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This qualitative, focused critical ethnographic study explores how young people’s ‘lived SRH citizenship’ and their active roles realising their sexual and reproductive health (SRH) and rights, shape their agency and participation in decision-making in Malawi. Informed by postcolonial feminist and difference-centred citizenship theories, our findings reveal that age-based power differentials, systems of gerontocracy and a culture of adultism impede bona fide youth involvement in SRH policymaking, making young citizens’ participation more of an illusion than reality. Although democratisation and decentralisation aim to promote youth engagement, SRH policy spaces/processes lack institutionalised processes for integrating youth and remain dominated by donors and government. Collective efforts to build young citizens’ capacity and to support their engagement are essential for realising their active and meaningful participation in SRH decision-making. Recognising youth as equal members of society is vital to expose systemic gerontocracy/adultism, and democratise power to youth in Malawi, and beyond.

ABSTRACTOrphans are at higher risk of HIV infection and several important HIV risk factors than non-orphans; however, this may be due to a combination of related social, psychological, and economic factors, as well as care environment, rather than orphan status alone. Understanding these complex relationships may aid policy makers in supporting evidence-based, cost-effective programming for this vulnerable population. This longitudinal study uses a causal effect model to examine, through decomposition, the relationship between care environment and HIV risk factors in orphaned and separated adolescents and youths (OSAY) in Uasin Gishu County, Kenya; considering resilience, social, peer, or family support, volunteering, or having one's material needs met as potential mediators. We analysed survey responses from 1105 OSAY age 10–26 living in Charitable Children's Institutions (CCI) (orphanages) and family-based care settings (FBS). Follow-up time was 7–36 months. Care in CCIs (vs. FBS) was associated with a decreased likelihood of engaging in forced, exchange, and consensual sex. Excess relative risks (ERR) attributable to the indirect pathway, mediation, or interaction were not significant in any model. Care environment was not statistically associated with differences in substance use. Our findings support the direct, unmediated, association between institutional care and HIV risk factors.

Abstract Background Street-connected individuals (SCI) in Kenya experience barriers to accessing HIV care. This pilot study provides proof-of-concept for Enabling Adherence to Treatment (EAT), a combination intervention providing modified directly observed therapy (mDOT), daily meals, and peer navigation services to SCI living with HIV or requiring therapy for other conditions (e.g. tuberculosis). The goal of the EAT intervention was to improve engagement in HIV care and viral suppression among SCI living with HIV in an urban setting in Kenya. Methods This pilot study used a single group, pre/post-test design, and enrolled a convenience sample of self-identified SCI of any age. Participants were able to access free hot meals, peer navigation services, and mDOT 6 days per week. We carried out descriptive statistics to characterize participants’ engagement in EAT and HIV treatment outcomes. We used McNemar’s chi-square test to calculate unadjusted differences in HIV outcomes pre- and post-intervention among participants enrolled in HIV care prior to EAT. We compared unadjusted time to initiation of antiretroviral therapy (ART) and first episode of viral load (VL) suppression among participants enrolled in HIV care prior to EAT vs. concurrently with EAT using the Wilcoxon rank sum test. Statistical significance was defined as p

Plain Language Summary Adolescent girls in Kenya experience poor sexual and reproductive health outcomes (SRH) and have low levels of educational attainment. In this study, we aimed to examine if school attendance was associated with sexual and reproductive health outcomes among adolescent girls aged 15 to 19 years in Homa Bay and Narok counties in Kenya. The study used data from the evaluation of the In Their Hands (ITH) program which occurred between September to October 2018. A total of 1840 adolescent girls years participated in the baseline survey, of which 1810 were included in this study. We found that compared to adolescent girls in-school, those who were out-of-school were significantly more likely to report ever having sex, less likely to have used a condom during their last intercourse, and more likely to have ever been pregnant. This study found that attending school plays an important protective role in the SRH of adolescent girls. Therefore, it is important to develop and implement initiatives to support adolescent girls’ school attendance, and ultimately their education attainment.

