ltd. Women's access to natural resources for food and livelihoods is shaped by resource availability, income, and the gender dynamics that mediate access. In fisheries, where men often fish but women comprise 90% of traders, transactional sex is among the strategies women use to access resources. Using the case of Lake Victoria, we employed mixed methods (in-depth interviews, n = 30; cross-sectional survey, n = 303) to analyze the influence of fish declines on fish-for-sex relationships. We found that fish declines affect relationship duration and women's bargaining power. Our results have broad implications for the dynamics of economies dependent on increasingly scarce resources throughout the world.

Background: Despite progress in the global scale-up of antiretroviral therapy, sustained engagement in HIV care remains challenging. Social capital is an important factor for sustained engagement, but interventions designed to harness this powerful social force are uncommon. Methods: We conducted a quasiexperimental study evaluating the impact of the Microclinic Social Network intervention on engagement in HIV care and medication adherence on Mfangano Island, Kenya. The intervention was introduced into 1 of 4 similar communities served by this clinic; comparisons were made between communities using an intention-to-treat analysis. Microclinics, composed of patient-defined support networks, participated in 10 biweekly discussion sessions covering topics ranging from HIV biology to group support and group HIV status disclosure. Nevirapine concentrations in hair were measured before and after study. Results: One hundred thirteen (74%) intervention community participants joined a microclinic group, 86% of whom participated in group HIV status disclosure. Over 22-month follow-up, intervention community participants experienced one-half the rate of ≥90-day clinic absence as those in control communities (adjusted hazard ratio: 0.48; 95% confidence interval: 0.25 to 0.92). Nevirapine hair levels declined in both study arms; in adjusted linear regression analysis, the decline was 6.7 ng/mg less severe in the intervention arm than control arm (95% confidence interval: −2.7 to 16.1). Conclusions: The microclinic intervention is a promising and feasible community-based strategy to improve long-term engagement in HIV care and possibly medication adherence. Reducing treatment interruptions using a social network approach has important implications for individual patient virologic suppression, morbidity, and mortality and for broader community empowerment and engagement in healthcare.

Antiretroviral hair levels objectively quantify drug exposure over time and predict virologic responses. We assessed the acceptability and feasibility of collecting small hair samples in a rural Kenyan cohort. Ninety-five percentage of participants (354/373) donated hair. Although median self-reported adherence was 100% (interquartile range, 96%-100%), a wide range of hair concentrations likely indicates overestimation of self-reported adherence and the advantages of a pharmacologic adherence measure. Higher nevirapine hair concentrations observed in women and older adults require further study to unravel behavioral versus pharmacokinetic contributors. In resource-limited settings, hair antiretroviral levels may serve as a low-cost quantitative biomarker of adherence.

HIV treatment is life-long, yet many patients travel or migrate for their livelihoods, risking treatment interruption. We examine timely reengagement in care among patients who transferred-out or were lost-to-follow-up (LTFU) from a rural HIV facility. We conducted a cohort study among 369 adult patients on antiretroviral therapy between November 2011 and November 2013 on Mfangano Island, Kenya. Patients who transferred or were LTFU (i.e., missed a scheduled appointment by ≥90 days) were traced to determine if they reengaged or accessed care at another clinic. We report cumulative incidence and time to reengagement using Cox proportional hazards models adjusted for patient demographic and clinical characteristics. Among 369 patients at the clinic, 23(6%) requested an official transfer and 78(21%) were LTFU. Among official transfers, cumulative incidence of linkage to their destination facility was 91% at three months (95%CI (confidence intervals) 69-98%). Among LTFU, cumulative incidence of reengagement in care at the original or a new clinic was 14% at three months (95%CI 7-23%) and 60% at six months (95%CI 48-69%). In the adjusted Cox model, patients who left with an official transfer reengaged in care six times faster than those who did not (adjusted hazard ratio 6.2, 95%CI 3.4-11.0). Patients who left an island-based HIV clinic in Kenya with an official transfer letter reengaged in care faster than those who were LTFU, although many in both groups had treatment gaps long enough to risk viral rebound. Better coordination of transfers between clinics, such as assisting patients with navigating the process or improving inter-clinic communication surrounding transfers, may reduce delays in treatment during transfer and improve overall clinical outcomes.

Ethnopharmacological relevance Given the increasing coverage of antiretroviral therapy (ART) for HIV/AIDS treatment as well as the high utilization of herbal medicine, many persons living with HIV/AIDS in sub-Saharan Africa are thought to practice medical pluralism, or the adoption of more than one medical system for their care and treatment. Using a cross-sectional study we sought to document and identify the herbal medicines used by persons living with HIV/AIDS on Mfangano Island, Suba District, Nyanza Province, Kenya. Materials and methods We interviewed herbalists and knowledgeable mothers to obtain information regarding medicinal plants, particularly for HIV/AIDS-related symptoms, HIV/AIDS, and chira (an illness concept with similarities to HIV/AIDS regarding sexual transmission and wasting symptoms). Using systematic sampling, 67 persons living with HIV/AIDS (49 of whom were receiving ART) were selected from an Mfangano Island health clinic and participated in semi-structured interviews. Results Interviews with herbalists and mothers identified 40 plant species in 37 genera and 29 families that a person with HIV/AIDS or chira could use for herbal remedies. Overall, 70.1% of persons living with HIV/AIDS had used medicinal plants after HIV diagnosis, most commonly to treat symptoms related to HIV/AIDS. In addition to common vegetables and fruits that can serve medicinal purposes, Azadirachta indica A. Juss. (Meliaceae), Carissa edulis (Forssk.) Vahl (Apocynaceae), and Ximenia americana L. (Olacaceae) were the most frequently cited medicinal plants used by persons living with HIV/AIDS. Conclusions Collaboration and communication between biomedical clinicians and herbalists should be encouraged given high rates of concomitant ART-herb usage. Pharmacological, toxicological, and ART-herb interaction studies based on the plants identified in this study and their constituent ingredients should be considered.