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Despite disproportionately high rates of Hepatitis C (HCV) among people who inject drugs (PWID) in low- and middle-income countries (LMICs), understanding of HCV-related knowledge, attitudes and perceived risk behaviours among this population remains limited. We aimed to elucidate knowledge, attitudes and experiences that could minimise transmission risk and maximise HCV treatment engagement among PWID in Kenya following the integration of HCV screening and education with needle and syringe programmes in drop-in-centres (DICs). We recruited 40 PWID with chronic HCV attending DICs in Nairobi and Coastal Kenya. Semi-structured interviews revealed a general understanding of HCV and awareness of HCV risk behaviours among participants; however, many felt limited control over their transmission risk due to factors such as 'local doctors', or individuals who perform a high volume of high-risk injections. Financial barriers, distance to clinic, poor health status and HCV-related stigma were all noted as barriers to HCV treatment. In conclusion, basic knowledge of and motivation for HCV treatment among PWID accessing DICs in Kenya was high; however, structural barriers and stigma complicate access to care. Local education programmes can address knowledge gaps, and behavioural and structural interventions can maximise the impact of HCV care in LMICs. [ABSTRACT FROM AUTHOR]

Problem In 2003, the goal of the Kenyan Ministry of Health was to avail antiretroviral treatment (ART) to 50% of the estimated 250 000 eligible individuals by the end of 2005. By July 2005, 45 000 adults and more than 2000 children were on treatment. A study was conducted to determine the barriers to identification of HIV-infected children. Approach Existing government policies were reviewed and the ART register of the Kenya National AIDS Control Programme was used to identify facilities providing ART. This paper reports the findings around diagnosis and staging of HIV infection in children. Local setting At the time of the study, 58 health facilities were providing ART to children. Only one institution had achieved universal HIV testing in the antenatal clinics. Six facilities systematically followed up HIV-exposed children. HIV antibody testing was not readily available to the children. Although four research centres were capable of carrying out diagnostic HIV polymerase chain reaction (PCR), the services were restricted to research purposes. Other constraints were inadequate physical infrastructure, inadequate systems for quality control in the laboratories and shortage of staff. Lessons learnt The policy framework to support identification of HIV-infected children had been established, albeit with narrow focus on sick children. The assessment identified the weaknesses in the structures for systematic diagnosis of HIV through laboratory or clinical-based algorithms. The researchers concluded that health staff training and implementation of a systematic standard approach to identification of HIV-infected children is urgently required. Problematique En 2003, Le Ministere de la sante kenyan s'etait donne pour objectif de faire beneficier d'ici fin 2005 d'un traitement antiretroviral (ART) 50 % des 250 000 personnes qui pourraient y pretendre d'apres les estimations. En juillet 2005, 45 000 adultes et plus de 2000 enfants etaient sous traitement. Une etude a ete menee pour determiner les obstacles s'opposant a l'identification des enfants infectes par le VIH. Demarche Les politiques gouvernementales existantes ont ete examinees et le registre de delivrance du traitement ART du programme kenyan anti-VIH/sida a ete utilise pour identifier les etablissements distribuant ce traitement. Le present article rapporte les resultats en rapport avec le diagnostic et le stadage de l'infection a VIH chez l'enfant. Contexte local Lors de la realisation de l'etude, 58 etablissements de sante dispensaient le traitement ART a des enfants. Un seul de ces etablissements appliquait un depistage systematique du VIH dans son service antenatal. Six etablissements pratiquaient un suivi systematique des enfants exposes au VIH. On ne disposait pas facilement d'un test de recherche des anticorps applicabie aux enfants. Si quatre centres de recherche etaient en mesure de diagnostiquer le VIH/sida par une technique de type PCR, lis n'exercaient ces capacites qu'a des fins de recherche. L'etude a revele d'autres contraintes : infrastructure materielie inadequate, insuffisance des systemes de controle de la qualite des laboratoires et penurie de personnel. Enseignements tires Un cadre politique pour l'identification des enfants infectes par le VIH a ete etabli, meme s'il est trop etroitement axe sur les enfants malades. L'evaluation a mis en evidence les faiblesses des structures de diagnostic systematique du VIH par des examens en laboratoire ou par des algorithmes partant de donnees cliniques. Les chercheurs ont conclu qu'une formation du personnel de sante et que l'application de la demarche standard d'identification systematique des enfants infectes par le VIH s'imposaient d'urgence. Problema En 2003 la meta del Ministerio de Salud de Kenya para fines de 2005 era proporcionar tratamiento antirretroviral (TAR) a un 50% de las 250 000 personas que se estimaba que debian recibirlo. En julio de 2005, 45 000 adultos y mas de 2000 ninos estaban recibiendo tratamiento. Se realizo un estudio para determinar los obstaculos que dificultaban la identificacion de los ninos infectados por el VIH. Enfoque Se revisaron las politicas nacionales en vigor y se utilizo el registro de TAR del Programa Nacional de Lucha contra el SIDA de Kenya para localizar los centros que ofrecian ese tratamiento. En este articulo se informa sobre los resultados relativos al diagnostico y la estadificacion de la infeccion por VIH en los ninos. Contexto local En el momento de realizar el estudio, 58 establecimientos de salud proporcionaban TARa pacientes infantiles. Solo una institucion habia logrado implantar de forma universal las pruebas de deteccion del VIH en los dispensarios prenatales. Seis establecimientos sometieron a seguimiento sistematico a los ninos expuestos al VIH, pero estos no tenian facil acceso a la prueba de deteccion de anticuerpos contra el VIH. Aunque habia cuatro centros de investigacion que podian llevar a cabo la prueba diagnostica del VIH basada en la reaccion en cadena de la polimerasa (PRC), esos servicios se limitaban a los trabajos de investigacion. Otras restricciones eran una infraestructura fisica inadecuada, unos sistemas insuficientes de control de la calidad en los laboratorios y la escasez de personal. Ensenanzas extraidas Se habia establecido el marco normativo de apoyo a la identificacion de los ninos infectados por el VIH, si bien focalizando estrechamente esa actividad en los ninos enfermos. La evaluacion permitio identificar las deficiencias de que adolecian las estructuras de diagnostico sistematico de la infeccion por VIH mediante algoritmos clinicos o de laboratorio. Los investigadores llegaron a la conclusion de que urge emprender actividades de capacitacion del personal sanitario y aplicar un procedimiento normalizado sistematico de identificacion de los ninos infectados por el VIH. [TEXT NOT REPRODUCIBLE IN ASCII], Background Kenya's population of 30 million people has nearly 1.2 million people living with HIV/AIDS with at least 250 000 in need of immediate antiretroviral therapy (ART). In 2003, the [...]

