Search

Introduction Menstrual product waste creates approximately 200,000 tons of waste annually in the United Kingdom. This contributes to sewage blockages, beach and marine litter, and to the plastics and chemicals found in water. The full impact of menstrual product waste on water pollution in the United Kingdom is not well understood due to minimal research, no standard quantification method, and lack of transparency from menstrual product producers. This scoping review aims to determine how menstrual waste contributes to water pollution, to identify the methods used to quantify the proportion of water pollution attributable to menstrual products in the United Kingdom, and to assess the strengths and limitations of the identified methods in the United Kingdom. Methods and analysis The review will include literature from 2015-present day published in English. The peer-reviewed literature will be searched using MedLine, Scopus, Web of Science and ScienceDirect. The grey literature will focus on government and stakeholder reports and publications that will be manually searched and retrieved directly from stakeholders. Pre-determined key words will be used when searching the databases. The Mixed Method Appraisal Tool will be utilized for quality appraisal. It will also help ensure that identified literature applies to the objectives and assist in discussing the various methods used. The literature will then be analyzed and organized into themes. Ethics and dissemination The scoping review will synthesize the impact that menstrual products have on water pollution and how it is being quantified in the United Kingdom. It is an early step in determining a best practice for quantifying the water pollution impact that menstrual products have allowing for future comparisons to be made. The review will be disseminated in a peer reviewed journal and in coordination with key stakeholders.

BACKGROUND: Exclusive breastfeeding (EBF) is the optimal way to feed young infants. Guidelines recommend that women living with HIV on antiretroviral therapy (ART) should EBF for six months and continue breastfeeding for up to 24 months or longer. Parents may face social or logistical barriers creating challenges to EBF. PURPOSE: To explore barriers, facilitators and community norms influencing EBF practices in Kenya. METHODS: This qualitative research was nested within a longitudinal study of intensive maternal counseling to increase EBF among HIV-positive mothers. HIV-negative and HIV-positive mothers were recruited from four public clinics in Nairobi. Women participated in focus group discussions (FGDs) that explored beliefs about and experiences with infant feeding. Conventional content analysis was used to describe and compare barriers and facilitators influencing HIV-positive and HIV-negative women’s EBF experiences. RESULTS: We conducted 17 FGDs with 80 HIV-positive and 53 HIV-negative women between 2009- 2012. Overall, women agreed that breastmilk is good for infants. However, early mixed feeding was a common cultural practice. HIV-positive women perceived that infant feeding methods and durations were their decision. In contrast, HIV-negative women reported less autonomy and more mixed feeding, citing peer pressure and lack of HIV transmission concerns. Autonomy in decision-making was facilitated by receiving EBF counseling and family support, especially from male partners. Low milk production was a barrier to EBF, regardless of HIV status, and perceived to represent poor maternal nutrition. CONCLUSIONS: Despite challenges, counseling empowered women living with HIV to advocate for EBF with spouses and family.

Background: Primary prevention strategies are needed to reduce high levels of intimate partner violence (IPV) in low- and middle-income countries (LMICs), and their effectiveness may be improved by targeting the most vulnerable populational groups and by focusing on context-specific risk factors. Methods: We selected the most recent Demographic and Health Survey carried out since 2010 and with available information on IPV. Exposure to IPV was defined as having experienced physical and/or sexual IPV in the past 12 months. We selected 15 recognized IPV risk factors (or proxies) which were available in the surveys and had a potential for tailoring and targeting interventions. To identify groups of women most vulnerable to IPV, we applied a decision tree approach, creating individual trees for each country and for all countries combined. Findings: We identified 48 countries with suitable data. In the pooled decision tree, witnessing IPV during childhood, a lower empowerment level (attitude to violence) and partner’s alcohol use were the strongest markers of IPV vulnerability. IPV prevalence among the most vulnerable women was 43% compared to 21% in the overall sample. This high-risk group concentrated 1 in every 4 women who experienced IPV in LMICs. Across the individual national trees, the subnational regions emerged as the most frequent markers of IPV occurrence. Interpretation: This study contributes evidence that can be used to plan and improve policies and programmes aimed at reducing population levels of IPV by reaching high-risk women and families with focused interventions in LMICs. By using a decision-tree approach - a simple-to-use yet powerful statistical tool we provide important insights about subpopulations of women where IPV have very high prevalence and to which interventions could be prioritised and tailored. Funding Information: Grant number: 101815/Z/13/Z and The Bill & Melinda Gates Foundation Health - Grant Number: INV-007594 / OPP1148933 Declaration of Interests: None to declare. Ethics Approval Statement: Ethical approval was obtained by the national agencies responsible for conducting each survey. All analyses relied on publicly available, anonymized databases for which permission to access was received through the DHS Program.