Abstract Introduction UNICEF estimates that there are as many as 100 million street-involved youth (SIY) globally. Marginalized conditions put SIY at higher risk of HIV and adverse outcomes once HIV-positive. The objective of this analysis was to describe barriers and facilitators of accessing HIV prevention, testing, and treatment services as Phase I of an implementation study evaluating the use of peer navigators to increase access to HIV services. Methods Semi-structured interviews, focus group discussions (FGD), and theatre testing were conducted with individuals who identify as SIY, health care providers, and community stakeholders living in Canada (Toronto, Montreal, London) and Kenya (Eldoret, Huruma, Kitale). Data were analyzed using a directed content approach, guided by the socio-ecological model (SEM). Results Across the six sites were 195 participants: 64 SIY, 42 healthcare providers, and 97 community-based stakeholders. Barriers were identified at the societal (e.g. intersectional stigma and discrimination), public policy (e.g., inadequate access to basic needs, legal documentation, lack of health insurance, and limited community-based funding), institutional (e.g. lack of inclusive education and training, inadequate HIV educational outreach, and restrictive service provision), interpersonal (e.g., ineffective communication from healthcare providers), and intrapersonal levels (e.g. lack of trust and associated fear, low perception for healthcare, and lack of self-esteem). These contributed to limited HIV services utilization among SIY. Conversely, numerous facilitators were also identified at the public policy (e.g. affordable HIV services and treatment), institutional (e.g. available and accessible HIV prevention tools, HIV education and awareness programs, and holistic models of care), interpersonal level (e.g., systems navigation support, peer support, and personal relationships), and intrapersonal levels (e.g. self-efficacy) as positively supporting SIY access to HIV services. Conclusion Intersectional stigma was a critical barrier in all sites, and policies and programs that foster welcoming environments for youth from diverse backgrounds and living circumstances may be better able to respond to the HIV service needs of this high risk population. Social support and navigation services were reported to facilitate access to HIV services in all sites.

Abstract Introduction Street‐connected young people (SCY) experience structural and social barriers to engaging in the HIV prevention‐care continuum. We sought to elicit recommendations for interventions that may improve SCY's engagement along the HIV prevention‐care continuum from healthcare providers, policymakers, community members and SCY in Kenya. Methods This qualitative study was conducted in Uasin Gishu, Trans Nzoia, Bungoma, Nakuru and Kitale counties in Kenya between May 2017 and September 2018 to explore and describe the public perceptions of, and proposed and existing responses to, the phenomenon of SCY. This secondary analysis focuses on a subset of data interviews that investigated SCY's healthcare needs in relation to HIV prevention and care. We conducted 41 in‐depth interviews and seven focus group discussions with 100 participants, of which 43 were SCY. In total, 48 participants were women and 52 men. Results Our analysis resulted in four major themes corresponding to stages in the HIV prevention‐care continuum for key populations. We identified the need for an array of strategies to engage SCY in HIV prevention and testing services that are patient‐centred and responsive to the diversity of their circumstances. The use of pre‐exposure prophylaxis was a biomedical prevention strategy that SCY and healthcare providers alike stressed the need to raise awareness around and access to for SCY. Several healthcare providers suggested peer‐based approaches for engaging SCY throughout the continuum. However, SCY heavily debated the appropriateness of using peer‐based methods. Structural interventions, such as the provision of food and housing, were suggested as strategies to improve antiretroviral therapy adherence. Conclusions This study identified contextually relevant interventions that should be adapted and piloted for use with SCY. Education and sensitization of SCY and healthcare providers alike were identified as possible strategies, along with affordable housing and anti‐poverty strategies as cash transfers and provision of food. Peer‐based interventions are a clear option but require SCY‐specific adaptation to be implemented effectively.

Research has uncovered substantial gender, social, and health disparities among children and youth in street situations (CYSS) in Eldoret, Kenya. From 2013-2014 we engaged CYSS aged 11-24 years in a qualitative study to explore the sexual language and practices used in the street subculture in Eldoret, Kenya. We engaged 65 CYSS in 25 in-depth interviews and 5 focus group discussions. This work uncovered stark gender inequities, which result in girls and young women in street situations experiencing profound levels of sexual and gender-based violence and harmful sexual and reproductive health outcomes. To comprehend the underlying drivers of these inequities and to appropriately and adequately intervene, we sought to comprehend how CYSS’s social identities intersect with systems of oppression and privilege to produce and maintain these inequities. We therefore sought to reanalyze the original data from this study using intersectionality as a theoretical framework to explore how systems of oppression in Kenya have shaped the street subculture, construct CYSS’s street and resistance social identities, and how these social identities and the street subculture intersect with macro-level structural factors to produce health and gender inequities. Our analysis identified three distinct social identities that are given to CYSS in Eldoret: Chokoraa (garbage pickers), Mshefa (hustlers), and Mboga ya jeshi (vegetables for soldiers). Our findings revealed how these identities and the street subculture intersect with the Patriarchy, the political-economic context, and social cultural forces in Kenya, resulting in hegemonic masculinity and detrimental gender roles and norms for young men and women. Our findings show that CYSS are a product of the oppressive systems that construct their circumstances and shape their social identities. This population urgently requires policies and programs that intervene at multiple levels to halt the harmful practices within street subculture and associated with street-involvement.