Background and aims: Hepatitis C virus (HCV) treatment is essential for eliminating HCV in people who inject drugs (PWID), but has limited coverage in resource‐limited settings. We measured the cost‐effectiveness of a pilot HCV screening and treatment intervention using directly observed therapy among PWID attending harm reduction services in Nairobi, Kenya. Design We utilized an existing model of HIV and HCV transmission among current and former PWID in Nairobi to estimate the cost‐effectiveness of screening and treatment for HCV, including prevention benefits versus no screening and treatment. The cure rate of treatment and costs for screening and treatment were estimated from intervention data, while other model parameters were derived from literature. Cost‐effectiveness was evaluated over a life‐time horizon from the health‐care provider's perspective. One‐way and probabilistic sensitivity analyses were performed. Setting Nairobi, Kenya. Population PWID. Measurements Treatment costs, incremental cost‐effectiveness ratio (cost per disability‐adjusted life year averted). Findings The cost per disability‐adjusted life‐year averted for the intervention was $975, with 92.1% of the probabilistic sensitivity analyses simulations falling below the per capita gross domestic product for Kenya ($1509; commonly used as a suitable threshold for determining whether an intervention is cost‐effective). However, the intervention was not cost‐effective at the opportunity cost‐based cost‐effectiveness threshold of $647 per disability‐adjusted life‐year averted. Sensitivity analyses showed that the intervention could provide more value for money by including modelled estimates for HCV disease care costs, assuming lower drug prices ($75 instead of $728 per course) and excluding directly‐observed therapy costs. Conclusions: The current strategy of screening and treatment for hepatitis C virus (HCV) among people who inject drugs in Nairobi is likely to be highly cost‐effective with currently available cheaper drug prices, if directly‐observed therapy is not used and HCV disease care costs are accounted for. [ABSTRACT FROM AUTHOR]