Background\ud In Kenya, most sexual violence survivors either do not access healthcare, access healthcare late or do not complete treatment. To design interventions that ensure optimal healthcare for survivors, it is important to understand the characteristics of those who do and do not access healthcare. In this paper, we aim to: compare the characteristics of survivors who present for healthcare to those of survivors reporting violence on national surveys; understand the healthcare services provided to survivors; and, identify barriers to treatment.\ud \ud Methods\ud A mixed methods approach was used. Hospital records for survivors from two referral hospitals were compared with national-level data from the Kenya Demographic and Health Survey 2014, and the Violence Against Children Survey 2010. Descriptive summaries were calculated and differences in characteristics of the survivors assessed using chi-square tests. Qualitative data from six in-depth interviews with healthcare providers were analysed thematically.\ud \ud Results\ud Among the 543 hospital respondents, 93.2% were female; 69.5% single; 71.9% knew the perpetrator; and 69.2% were children below 18 years. Compared to respondents disclosing sexual violence in nationally representative datasets, those who presented at hospital were less likely to be partnered, male, or assaulted by an intimate partner. Data suggest missed opportunities for treatment among those who did present to hospital: HIV PEP and other STI prophylaxis was not given to 30 and 16% of survivors respectively; 43% of eligible women did not receive emergency contraceptive; and, laboratory results were missing in more than 40% of the records. Those aged 18 years or below and those assaulted by known perpetrators were more likely to miss being put on HIV PEP. Qualitative data highlighted challenges in accessing and providing healthcare that included stigma, lack of staff training, missing equipment and poor coordination of services.\ud \ud Conclusions\ud Nationally, survivors at higher risk of not accessing healthcare include older survivors; partnered or ever partnered survivors; survivors experiencing sexual violence from intimate partners; children experiencing violence in schools; and men. Interventions at the community level should target survivors who are unlikely to access healthcare and address barriers to early access to care. Staff training and specific clinical guidelines/protocols for treating children are urgently needed.

Background\ud Primary prevention strategies are needed to reduce high rates of intimate partner violence (IPV) in low- and middle-income countries (LMICs). The effectiveness of population-based approaches may be improved by adding initiatives targeted at the most vulnerable groups and tailored to context-specificities.\ud \ud Methods\ud We applied a decision-tree approach to identify subgroups of women at higher risk of IPV in 48 LMICs and in all countries combined. Data from the most recent Demographic and Health Survey carried out between 2010 and 2019 with available information on IPV and sociodemographic indicators was used. To create the trees, we selected 15 recognized risk factors for IPV in the literature which had a potential for targeting interventions. Exposure to IPV was defined as having experienced physical and/or sexual IPV in the past 12 months.\ud \ud Findings\ud In the pooled decision tree, witnessing IPV during childhood, a low or medium empowerment level and alcohol use by the partner were the strongest markers of IPV vulnerability. IPV prevalence amongst the most vulnerable women was 43% compared to 21% in the overall sample. This high-risk group included women who witnessed IPV during childhood and had lower empowerment levels. These were 12% of the population and 1 in 4 women who experienced IPV in the selected LMICs. Across the individual national trees, subnational regions emerged as the most frequent markers of IPV occurrence.\ud \ud Interpretation\ud Starting with well-known predictors of IPV, the decision-tree approach provides important insights about subpopulations of women where IPV prevalence is high. This information can help designing targeted interventions. For a large proportion of women who experienced IPV, however, no particular risk factors were identified, emphasizing the need for population wide approaches conducted in parallel, including changing social norms, strengthening laws and policies supporting gender equality and women´s rights as well as guaranteeing women´s access to justice systems and comprehensive health services.\ud \ud Funding\ud Bill and Melinda Gates Foundation (Grant INV-010051/OPP1199234), Wellcome Trust (Grant Number: 101815/Z/13/Z ) and Associação Brasileira de Saúde Coletiva (ABRASCO).

