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BackgroundMethadone, as part of Medically Assisted Therapy (MAT) for treatment of opioid dependence and supporting HIV prevention and treatment, has been recently introduced in Kenya. Few low income settings have implemented methadone, so there is little evidence to guide ongoing scale-up across the region. We specifically consider the role of community level access barriers and support.ObjectivesTo inform ongoing MAT implementation we implemented a qualitative study to understand access barriers and enablers at a community level.MethodsWe conducted 30 semi-structured interviews with people who use drugs accessing MAT, supplemented by interviews with 2 stakeholders, linked to participant observation in a community drop in center within one urban area in Kenya. We used thematic analysis.ResultsWe developed five themes to express experiences of factors enabling and disabling MAT access and how community support can address these: 1) time, travel and economic hardship; 2) managing methadone and contingencies of life, 3) peer support among MAT clients as treatment ambassadors, 4) family relations, and 5)outreach project contributions. Crosscutting themes address managing socioeconomic constraints and gender inequities.ConclusionsPeople who use drugs experience and manage socio-economic constraints and gender inequities in accessing MAT with the support of local communities. We discuss how these access barriers could be addressed through strengthening the participation of networks of people who use drugs in drug treatment and supporting community projects working with people who use drugs. We also explore potential for how socio-economic constraints could be managed within an integrated health and social care response.

Integrating methadone and HIV care is a priority in many low- and middle-income settings experiencing a growing challenge of HIV epidemics linked to injecting drug use. There is as yet little understanding of how to integrate methadone and HIV care in these settings and how such services can be implemented; such a gap reflects, in part, limitations in theorizing an implementation science of integrated care. In response, we qualitatively explored the delivery of methadone after its introduction in Kenya to understand integration with HIV care. Semi-structured interviews with people using methadone (n = 30) were supplemented by stakeholder interviews (n = 2) and participant observation in one city. Thematic analysis was used, that also drew on Mol's logic of care as an analytical framework. Respondents described methadone clinic-based care embedded in community support systems. Daily observed clinic care was challenging for methadone and stigmatizing for HIV treatment. In response to these challenges, integration evolved and HIV care differentiated to other sites. The resulting care system was acceptable to respondents and allowed for choice over locations and approaches to HIV care. Using Mol's logic of care as an analytical framework, we explore what led to this differentiation in integrated care. We explore co-production and experimentation around HIV care that compares with more limited experimentation for methadone. This experimentation is bounded by available discourses and materials. The study supports continued integration of services whilst allowing for differentiation of these models to adapt to client preferences. Co-location of integrated services must prioritize clinic organization that prevents HIV status disclosure. Our analysis fosters a material perspective for theory of implementation science and integration of services that focuses attention on local experimentation shaped by context.

Background Exclusive breastfeeding (EBF) is the optimal way to feed young infants. Guidelines recommend that women living with HIV on antiretroviral therapy should EBF for 6 months and continue breastfeeding for up to 24 months or longer. Parents may face social or logistical barriers creating challenges to EBF. Objectives 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 and 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., Author(s): Miriana C. Duran [sup.1] , Rose Bosire [sup.2] , Kristin M. Beima-Sofie [sup.1] , Emmy Kageha Igonya [sup.3] [sup.4] , Adam R. Aluisio [sup.5] , Anne Gatuguta [sup.6] , [...]

This article has two objectives: first, to contribute to the academic understanding of the relationship of money with sex work by going beyond purely instrumentalist conceptualizations; and second, to inform interventions aiming to empower sex workers' economically. Qualitative research was conducted to better understand the financial lives of sex workers in Mombasa, Kenya. The article draws largely on a participatory method using 12 economic diaries accompanied by 30 informal discussions. We complement the economic diaries with 24 in-depth interviews, key informant interviews and participant observations conducted between 2014 and 2017. We found that sex workers' savings, spending, and earning practices were highly influenced by stigma, mobility and economic insecurity. We also found that sex workers gave substantial meaning to the idea of 'quick money', which reflected their daily financial strategies. The likelihood for development interventions to succeed will increase when sex workers are directly involved and not just recipients in programmes; furthermore, that programmes adequately recognize and address the needs and desires of sex workers and understand the socio-economic dynamics shaping sex work. In this article, these socio-economic factors revealed through the process and method of participants' writing economic diaries. [ABSTRACT FROM AUTHOR]

In the early 2000s, massive economic and technical resources accompanied the framing of HIV as a humanitarian and global health crisis in much of the Global South. These resources and framing combined to produce and enhance a wide range of HIV-related structures, skills, and knowledge with afterlives that have exceeded the crisis period in Kenya and elsewhere. Drawing on ethnographic fieldwork among HIV support groups in Nairobi, Kenya, conducted in the decade that followed the declared crisis period, we examine how local providers of HIV care and services understood the crisis and crisis narratives and practices. We highlight the consequences of after-crisis financial cutbacks, including anxiety, redundancy, financial hardship, and the devaluation and underutilization of expertise and care infrastructures. We argue that the structures, knowledge, and skills developed through engagements with international aid have complex afterlives, often concealed for lack of funding and forced dormancy. Our research examines strategies deployed by actors on the ground to continue offering services and support in the wake of crisis. [ABSTRACT FROM AUTHOR]

Disclosure of HIV status is routinely promoted as a public health measure to prevent transmission and enhance treatment adherence support. While studies show a range of positive and negative outcomes associated with disclosure, it has also been documented that disclosing is a challenging and ongoing process. This article aims to describe the role of health-care workers in Central and Nairobi provinces in Kenya in facilitating disclosure in the contexts of voluntary counselling and testing and provider-initiated testing and counselling and includes a discussion on how participants perceive and experience disclosure as a result. We draw on in-depth qualitative research carried out in 2008-2009 among people living with HIV (PLHIV) and the health workers who provide care to them. Our findings suggest that in everyday practice, there are three models of disclosure at work: (1) voluntary-consented disclosure, in alignment with international guidelines; (2) involuntary, non-consensual disclosure, which may be either intentional or accidental; and (3) obligatory disclosure, which occurs when PLHIV are forced to disclose to access services at health facilities. Health-care workers were often caught between the three models and struggled with the competing demands of promoting prevention, adherence, and confidentiality. Findings indicate that as national and global policies shift to normalize HIV testing as routine in a range of clinical settings, greater effort must be made to define suitable best practices that balance the human rights and the public health perspectives in relation to disclosure.