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Background The majority of women living in rural Kenya access antenatal care (ANC) late in pregnancy, and approximately 20% have an unmet need for family planning (FP). This study aimed to determine whether training community health volunteers (CHVs) to deliver urine pregnancy testing (UPT), post-test counselling, and referral to care was an acceptable and feasible intervention to support timely initiation of ANC and uptake of FP. Methods We applied community-based participatory methods to design and implement the pilot intervention between July 2018 and May 2019. We conducted qualitative content analysis of 12 pre-intervention focus group discussions (FGDs) with women, men, and CHVs, and of 4 post-intervention FGDs with CHVs, each with 7–9 participants per FGD group. Using a pragmatic approach, we conducted inductive line-by-line coding to generate themes and subthemes describing factors that positively or negatively contributed to the intervention’s acceptability and feasibility, in terms of participants’ views and the intervention aims. Results We found that CHV-delivered point of care UPT, post-test counselling, and referral to care was an acceptable and feasible intervention to increase uptake of ANC, FP, and other reproductive healthcare services. Factors that contributed to acceptability were: (1) CHV-delivery made UPT more accessible; (2) UPT and counselling supported women and men to build knowledge and make informed choices, although not necessarily for women with unwanted pregnancies interested in abortion; (3) CHVs were generally trusted to provide counselling, and alternative counselling providers were available according to participant preference. A factor that enhanced the feasibility of CHV delivering UPT and counselling was CHV's access to appropriate supplies (e.g. carrying bags). However, factors that detracted from the feasibility of women actually accessing referral services after UPT and counselling included (1) downstream barriers like cost of travel, and (2) some male community members’ negative attitudes toward FP. Finally, improved financial, educational, and professional supports for CHVs would be needed to make the intervention acceptable and feasible in the long-term. Conclusion Training CHVs in rural western Kenya to deliver UPT, post-test counselling, and referral to care was acceptable and feasible to men, women, and CHVs in this context, and may promote early initiation of ANC and uptake of FP. Additional qualitative work is needed to explore implementation challenges, including issues related to unwanted pregnancies and abortion, the financial burden of volunteerism on CHVs, and educational and professional supports for CHVs.

The rollout of dolutegravir (DTG) in low- and middle-income countries was disrupted by a potential association reported with periconceptional DTG exposure among women living with HIV (WLHIV) and infant neural tube defects. This prompted countries to issue interim guidance limiting DTG use among women of reproductive potential to those on effective contraception. Data to understand the potential impact of such guidance on WLHIV are limited.We conducted a retrospective cohort analysis of WLHIV 15-49 years initiating DTG-containing antiretroviral treatment (ART) in Kenya from 2017 to 2020. We determined baseline effective (oral, injectable or lactational amenorrhea) and very effective (implant, intrauterine device or female sterilization) contraception use among women who initiated DTG before (Group 1) or during (Group 2) the interim guideline period. We defined incident contraception use in each group as the number of contraceptive methods initiated ≤180 days post-guideline (Group 1) or post-DTG initiation (Group 2). We determined the proportions of all women who switched from DTG- to non-nucleoside reverse transcriptase inhibitor (NNRTI)- (efavirenz or nevirapine) containing ART ≤12 months post-DTG initiation, compared their viral suppression (1000 copies/ml) and conducted multivariable logistic regression to determine factors associated with switching from DTG to NNRTI-containing ART.Among 5155 WLHIV in the analysis (median age 43 years), 89% initiated DTG after transitioning from an NNRTI. Baseline effective and very effective contraception use, respectively, by the group were: Group 1 (12% and 13%) and Group 2 (41% and 35%). Incident contraception use in each group was5%. Overall, 498 (10%) women switched from DTG to an NNRTI. Viral suppression among those remaining on DTG versus switched to NNRTI was 95% and 96%, respectively (p = 0.63). In multivariable analysis, incident effective and very effective contraception use was not associated with switching.Baseline, but not incident, effective contraception use was higher during the interim guideline period compared to before it, suggesting women already using effective contraception were preferentially selected to initiate DTG after the guideline was released. These findings reveal challenges in the implementation of policy which ties antiretroviral access to contraceptive use. Future guidance should capture nuances of contraception decision-making and support women's agency to make informed decisions.