Child sexual abuse (CSA) is a global health problem with significant health consequences. The World Health Organization recommends immediate and long-term treatment for all survivors. However, in low- and middle-income countries, less than 10 % of sexually abused children seek health services. Community health workers (CHWs) can potentially increase uptake of services, but, the risks and benefits of services provided by CHWs are poorly understood. Methods Through in-depth interviews, we examined the experiences of CHWs providing services to children in Kenya. Sixteen CHWs were purposively selected from two locations. Data were audio-recorded, transcribed verbatim and analysed thematically. Findings Nearly all the CHWs reported assisting children who had experienced sexual abuse. Children were brought to their attention by caregivers, neighbours, teachers, local authorities or the police. CHWs roles included providing information and advice, assisting the child to report to the police, access healthcare or find shelter. Multiple challenges were reported including lack of support from formal institutions; community norms; safety concerns; inadequate resources and interference from family, perpetrators and local authorities. Lack of protocols and training on how to handle children was evident. Conclusions CHWs are a crucial community-level resource for CSA survivors and their caregivers. However, community norms, lack of guidelines and training may compromise the quality of services provided. There is a significant gap in literature on service models for CHWs delivering CSA services. Data are lacking on what services CHWs can effectively offer, how they should be delivered and what factors may influence delivery, acceptance and uptake of services.

Background Sexual violence is widespread, yet relatively few survivors receive healthcare or complete treatment. In low and middle-income countries, community health workers (CHWs) have the potential to provide support services to large numbers of survivors. The aim of this review was to document the role of CHWs in sexual violence services. We aimed to: 1) describe existing models of CHWs services including characteristics of CHWs, services delivered and populations served; 2) explore acceptability of CHWs’ services to survivors and feasibility of delivering such services; and 3) document the benefits and challenges of CHW-provided sexual violence services. Methods Quantitative and qualitative studies reporting on CHWs and other community-level paraprofessional volunteer services for sexual violence were eligible for inclusion. CHWs and sexual violence were defined according to WHO criteria. The review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Quality of included studies was assessed using two quality assessment tools for quantitative, and, the methodology checklist by the National Institute for Health and Clinical Excellence for qualitative studies. Data were extracted and analysed separately for quantitative and qualitative studies and results integrated using a framework approach. Results Seven studies conducted in six countries (Democratic Republic of Congo, Rwanda, Burma, United States of America, Scotland, Israel) met the inclusion criteria. Different models of care had diverse CHWs roles including awareness creation, identifying, educating and building relationships with survivors, psychosocial support and follow up. Although sociocultural factors may influence CHWs’ performance and willingness of survivors to use their services, studies often did not report on CHWs characteristics. Few studies assessed acceptability of CHWs’ to survivors or feasibility of delivery of services. However, participants mentioned a range of benefits including decreased incidence of violence, CHWs being trusted, approachable, non-judgmental and compassionate. Challenges identified were high workload, confidentiality issues and community norms influencing performance. Conclusions There is a dearth of research on CHWs services for sexual violence. Findings suggest that involving CHWs may be beneficial, but potential challenges and harms related to CHW-provided services exist. No different models of CHW-provided care have been robustly evaluated for effects on patient outcomes. Further research to establish survivors’ views on these services, and, their effectiveness is desperately needed. Electronic supplementary material The online version of this article (10.1186/s12914-017-0137-z) contains supplementary material, which is available to authorized users.

Appendix 1. Database Search Strategy. Appendix 2. Methodological quality rating of quantitative studies. Appendix 3. Methodological quality assessment for qualitative studies. (DOCX 57 kb)