Abstract Background There are approximately 140 million orphaned and separated children (OSCA) around the world. In Kenya, many of these children live with extended family while others live in institutions. Despite evidence that orphans are less likely to be enrolled in school than non-orphans, there is little evidence regarding the role of care environment. This evidence is vital for designing programs and policies that promote access to education for orphans, which is not only their human right but also an important social determinant of health. The purpose of this study was to compare educational attainment among OSCA living in Charitable Children’s Institutions and family-based settings in Uasin Gishu County, Kenya. Methods This study analyses follow up data from a cohort of OSCA living in 300 randomly selected households and 17 institutions. We used Poisson regression to estimate the effect of care environment on primary school completion among participants age ≥ 14 as well as full and partial secondary school completion among participants age ≥ 18. Risk ratios and 95% confidence intervals were estimated using a bootstrap method with 1000 replications. Results The analysis included 1406 participants (495 from institutions, 911 from family-based settings). At baseline, 50% were female, the average age was 9.5 years, 54% were double orphans, and 3% were HIV-positive. At follow-up, 76% of participants age ≥ 14 had completed primary school and 32% of participants age ≥ 18 had completed secondary school. Children living in institutions were significantly more likely to complete primary school (aRR: 1.18, 95% CI: 1.10–1.28) and at least 1 year of secondary school (aRR: 1.28, 95% CI: 1.18–1.39) than children in family-based settings. Children living in institutions were less likely to have completed all 4 years secondary school (aRR: 0.79, 95% CI: 0.43–1.18) than children in family-based settings. Conclusion Children living in institutional environments were more likely to complete primary school and some secondary school than children living in family-based care. Further support is needed for all orphans to improve primary and secondary school completion. Policies that require orphans to leave institution environments upon their eighteenth birthday may be preventing these youth from completing secondary school.

We examined the association between adolescents' sexual and reproductive health (SRH) service utilization in the past 12 months and structural, health facility, community, interpersonal, and individual level factors in Kenya. This cross-sectional analysis used baseline data collected in Homa Bay and Narok counties as part of the In Their Hands intervention evaluation from September to October 2018. In total, 1840 adolescent girls aged 15 to 19 years were recruited to complete a baseline survey. We used unadjusted and adjusted logistic regression to model factors associated with SRH utilization across the social-ecological framework levels. Overall, 36% of participants reported visiting a health facility for SRH services in the past 12 months. At the structural level being out-of-school (AOR: 2.12 95% CI: 1.60-2.82) and not needing to get permission to go (AOR: 1.37 95%CI: 1.04-1.82) were associated with SRH service utilization. At the interpersonal level, participants who reported being able to ask adults for help when they needed it were more likely to report using SRH services in the past 12 months (AOR: 1.98, 95% CI: 1.09-3.78). At the individual level, having knowledge about where to obtain family planning (AOR = 2.48 95% CI: 1.74-3.57) and receiving information on SRH services in the past year (AOR: 1.44 95% CI:1.15-1.80) were associated with SRH service utilization. Our findings demonstrate the need for interventions, policies, and practices to be implemented across structural, health facility, community, interpersonal, and individual levels to comprehensively support adolescent girls to access and use SRH services.