Background: Rheumatic heart disease (RHD) in sub-Saharan Africa contributes to significant cardiac morbidity and mortality, yet prevalence estimates of RHD lesions in pregnancy are lacking. Objectives: Our first aim was to evaluate women using echocardiography to estimate the prevalence of RHD and other cardiac lesions in low-risk pregnancies. Our second aim was to assess the feasibility of screening echocardiography and its acceptability to patients. Methods: We prospectively recruited 601 pregnant women from a low-risk antenatal clinic at a tertiary care maternity centre in Western Kenya. Women completed a questionnaire about past medical history and cardiac symptoms. They underwent standardized screening echocardiography to evaluate RHD and non-RHD associated cardiac lesions. Our primary outcome was RHD-associated cardiac lesions and our secondary outcome was a composite of any clinically-relevant cardiac lesion or echocardiography finding. We also recorded duration of screening echocardiography and its acceptability among pregnant women in this sample. Results: The point prevalence of RHD-associated cardiac lesions was 5.0/1,000 (95% confidence interval: 1.0–14.5), and the point prevalence of all clinically significant lesions/findings was 21.6/1,000 (11.6–36.7). Mean screening time was seven minutes (SD 1.7, range: 4–17) for women without cardiac abnormalities and 13 minutes (SD 4.6, range: 6–23) for women with abnormal findings. Echocardiography was acceptable to women with 74.2% agreeing to participate. Conclusions: The prevalence of clinically-relevant cardiac lesions was moderately high in a low-risk population of pregnant women in Western Kenya.

Dolutegravir (DTG) is currently the first and second line antiretroviral therapy (ART) for women living with HIV (WLHIV). However, in 2018 Botswana Harvard AIDS Institute Partnership found that DTG exposure at conception corresponded with an increase in neural tube defects. Therefore, it is important that providers work with WLHIV to ensure they are aware of how to avoid unplanned pregnancies while on DTG. Telephone interviews were conducted with women living with HIV ages 21-59. The interviews were conducted in western Kenya, at clinical sites of the Academic Model Providing Access to Healthcare (AMPATH) program. Nineteen interview transcripts were coded using NVIVO 12. Domains included family planning use and shared decision making (SDM). Within these domains, three themes were used for this analysis: 1) tensions in ARV SDM and pregnancy, 2) decision making in family planning, and 3) decision making in family planning with DTG. The following three themes were discussed frequently: 1) When making decisions surrounding family planning, women preferred in person counseling and prioritized knowing the side effects of contraceptive methods; 2) WLHIV were often aware of the risk of HIV vertical transmission and valued preventing birth defects if told a medication may cause them; 3) When asked about using family planning while on DTG, WLHIV saw the benefit of preventing pregnancies. However, they did not believe family planning should be mandatory and preferred having a wide variety of contraceptive options. Understanding what factors influence women’s family planning choices may improve SDM between patients and providers. This is especially important when it comes to preventing pregnancies in women taking DTG. WLHIV often understood the importance of effective ARTs and wanted to prevent birth defects. Therefore, it is important to navigate SDM conversations such that WLHIV are given control of their own health decisions.

In the global HIV epidemic, solidarity-building approaches to engage adolescents in HIV prevention research are not just advisable but are imperative. In low resource settings, research-driven inte...

Social media outlets are inundated with quips about the baby boom coming nine months after the COVID-19 pandemic.It’s not that funny. Or that simple.The global spread of the coronavirus has resulte...

The rate of adolescent pregnancy worldwide remains unacceptably high. Sixteen million adolescent girls between the ages of 15 and 19, and 2 million under the age of 15 become pregnant each year. Ninety-five percent of these births occur in low-income countries, with four times the rate of adolescent pregnancy in the poorest regions of the world compared to high-income countries. There has been a shift globally to focus on the sexual and reproductive health needs of adolescents, including adolescent pregnancy. With increased awareness of this need has come a renewed call for evidence-based provision of adolescentfocused sexual and reproductive health (ASRH) services, as well as programs to prevent pregnancy in this age group. “Human-centered design” methodology is emerging as an innovative, feasible, and effective participatory approach to program design and implementation in health care. The standard Human Centered Design format includes 5 steps: (1) Understand people’s experiences, challenges, and priorities; (2) Use existing knowledge and new research to define and clarify the problem; (3) Prompt creative thinking to design many different solutions; (4) Build and workshop prototypes of ideas to quickly learn how they can be improved; and (5) Deliver solutions that meet the needs of the target population. Through this process, design team members identified a need to “help adolescents by removing the uncertainty that surrounds information on pregnancy and treatment choices”. To meet this need, we utilized participatory program development to build an adolescent-specific sex and pregnancy education program at Moi Teaching and Referral Hospital in Eldoret, Kenya.