Individual and sexual partner characteristics may increase the risk of abnormal cervical cytology among women in human immunodeficiency virus (HIV)-discordant relationships. Papanicolaou smears were obtained in a prospective cohort of Kenyan HIV-discordant couples. Of 441 women, 283 (64%) were HIV-infected and 158 (36%) were HIV-uninfected with HIV-infected partners. Overall, 79 (18%) had low-grade and 25 (6%) high-grade cervical abnormalities. Male herpes simplex virus type 2 (HSV-2) seropositivity and lower couple socioeconomic status were associated with cervical abnormalities ( p 350 cells/µL) had the lowest prevalence of high-grade cervical lesions. HIV-infected women (CD4 > 350 cells/µL) and HIV-uninfected women with HIV-infected partners (CD4 ≤ 350 cells/µL) were at similar intermediate risk ( p > 0.05), and HIV-infected women (CD4 ≤ 350 cells/µL) had significantly higher risk of high-grade cervical abnormalities ( p = 0.05). Women in HIV-discordant relationships have high rates of cervical lesions and this may be influenced by couple-level factors, including HIV status and CD4 count of the infected partner.

Herpes simplex virus type 2 (HSV-2) is the most common cause of genital ulcer disease in the world, and sub-Saharan Africa bears a heavy burden of infections [1, 2]. Manifestations of HSV-2 infection range from asymptomatic or nonulcerative symptoms to periodic outbreaks of painful ulcers [3, 4]. There is a strong synergistic relationship between HSV-2 and human immunodeficiency virus type 1 (HIV-1), resulting in greater shedding and elevated infectiousness of both viruses [5–10]. HSV-2 can be managed with episodic antiviral medication (eg, acyclovir, valacyclovir, or famciclovir) to abort or reduce the duration of outbreaks or with daily suppressive treatment to prevent outbreaks and reduce asymptomatic viral shedding [11]. Although suppressive HSV-2 treatment reduces plasma HIV-1 viral load, a recent randomized trial failed to show a benefit of suppressive acyclovir therapy in reducing HIV-1 transmission [12]. However, daily suppressive therapy with valacyclovir decreases herpes transmission to sexual partners [13]. Prevention of new HSV-2 infections may be an effective HIV-1 prevention strategy, particularly among HIV-1-discordant couples in which either member of the couple is HSV-2 seronegative. While estimates vary due to population characteristics, 10%–25% of new HIV-1 infections in sub-Saharan Africa occur in HIV-1-discordant couples [14–17]. In this region, HSV-2 prevalence in one or both members of HIV-1-discordant couples is as high as 80% [18]. Yet there is limited knowledge about the timing and risk factors for HSV-2 acquisition in this high-risk population. Given the importance of HSV-2 in mediating HIV-1 transmission, we sought to better understand HSV-2 transmission in HIV-1-discordant couples by investigating its prevalence and incidence among stable HIV-1-discordant heterosexual couples in Nairobi, Kenya.

HIV-1 serodiscordant couples may experience increased risks of relationship dissolution; however, longitudinal stability of these relationships is poorly understood. We determined rates and correlates of separation among 469 serodiscordant couples in Nairobi and found that 113 (24 %) separated during 2 years of follow-up. Couples with a female HIV-1 infected partner (F+M–) and no income were more likely to separate than M+F– couples without income (HR = 5.0; 95 % CI 1.1–25.0), and F+M– and M+F– couples with income (HR = 2.4; 95 % CI 1.3–4.5 and HR = 2.3; 95 % CI 1.2–4.8, respectively). High separation rates may be important for couple support services and for conducting discordant couple studies.

Exclusive breastfeeding (EBF) means giving only breast milk to an infant. Although it is the optimal mode of feeding for infants younger than 6 months, its prevalence is low in HIV-endemic regions. Extensive promotion of EBF for 6 months in prevention of mother-to-child HIV transmission (PMTCT) programs could inadvertently result in stigma due to women's perceived association of EBF with HIV infection. In this qualitative study, we describe how stigma impacts the uptake of EBF among HIV-positive and -negative women.Pregnant and postpartum women and their male partners were recruited to participate in a total of 22 focus group discussions (FGDs). Transcripts were analyzed using ATLAS.ti. Codes were identified both a priori and inductively using the open coding approach. Major themes and subthemes were identified.There was a broad and strong consensus among some FGD participants that HIV-related stigma was a barrier to EBF. EBF was perceived as a practice for HIV-positive women. Thus, fear of discrimination deterred both HIV-positive and -negative women from EBF. However, with health education, peer counselor, and male partner support, some women were able to breastfeed exclusively regardless of opposing social norms.Stigma related to HIV poses a formidable barrier to EBF in HIV-endemic regions. There is an urgent need to widely target all women with EBF information and support EBF practices regardless of maternal HIV infection status. The lessons learned from this study indicate that vertical programs can hinder promotion of infant health interventions and therefore negatively affect child survival.