Background: Recommendations about scaling up HIV testing and counseling highlight the need to provide key services and to protect clients' rights, but it is unclear to what extent different modes of testing differ in this respect. This paper examines whether practices regarding consent, confidentiality, and referral vary depending on whether testing is provided through voluntary counseling and testing (VCT) or provider-initiated testing. Methods and Findings: The MATCH (Multi-Country African Testing and Counseling for HIV) study was carried out in Burkina Faso, Kenya, Malawi, and Uganda. Surveys were conducted at selected facilities. We defined eight outcome measures related to pre- and post-test counseling, consent, confidentiality, satisfactory interactions with providers, and (for HIV-positive respondents) referral for care. These were compared across three types of facilities: integrated facilities, where testing is provided along with medical care; stand-alone VCT facilities; and prevention of mother-to-child transmission (PMTCT) facilities, where testing is part of PMTCT services. Tests of bivariate associations and modified Poisson regression were used to assess significance and estimate the unadjusted and adjusted associations between modes of testing and outcome measures. In total, 2,116 respondents tested in 2007 or later reported on their testing experience. High percentages of clients across countries and modes of testing reported receiving recommended services and being satisfied. In the unadjusted analyses, integrated testers were less likely to meet with a counselor before testing (83% compared with 95% of VCT testers; p < 0.001), but those who had a pre-test meeting were more likely to have completed consent procedures (89% compared with 83% among VCT testers; p < 0.001) and pre-test counseling (78% compared with 73% among VCT testers; p = 0.015). Both integrated and PMTCT testers were more likely to receive complete post-test counseling than were VCT testers (59% among both PMTCT and integrated testers compared with 36% among VCT testers; p < 0.001). Adjusted analyses by country show few significant differences by mode of testing: only lower satisfaction among integrated testers in Burkina Faso and Uganda, and lower frequency of referral among PMTCT testers in Malawi. Adjusted analyses of pooled data across countries show a higher likelihood of pre-test meeting for those testing at VCT facilities (adjusted prevalence ratio: 1.22, 95% CI: 1.07-1.38) and higher satisfaction for stand-alone VCT facilities (adjusted prevalence ratio: 1.15; 95% CI: 1.06-1.25), compared to integrated testing, but no other associations were statistically significant. Conclusions: Overall, in this study most respondents reported favorable outcomes for consent, confidentiality, and referral. Provider-initiated ways of delivering testing and counseling do not appear to be associated with less favorable outcomes for clients than traditional, client-initiated VCT, suggesting that testing can be scaled up through multiple modes without detriment to clients' rights. Please see later in the article for the Editors' Summary., Introduction Since HIV tests became available in the mid-1980s, concerns about human rights have led to heated discussions among those promoting wider testing and those who fear the social consequences [...]

Background: Following confirmation of the effectiveness of voluntary medical male circumcision (VMMC) for HIV prevention, the World Health Organization and the Joint United Nations Programme on HIV/AIDS issued recommendations in 2007. Less than 5 y later, priority countries are at different stages of program scale-up. This paper analyzes the progress towards the scale-up of VMMC programs. It analyzes the adoption of VMMC as an additional HIV prevention strategy and explores the factors may have expedited or hindered the adoption of policies and initial program implementation in priority countries to date. Methods and Findings: VMMCs performed in priority countries between 2008 and 2010 were recorded and used to classify countries into five adopter categories according to the Diffusion of Innovations framework. The main predictors of VMMC program adoption were determined and factors influencing subsequent scale-up explored. By the end of 2010, over 550,000 VMMCs had been performed, representing approximately 3% of the target coverage level in priority countries. The 'early adopter' countries developed national VMMC policies and initiated VMMC program implementation soon after the release of the WHO recommendations. However, based on modeling using the Decision Makers' Program Planning Tool (DMPPT), only Kenya appears to be on track towards achievement of the DMPPT-estimated 80% coverage goal by 2015, having already achieved 61.5% of the DMPPT target. None of the other countries appear to be on track to achieve their targets. Potential predicators of early adoption of male circumcision programs include having a VMMC focal person, establishing a national policy, having an operational strategy, and the establishment of a pilot program. Conclusions: Early adoption of VMMC policies did not necessarily result in rapid program scale-up. A key lesson is the importance of not only being ready to adopt a new intervention but also ensuring that factors critical to supporting and accelerating scale-up are incorporated into the program. The most successful program had country ownership and sustained leadership to translate research into a national policy and program. Please see later in the article for the Editors' Summary., Introduction In 2009, more than 25 y after HIV was first identified, 2.6 million people had become infected, and there were an estimated 33.3 million people living with HIV worldwide [...]