OBJECTIVE: To determine the impact of introducing an emergency obstetric and neonatal care training program on maternal and perinatal morbidity and mortality at Moi Teaching and Referral Hospital Eldoret Kenya. METHODS: A prospective chart review was conducted of all deliveries during the 3-month period (November 2009 to January 2010) before the introduction of the Advances in Labor and Risk Management International Program (AIP) and in the 3-month period (August-November 2011) 1 year after the introduction of the AIP. All women who were admitted and delivered after 28 weeks of pregnancy were included. The primary outcome was the direct obstetric case fatality rate. RESULTS: A total of 1741 deliveries occurred during the baseline period and 1812 in the postintervention period. Only one mother died in each period. However postpartum hemorrhage rates decreased affecting 59 (3.5%) of 1669 patients before implementation and 40 (2.3%) of 1751 afterwards (P=0.029). The number of patients who received oxytocin increased from 829 (47.6%) to 1669 (92.1%; P

Objectives Adolescent pregnancy rates in Kenya remain high. Health and socio-economic outcomes are poor. Little has changed since the introduction of government policy to address adolescent sexual and reproductive health in 2003. As an innovative approach to address this issue, we aim to use human-centered design to build an adolescent-centered pregnancy program in Western Kenya. We further aim to demonstrate that this approach is feasible and acceptable to all involved stakeholders. Methods A team of 8 Kenyan designers, including pregnant or parenting adolescents, were recruited at Moi Teaching and Referral Hospital to learn human centered design. Designers were required to commitment to 2 weeks and 100% attendance. Further community stakeholders were recruited as research participants for context and co-creation labs. Results Our partner Idea Couture taught the Design Team qualitative research methodologies and prototyping of ideas. A total of six 1:1 interviews and 9 focus groups as context and co-creation labs were completed. There were 10 programmatic solutions generated, including Healthcare Provider Empathy Training, Community Outreach Support, and Peer Support Groups, under the umbrella of an Adolescent-Centered Clinic. The design team members found the process to be engaging and empowering; attendance was 100%. Conclusions Human centered design is a unique methodology to generate solutions to complex health challenges that target both patient experience and health outcomes. Partnerships with industry firms such as Idea Couture provide both research and care driven initiatives with unique expertise to facilitate this process. Next steps include engaging the design team in launching and evaluating the top priority prototypes.

People living with HIV/AIDS (PHAs) are increasingly recognized as experts in HIV and their own health. We developed a simulated clinical encounter (SCE) in which medical students provided HIV pre- and post-test counselling and point-of-care HIV testing for PHAs as patient instructors (PHA-PIs) under clinical preceptor supervision. The study assessed the acceptability of this teaching tool with a focus on assessing impact on HIV-related stigma among medical students. University of Toronto pre-clerkship medical students participated in a series of SCEs facilitated by 16 PHA-PIs and 22 clinical preceptors. Pre- and post-SCE students completed the validated Health Care Provider HIV/AIDS Stigma Scale (HPASS). HPASS measures overall stigma, as well as three domains within HIV stigma: stereotyping, discrimination, and prejudice. Higher scores represented higher levels of stigma. An additional questionnaire measured comfort in providing HIV-related care. Mean scores and results of paired t-tests are presented. Post-SCE, students (n = 62) demonstrated decreased overall stigma (68.74 vs. 61.81, p .001) as well as decreased stigma within each domain. Post-SCE, students (n = 67) reported increased comfort in providing HIV-related care (10.24 vs. 18.06, p .001). Involving PHA-PIs reduced HIV-related stigma among medical students and increased comfort in providing HIV-related care.

The literature indicates that medical students require more comprehensive HIV training.Medical students at the University of Toronto developed and implemented the preclerkship HIV elective (PHE) with the aim to increase trainee HIV knowledge, address important issues in HIV care, and prepare students to serve affected populations.Developed in partnership with the Ontario HIV Treatment Network and in consultation with local AIDS service organizations and the University of Toronto Faculty of Medicine, the PHE was inaugurated in November 2008 as an elective supplement to medical curriculum content. Eighteen second-year medical students participated in the PHE, consisting of lectures, small group sessions, clinical observerships, community placements, reading assignments, and an HIV counseling and testing workshop. Participants completed a self-assessment of HIV knowledge prior to starting and after PHE completion.Self-assessment scores of HIV knowledge among PHE participants significantly increased from 78.1% (pre-PHE) to 90.2% (post-PHE) (p = 0.0016). Common themes from feedback on participant satisfaction included enthusiasm for small group sessions, clinical observerships, community agency placements, and the diversity of topics covered.Student-run initiatives can supplement medical curriculum content and program feedback may be used to advocate for curriculum changes. Factors influencing success include student leadership and interest, community partnerships, and faculty mentorship.

Dear SirWhile the use of standardized patients has become a cornerstone of many current medical curricula, the role of patients as teachers or instructors in medical education is less thoroughly ex...