BACKGROUND: In Kenya and much of sub-Saharan Africa nearly half of all couples affected by HIV are discordant. Antiretroviral therapy (ART) slows disease progression in HIV-1-infected individuals and reduces transmission to uninfected partners. We examined time to ART initiation and factors associated with delayed initiation in HIV-1-discordant couples in Nairobi. METHODS: HIV-1-discordant couples were enrolled and followed quarterly for up to 2 years. Clinical staff administered questionnaires and conducted viral loads and CD4 counts. Participants with a CD4 count meeting ART criteria were referred to a nearby US Presidents Emergency Plan for AIDS Relief-funded treatment center. Barriers to ART initiation among participants with a CD4 count eligible for ART were assessed by Cox regression. RESULTS: Of 439 HIV-1-infected participants (63.6% females and 36.4% males) 146 met CD4 count criteria for ART during follow-up. Median time from meeting CD4 criteria until ART initiation was 8.9 months with 42.0% of eligible participants on ART by 6 months and 63.4% on ART by 1 year. The CD4 count at the time of eligibility was inversely associated with time to ART initiation (hazard ratio = 0.49 P < 0.001). Compared with homeowners those paying higher rents started ART 48% more slowly (P = 0.062) and those paying lower rents started 71% more slowly (P = 0.002). CONCLUSIONS: Despite access to regular health care referrals to treatment centers and free access to ART over one-third of participants with an eligible CD4 count had not started ART within 1 year. Factors of lower socioeconomic status may slow ART initiation and targeted approaches are needed to avoid delays in treatment initiation.

This article describes results from a cross-sectional study among HIV-infected children 15 months to 12 years of age who were receiving antiretroviral therapy. We found a low prevalence of measles IgG seropositivity (45.7%) and identified CD4% ≥ 25 as a predictor. Most HIV-infected children on ART were not measles seropositive and might benefit from revaccination.

Background Longitudinal studies of HIV-1-infected individuals or those at risk of infection are subject to missed study visits that may have negative consequences on the care of participants and can jeopardize study validity due to bias and loss of statistical power. Distance between participant residence and study clinic, as well as other socioeconomic and demographic factors, may contribute to interruptions in patient follow-up. Methods HIV-1-serodiscordant couples were enrolled between May 2007 and October 2009 and followed for two years in Nairobi, Kenya. At baseline, demographic and home location information was collected and linear distance from each participant’s home to the study clinic was determined. Participants were asked to return to the study clinic for quarterly visits, with follow-up interruptions (FUI) defined as missing two consecutive visits. Cox proportional hazards regression was used to assess crude and adjusted associations between FUI and home-to-clinic distance, and other baseline characteristics. Results Of 469 enrolled couples, 64% had a female HIV-1-infected partner. Overall incidence of FUI was 13.4 per 100 person-years (PY), with lower incidence of FUI in HIV-1-infected (10.8 per 100 PY) versus -uninfected individuals (16.1 per 100 PY) (hazard ratio [HR] = 0.66; 95% confidence interval [CI]: 0.50, 0.88). Among HIV-1-infected participants, those living between 5 and 10 kilometers (km) from the study clinic had a two-fold increased rate of FUI compared to those living

Objectives Our study aimed to assess adult women’s knowledge of human papillomavirus (HPV) and cervical cancer, and characterize their attitudes towards potential screening and prevention strategies. Methods Women were participants of an HIV-discordant couples cohort in Nairobi, Kenya. An interviewer-administered questionnaire was used to obtain information on sociodemographic status, and sexual and medical history at baseline and on knowledge and attitudes towards Pap smears, self-sampling, and HPV vaccination at study exit. Results Only 14% of the 409 women (67% HIV-positive; median age 29 years) had ever had a Pap smear prior to study enrollment and very few women had ever heard of HPV (18%). Although most women knew that Pap smears detect cervical cancer (69%), very few knew that routine Pap screening is the main way to prevent ICC (18%). Most women reported a high level of cultural acceptability for Pap smear screening and a low level of physical discomfort during Pap smear collection. In addition, over 80% of women reported that they would feel comfortable using a self-sampling device (82%) and would prefer at-home sample collection (84%). Nearly all women (94%) reported willingness to be vaccinated to prevent cervical cancer if offered at no or low cost. Conclusions These findings highlight the need to educate women on routine use of Pap smears in the prevention of cervical cancer and demonstrate that vaccination and self-sampling would be acceptable modalities for cervical cancer prevention and screening.