Purpose. Strengthening family-based care is a key policy response to the more than 15 million orphaned and separated children who have lost 1 or both parents in sub-Saharan Africa. This analysis estimated the cost-effectiveness of family-based care environments for preventing HIV and death in this population. Design. We developed a time-homogeneous Markov model to simulate the incremental cost per disability-adjusted life year (DALY) averted by supporting family-based environments caring for orphaned and separated children in western Kenya. Model parameters were based on data from the longitudinal OSCAR’s Health and Well-Being Project and published literature. We used a societal perspective, annual cycle length, and 3% discount rate. Incremental cost-effectiveness ratios were simulated over 5- to 15-y horizons, comparing family-based settings to street-based “self-care.” Parameter uncertainty was addressed via deterministic and probabilistic sensitivity analyses. Results. Under base-case assumptions, family-based environments prevented 422 HIV infections and 298 deaths in a simulated cohort of 1,000 individuals over 10 y. Compared with street-based self-care, family-based care had an incremental cost of $2,528 per DALY averted (95% confidence interval [CI]: 1,798, 2,599) and $2,355 per quality-adjusted life year gained (95% CI: 1,667, 2,413). The probability of family-based care being highly cost-effective was >80% at a willingness-to-pay (WTP) threshold of $2,250/DALY averted. Households receiving government cash transfers had minimally higher cost-effectiveness ratios than households without cash transfers but were still cost-effective at a WTP threshold of twice Kenya’s GDP per capita. Conclusions. Compared with the status quo of street-based self-care, family-based environments offer a cost-effective approach for preventing HIV and death among orphaned children in lower-middle income countries. Decision makers should consider increasing resources to these environments in tandem with social protection programs. Highlights UNICEF and more than 200 other international organizations endorsed efforts to redirect services toward family-based care as part of the 2019 UN Resolution on the Rights of the Child; yet this study is one of the first to quantify the cost-effectiveness of family-based care environments serving some of the world’s most vulnerable children. This health economic modeling analysis found that family-based environments would prevent 422 HIV infections and 298 deaths in a cohort of 1,000 orphaned and separated children over a 10-y time horizon. Compared with street-based “self-care,” family-based care resulted in an incremental cost of $2,528 per DALY averted (95% CI: 1,798, 2,599) and $2,355 per quality-adjusted life year gained (95% CI: 1,667, 2,413) after 10 y. Annual per-child expenditures for children living in family-based care environments in sub-Saharan Africa could potentially be increased by at least 25% and remain highly cost-effective.

Theatre testing (TT) method demonstrates whole or portions of an evidence-based intervention to stakeholders to elicit feedback on context-specific adaptations and future implementation. The Peer Navigator Project (PNP) studied the adaptation and implementation of Peer Navigators in five urban sites to increase street-connected youth (SCY) access to HIV prevention, testing, and treatment in Canada and Kenya. TT was used with SCY, healthcare providers, and community stakeholders to collect feedback on the optimal characteristics of the PNs (e.g., social identities) and their professional activities and responsibilities in each site. Sites scripted unique scenarios of PNs supporting SCY and interacting with social service providers. Local actors were employed, and the scenarios were filmed and edited into videos alongside audience discussion questions. Videos were screened to separate audiences of SCY (n = 40), healthcare providers (n = 12), and community stakeholders (n = 59). Facilitated discussion about the scenarios were recorded as data, and transcripts were analyzed thematically by the research team. The scenario videos are presented as a unique adaptation to the TT method. The adaptations were time-consuming and limited the ability to present responsive changes while presenting the method to different audiences. They were also effective at maintaining presentation fidelity and eliciting diverse and meaningful responses from different stakeholder groups. One site successfully adapted the method for use in a physically distanced manner that complied with COVID-19 public health regulations. TT using video scenarios is an engaging approach that garners rich responses from diverse stakeholder groups about the adaptation of evidence-based interventions preparing for implementation in international settings.

Abstract Background The objective of this study was to estimate the prevalence, incidence and risk factors for pregnancy among HIV-positive adolescents in a large HIV treatment program in western Kenya. Methods The Academic Model Providing Access to Healthcare (AMPATH) program is a partnership between Moi University, Moi Teaching and Referral Hospital and a consortium of 11 North American academic institutions. AMPATH currently provides care to 85,000 HIV-positive individuals in western Kenya. Included in this analysis were adolescents aged 10–19 enrolled in AMPATH between January 2005 and February 2017. Socio-demographic, behavioural, and clinical data at baseline and time-updated antiretroviral treatment (ART) data were extracted from the electronic medical records and summarized using descriptive statistics. Follow up time was defined as time of inclusion in the cohort until the date of first pregnancy or age 20, loss to follow up, death, or administrative censoring. Adolescent pregnancy rates and associated risk factors were determined. Results There were 8565 adolescents eligible for analysis. Median age at enrolment in HIV care was 14.0 years. Only 17.7% had electricity at home and 14.4% had piped water, both indicators of a high level of poverty. 12.9% (1104) were pregnant at study inclusion. Of those not pregnant at enrolment, 5.6% (448) became pregnant at least once during follow-up. Another 1.0% (78) were pregnant at inclusion and became pregnant again during follow-up. The overall pregnancy incidence rate was 21.9 per 1000 woman years or 55.8 pregnancies per 1000 women. Between 2005 and 2017, pregnancy rates have decreased. Adolescents who became pregnant in follow-up were more likely to be older, to be married or living with a partner and to have at least one child already and less likely to be using family planning. Conclusions A considerable number of these HIV-positive adolescents presented at enrolment into HIV care as pregnant and many became pregnant as adolescents during follow-up. Pregnancy rates remain high but have decreased from 2005 to 2017. Adolescent-focused sexual and reproductive health and ante/postnatal care programs may have the potential to improve maternal and neonatal outcomes as well as further decrease pregnancy rates in this high-risk group.