Since the World Health Organization and the Joint United Nations Programme on HIV/AIDS recommended implementation of medical male circumcision (MC) as part of HIV prevention in areas with low MC and high HIV prevalence rates in 2007, the government of Kenya has developed a strategy to circumcise 80% of uncircumcised men within five years. To facilitate the quick translation of research to practice, a national MC task force was formed in 2007, a medical MC policy was implemented in early 2008, and Nyanza Province, the region with the highest HIV burden and low rates of circumcision, was prioritized for services under the direction of a provincial voluntary medical male circumcision (VMMC) task force. The government's early and continuous engagement with community leaders/elders, politicians, youth, and women's groups has led to the rapid endorsement and acceptance of VMMC. In addition, several innovative approaches have helped to optimize VMMC scale-up. Since October 2008, the Kenyan VMMC program has circumcised approximately 290,000 men, mainly in Nyanza Province, an accomplishment made possible through a combination of governmental leadership, a documented implementation strategy, and the adoption of appropriate and innovative approaches. Kenya's success provides a model for others planning VMMC scale-up programs., Introduction In the past two decades, observational studies have provided increasing evidence that male circumcision (MC) has an HIV prevention effect [1]. Moreover, three randomized controlled trials have reported that [...]

Voluntary medical male circumcision (VMMC) reduces female-to-male HIV transmission by approximately 60%;modeling suggests that scaling up VMMC to 80% of men 15- to 49-years-old within five years would avert over 3.3 million new HIV infections in 14 high priority countries/regions in southern and eastern Africa by 2025 and would require 20.33 million circumcisions. However, the shortage of health professionals in these countries must be addressed to reach these proposed coverage levels. To identify human resource approaches that are being used to improve VMMC volume and efficiency, we looked at previous literature and conducted a program review. We identified surgical efficiencies, non-surgical efficiencies, task shifting, task sharing, temporary redeployment of public sector staff during VMMC campaign periods, expansion of the health workforce through recruitment of unemployed, recently retired, newly graduating, or on-leave health care workers, and the use of volunteer medical staff from other countries as approaches that address human resource constraints. Case studies from Kenya, Tanzania, and Swaziland illustrate several innovative responses to human resource challenges. Although the shortage of skilled personnel remains a major challenge to the rapid scale-up of VMMC in the 14 African priority countries/regions, health programs throughout the region may be able to replicate or adapt these approaches to scale up VMMC for public health impact., Introduction Observational and experimental studies have shown that volunteer medical male circumcision (VMMC) reduces HIV acquisition among heterosexual men by approximately 60% [1-4]. In 2007, after the completion of three [...]

Introduction: In this study, we describe and depict unexpected sequelae of adult medical male circumcision (MMC) using the PrePex device. Materials and Methods: The PrePex system is an elastic compression device for adult MMC. The device is well studied, has been pre-qualified by the World Health Organization (WHO), and its use is being scaled-up in African countries targeted by WHO. We conducted a PrePex implementation study in routine service delivery among 427 men in the age range of 18-49 in western Kenya. We captured penile photographs to create a record of adverse events (AEs) and to monitor healing. Several unexpected AEs ensued, including some that have not been reported in other PrePex studies. We describe and depict those unexpected complications and resulting treatments to alert circumcision providers in the relevant areas. Results: We observed 5 device displacements (1.2%); 3 cases of early sloughing of foreskin tissue (0.7%) among men with long foreskins; 2 cases of a long foreskin obstructing urine flow, as it became dry and necrotic (0.5%); and 2 cases of insufficient foreskin removal caused by invagination for which surgical completion was necessary (0.5%). All of the participants healed completely by day 42 post-circumcision or shortly thereafter. Conclusion: The potential for these complications should be incorporated into PrePex training programs. Integration of devices into MMC programs in medically underserved areas requires the availability of prompt surgical intervention for some sequelae, particularly displacement events. © 2015 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]