This study examines the incidence and predictors of pregnancy in HIV-1-discordant couples from Nairobi, Kenya. Women from 454 discordant couples were followed for up to 2 years. One-year cumulative incidence of pregnancy was 9.7%. Pregnancy rates did not differ significantly between HIV-1-infected and uninfected women (HR = 1.46). The majority of pregnancies occurred among women < 30 years old reporting a desire for future children (1-year incidence 22.2%). Pregnancy rates may be high among discordant couples, indicating desire for children may override concerns of HIV-1 transmission and increase unprotected sex, and highlighting the need to make conception safer.

ObjectivesOur study aimed to assess adult women’s knowledge of human papillomavirus (HPV) and cervical cancer, and characterize their attitudes towards potential screening and prevention strategies.MethodsWomen were participants of an HIV-discordant couples cohort in Nairobi, Kenya. An interviewer-administered questionnaire was used to obtain information on sociodemographic status, and sexual and medical history at baseline and on knowledge and attitudes towards Pap smears, self-sampling, and HPV vaccination at study exit.ResultsOnly 14% of the 409 women (67% HIV-positive; median age 29 years) had ever had a Pap smear prior to study enrollment and very few women had ever heard of HPV (18%). Although most women knew that Pap smears detect cervical cancer (69%), very few knew that routine Pap screening is the main way to prevent ICC (18%). Most women reported a high level of cultural acceptability for Pap smear screening and a low level of physical discomfort during Pap smear collection. In addition, over 80% of women reported that they would feel comfortable using a self-sampling device (82%) and would prefer at-home sample collection (84%). Nearly all women (94%) reported willingness to be vaccinated to prevent cervical cancer if offered at no or low cost.ConclusionsThese findings highlight the need to educate women on routine use of Pap smears in the prevention of cervical cancer and demonstrate that vaccination and self-sampling would be acceptable modalities for cervical cancer prevention and screening.

Background: Research shows that sexual violence is widespread and has multiple adverse health consequences. Globally, majority of sexual violence survivors either do not access care or access care late. Many of those who access care are lost to treatment follow-up before they can fully realise the benefits of medical care. Evidence suggests that community health workers (CHWs) have the potential to improve healthcare for survivors. There is limited data however, on how to deliver these services effectively.\ud Aim: To explore sexual violence survivors’ experience of seeking healthcare and experiences through the continuum of care in Kenya; and, to understand the benefits and drawbacks of using CHWs to provide support health services to sexual violence survivors.\ud Methods: A mixed methods approach was used: 1) a systematic literature review of CHWs services for sexual violence to explore the existing models of services as well as the benefits and drawbacks; 2) records for 543 survivors were reviewed and key informant interviews conducted with healthcare providers in two referral hospitals. These hospital data were compared with national-level data on survivors from the Kenya Demographic and Health Survey 2014, and the Violence Against Children Survey 2010; 3) survivors were interviewed on their care pathways, current experience of services, perceived health service’s needs and experience of CHWs services; 4) CHWs, healthcare workers and other stakeholder’s with expertise in providing care for sexual violence were interviewed on their experiences and views on CHWs services for sexual violence.\ud Results: There are multiple barriers to healthcare and missed treatment\ud opportunities for survivors, both at the community and hospital level. Children, men, partnered or ever-partnered survivors and survivors experiencing violence from intimate partners are more likely to miss treatment. CHWs are already involved in sexual violence healthcare pathways carrying out awareness creation, identifying survivors, linking survivors to care and providing psychosocial support. However, training, better definition of roles and support from the healthcare system is needed.\ud Conclusions: This thesis has identified specific barriers to services for sexual violence survivors and specific groups at risk of missing treatment. CHWs can form a part of interventions aimed to address the current barriers to treatment; however, more research is required to inform designing the models of services.