Despite the fact that street-connected children and youth (SCY) in low- and middle-income countries experience numerous social and health inequities, few evidence-based policies and interventions have been implemented to improve their circumstances. Our study analyzed strategies to advance health equity through action on the social determinants of health (SDH) for SCY in Kenya based on General Comment 21 of the United Nations Committee on the Rights of the Child. To identify policies and interventions, we analyzed archival newspaper articles and policy documents and elicited ideas from a diversity of social actors across Kenya. Our results identified three types of policies and interventions: repressive, welfare oriented, and child rights based. We then situated these strategies within the World Health Organization’s conceptual framework on SDH inequities to understand their mechanism of impact on health equity. Our results demonstrate that a child rights approach provides a strong avenue for advancing health equity through action on the SDH for SCY in Kenya. As a result of these findings, we developed a checklist for policy makers and other stakeholders to assess how their policies and interventions are upholding human rights, addressing needs, and working to advance health equity for SCY.

Despite the global prioritization of addressing adolescent girls' and young women's sexual and reproductive health (SRH) and participatory rights, little research has examined their lived experiences in shaping their engagement in SRH decision-making processes in the global South. Further, few studies have explored how structural and societal factors influence their agency and participation. This critical and focused ethnography, informed by postcolonial feminist and difference-centred citizenship theories, conducted in Malawi (2017-2018) elicited perspectives of youth and key informants to help address these knowledge gaps. Our findings show that the effective implementation and uptake of global discourse on participation and gender equity is hindered by inadequate consideration of girls' and young women's local political, cultural and social realities. Many girls and young women demonstrate passion to participate in SRH policymaking as agents of change. However, patriarchal and gerontocratic political and social structures/institutions, and gendered and adultist norms and practices limit their active and meaningful participation in SRH decision-making. In addition, donors' roles in SRH policymaking and their prioritization of the "girl child" highlight an enduring postcolonial power over agenda-setting processes. Understanding young people's experiences of gendered participation and scrutinizing underlying systemic forces are critical steps toward realizing young women's SRH and participatory rights.

Introduction In Kenya, distance to health facilities, inefficient vertical care delivery and limited financial means are barriers to retention in HIV care. Furthermore, the increasing burden of non-communicable diseases (NCDs) among people living with HIV complicates chronic disease treatment and strains traditional care delivery models. Potential strategies for improving HIV/NCD treatment outcomes are differentiated care, community-based care and microfinance (MF).Methods and analysis We will use a cluster randomised trial to evaluate integrated community-based (ICB) care incorporated into MF groups in medium and high HIV prevalence areas in western Kenya. We will conduct baseline assessments with n=900 HIV positive members of 40 existing MF groups. Group clusters will be randomised to receive either (1) ICB or (2) standard of care (SOC). The ICB intervention will include: (1) clinical care visits during MF group meetings inclusive of medical consultations, NCD management, distribution of antiretroviral therapy (ART) and NCD medications, and point-of-care laboratory testing; (2) peer support for ART adherence and (3) facility referrals as needed. MF groups randomised to SOC will receive regularly scheduled care at a health facility. Findings from the two trial arms will be compared with follow-up data from n=300 matched controls. The primary outcome will be VS at 18 months. Secondary outcomes will be retention in care, absolute mean change in systolic blood pressure and absolute mean change in HbA1c level at 18 months. We will use mediation analysis to evaluate mechanisms through which MF and ICB care impact outcomes and analyse incremental cost-effectiveness of the intervention in terms of cost per HIV suppressed person-time, cost per patient retained in care and cost per disability-adjusted life-year saved.Ethics and dissemination The Moi University Institutional Research and Ethics Committee approved this study (IREC#0003054). We will share data via the Brown University Digital Repository and disseminate findings via publication.Trial registration number NCT04417127.

Introduction The effect of care environment on orphaned and separated children and adolescents’ (OSCA) mental health is not well characterised in sub-Saharan Africa. We compared the risk of incident post-traumatic stress disorder (PTSD), depression, anxiety and suicidality among OSCA living in Charitable Children’s Institutions (CCIs), family-based care (FBC) and street-connected children and youth (SCY).Methods This prospective cohort followed up OSCA from 300 randomly selected households (FBC), 19 CCIs and 100 SCY in western Kenya from 2009 to 2019. Annual data were collected through standardised assessments. We fit survival regression models to investigate the association between care environment and mental health diagnoses.Results The analysis included 1931 participants: 1069 in FBC, 783 in CCIs and 79 SCY. At baseline, 1004 participants (52%) were male with a mean age (SD) of 13 years (2.37); 54% were double orphans. In adjusted analysis (adjusted HR, AHR), OSCA in CCIs were significantly less likely to be diagnosed with PTSD (AHR 0.69, 95% CI 0.49 to 0.97), depression (AHR 0.48 95% CI 0.24 to 0.97), anxiety (AHR 0.56, 95% CI 0.45 to 0.68) and suicidality (AHR 0.73, 95% CI 0.56 to 0.95) compared with those in FBC. SCY were significantly more likely to be diagnosed with PTSD (AHR 4.52, 95% CI 4.10 to 4.97), depression (AHR 4.72, 95% CI 3.12 to 7.15), anxiety (AHR 4.71, 95% CI 1.56 to 14.26) and suicidality (AHR 3.10, 95% CI 2.14 to 4.48) compared with those in FBC.Conclusion OSCA living in CCIs in this setting were significantly less likely to have incident mental illness, while SCY were significantly more, compared with OSCA in FBC.

There are currently no published estimates of mortality rates among street-connected young people in Kenya. In this short report, we estimate mortality rates among street-connected young people in an urban setting in Kenya and calculate standardized mortality ratios to assess excess mortality among street-connected young people compared to the general population of Kenyan adolescents. We collected data on deaths among street-connected young people aged 0–29 between 2010 and 2015. We calculated sex-stratified standardized mortality ratios for street-connected young people aged 0–19 and 20–29 from 2010 to 2015, using publicly available Kenya population data as reference. We found that between 2010 and 2015, there were 69 deaths among street-connected young people aged 0 to 29 years in 2013 was 1,248: 341 females (27%) and 907 males (73%). The standardized mortality ratios among street-connected females aged 0–19 and 20–29 years were 2.79 (95% CI 1.44–4.88) and 7.55 (95% CI 3.77–13.51), respectively; standardized mortality ratios among street-connected males aged 0–19 and 20–29 years were 0.71 (95% CI 0.32–1.35) and 5.48 (95% CI 3.86–7.55), respectively. In conclusion, we found that mortality among street-connected young people in an urban setting in Kenya is elevated compared to the general population of Kenyan young people. States should act urgently and take responsibility for protecting street-connected young people’s human rights by scaling up programs to prevent morbidity and death associated with youth street involvement.

PurposeThe 14-item Resilience Scale (RS14) is a tool designed to measure psychological resilience. It has been used effectively in diverse populations. However, its applicability is largely unknown for Sub-Saharan adolescent populations and completely unknown for orphaned and separated adolescents and youths (OSAY), a highly vulnerable population for whom resilience may be critical. This study assesses the RS14's psychometric properties for OSAY in Uasin Gishu County, Kenya.MethodsSurvey responses from a representative sample of 1016 OSAY (51.3% female) aged 10-25 (mean = 16; SD = 3.5) living in institutional and home-based environments in Uasin Gishu County were analyzed. The RS14's psychometric properties were assessed by examining internal consistency reliability, confirmatory factor analyses, and convergent validity using correlations between resilience and each of social support and depression. Sub-analyses were conducted by age and sex.ResultsResilience scores ranged from 14-98 (mean = 66; SD = 19) with no sex-based significant difference. Resilience was higher for those aged ≥18 (mean = 69; range = 14-98) versus age ConclusionThis study demonstrates reasonable evidence that the RS14 is both valid and reliable for measuring psychological resilience in the population of OSAY in western Kenya.

Abstract Background Street-connected young people carry a disproportionate burden of morbidities, and engage in a variety of practices that may heighten their risk of premature mortality, yet there are currently no reports in the literature on the rates or risk factors for mortality among them, nor on their causes of death. In low- and middle-income countries they are frequently in situations that violate their human rights, likely contributing to their increased burden of morbidities and vulnerability to mortality. We thus sought to describe the number of deaths annually, causes of death, and determine the number of deaths attributable to HIV among street-connected young people aged 0 to 30 years in Eldoret, Kenya. Methods Eldoret, Kenya has approximately 1900 street-connected young people. We collected data on deaths occurring from October 2009 to December 2016 from Moi Teaching and Referral Hospital records, Academic Model Providing Access to Healthcare HIV program records, and utilized verbal autopsies when no records were available. Descriptive analyses were conducted stratified by sex and age category, and frequencies and proportions were calculated to provide an overview of the decedents. We used logistic regression to assess the association between underlying cause of death and sex, while controlling for age and location of death. Results In total there were 100-recorded deaths, 66 among males and 34 among females; 37% of were among those aged ≤18 years. HIV/AIDS (37%) was the most common underlying cause of death, followed by assault (36%) and accidents (10%) for all decedents. Among males, the majority of deaths were attributable to assault (49%) and HIV/AIDS (26%), while females primarily died due to HIV/AIDS (59%). Conclusion Our results demonstrate a high number of deaths due to assault among males and HIV/AIDS among males and females. Our findings demonstrate the need for studies of HIV prevalence and incidence among this population to characterize the burden of HIV, particularly among young women given the higher number of deaths attributed to HIV/AIDS among them. Most deaths were preventable and require the urgent attention of service providers and policymakers to implement programs and services to prevent premature mortality and uphold children’s rights.

IntroductionData on engagement in HIV care from population-based samples in sub-Saharan Africa are limited. The objective of this study was to use double-sampling methods to estimate linkage to HIV care, ART initiation, and mortality among all adults diagnosed with HIV by a comprehensive home-based counseling and testing (HBCT) program in western Kenya.MethodsHBCT was conducted door-to-door from December 2009 to April 2011 in three sub-counties of western Kenya by AMPATH (Academic Model Providing Access to Healthcare). For those identified as HIV-positive, data were merged with electronic medical records to determine engagement with HIV care. A randomly-drawn follow-up sample of 120 adults identified via HBCT who had not linked to care as of June 2015 in Bunyala sub-county were visited by trained fieldworkers to ascertain HIV care engagement and vital status. Double-sampled data were used to generate, via multinomial regression, predicted probabilities of engagement in care and mortality among those whose status could not be ascertained by matching with the electronic medical records in the three catchments.ResultsIncorporating information from the double-sampling yielded estimates of prospective linkage to HIV care that ranged from 40-45%. Mortality estimates of those who did not engage in care following HBCT ranged from 12-16%. Among those who linked to care following HBCT, between 72-81% initiated ART.DiscussionIn settings without universal national identifiers, rates of linkage to care from community-based programs may be subject to substantial underestimation. Follow-up samples of those with missing information can be used to partially correct this bias, as has been demonstrated previously for mortality among those who were lost-to-care programs. There is a need for harmonized data systems across health systems and programs.

The burden on health systems due to increased volume of patients with HIV continues to rapidly increase. The goal of this study was to examine the experiences of HIV care providers in a high patient volume HIV treatment and care program in eastern Africa. Sixty care providers within the Academic Model Providing Access to Healthcare program in western Kenya were recruited into this qualitative study. We conducted in-depth interviews focused on providers’ perspectives on health system factors that impact patient engagement in HIV care. Results from thematic analysis demonstrated that providers perceive a work environment that constrained their ability to deliver high-quality HIV care and encouraged negative patient–provider relationships. Providers described their roles as high strain, low control, and low support. Health system strengthening must include efforts to improve the working environment and easing burden of care providers tasked with delivering antiretroviral therapy to increasing numbers of patients in resource-constrained settings.

Abstract Background Sub-Saharan Africa is increasingly being challenged in providing care and treatment for chronic diseases, both communicable and non-communicable. In order to address the challenges of linkage to and retention in chronic disease management, there is the need to understand the factors that can influence engagement in care. We conducted a qualitative study to identify barriers and facilitators to linkage and retention in chronic care for HIV, tuberculosis (TB) and Hypertension (HTN) as part of the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya. Methods In-depth interviews and focus group discussions were conducted July 2012-August 2013. Study participants were purposively sampled from three AMPATH clinics and included patients within the AMPATH program receiving HIV, TB, and HTN care, as well as caregivers of children with HIV, community leaders, and healthcare providers. A set of interview guides were developed to explore perceived barriers and facilitators to chronic disease management, particularly related to linkage to and retention in HIV, TB and HTN care. Data were coded and various themes were identified. We organized the concepts and themes generated using the Andersen-Newman Framework of Health Services Utilization. Results A total of 235 participants including 110 individuals living with HIV (n = 50), TB (n = 39), or HTN (n = 21); 24 caregivers; 10 community leaders; and 62 healthcare providers participated. Barriers and facilitators were categorized as predisposing characteristics, enabling resources and need factors. Many of the facilitators and barriers reported in this study were consistently reported across disease categories including personal drive, patient-provider relationships and the need for social and peer support. Conclusions Our findings provide insight into the individual as well as broader structural factors that can deter or encourage linkage and retention that are relevant across communicable and non-communicable chronic diseases. The findings of the present study suggest that interventions should consider the logistical aspects of accessing care in addition to predisposing and need factors that may affect an individuals’ decision to seek out and remain in appropriate care.

Background: Globally, droughts are occurring more regularly and are having negative effects on population health, particularly in countries such as Kenya, where agriculture is a primary driver of the economy and a source of subsistence for many communities. Children are particularly susceptible to weather-related shocks. Previous research has shown an association between drought and cross-sectional indicators of malnutrition, such as stunting. In this study, we explored various longitudinal and spatial analysis approaches to evaluating the effect of drought on height-for-age z-scores (HAZ) over time and space among young children in Kenya. Methods: Using anthropometric data from three georeferenced Kenyan Demographic and Health Surveys (KDHS) and the self-calibrated Palmer Drought Severity Index, we developed multivariate linear regression and spatial lag and error models (with Moran's I calculations) to investigate the association between drought severity and HAZ in children aged 0–5 years. Initial covariates included age of the child, sex, maternal age, height and education, wealth index, urban or rural location, and size at birth. We then did multilevel and geographically weighted regression modelling using frequentist or Bayesian methods and with inclusion of household-level covariates, such as livelihood zones. To assess the effect of changes in drought severity on child HAZ over time, KDHS data from 2003, 2008–09, and 2014 were analysed with spatiotemporal modelling. Findings: Preliminary results from the multivariate linear model showed a negative, non-significant association between drought severity and HAZ among Kenyan children in 2014 (β=0·033, p=0·101); however, there was a significant interaction between drought severity and age (β=–0·002, p

Retention, defined as continuous engagement in care, is an important indicator for quality of healthcare services. To achieve UNAIDS 90-90-90 targets, emphasis on retention as a predictor of viral suppression in patients initiated on ART is vital. Using routinely collected clinical data, the authors sought to determine the effect of age on retention post ART initiation.De-identified electronic data for 32965 HIV-infected persons aged ≥15 years at enrolment into the Academic Model Providing Access to Healthcare program between January 2008 and December 2014 were analyzed. Follow-up time was defined from the date of ART initiation until either loss to follow-up or death or close of the database (September 2016) was observed. Proportions were compared using Pearson's Chi-square test and medians using Mann-Whitney U test. Logistic regression model was used to assess differences in ART initiation between groups, adjusting for baseline characteristics. Cox proportional hazards model adjusting for baseline characteristics and antiretroviral therapy (ART) status was used to compute hazard ratios. Kaplan-Meier survival function was used to compare retention on ART at 12, 24, and 36 months post ART initiation.Of the total sample, 3924 (12.0%) were aged ≥50 years at enrolment. The median (IQR) age of young adults and older adults were 32.5 (26.6, 36.9) and 54.9 (51.7, 59.9) respectively. ART initiation rates were 70.5% among older adults and 68.2% among younger adults. Retention rates in care at 12, 24 and 36 months post ART initiation were 73.9% (95% CL: 72.2, 75.5), 62.9% (95% CL: 61.0, 64.7) and 55.4% (95% CL: 53.5, 57.3) among older adults compared to 69.8% (95% CL: 69.1, 70.4), 58.1% (95% CL: 57.4, 58.8) and 49.3% (95% CL: 48.6, 50.0) among younger adults (p

Background: The symposium Kuwa Tayari (“be prepared” in English): finding pathways to nutrition and food security resilience in response to climate change in East Africa was held in Eldoret, Kenya, in May, 2016. The goals of this symposium were to increase awareness, stimulate research ideas and recommendations, catalyse the development of training opportunities, and provide an evidence base for policy and decision-making in these regions in preparation for, and response to, our changing world. Here, we describe the structure, aims, and outcome of the symposium. Methods: The 2-day symposium was a partnership initiative between University of Toronto Dalla Lana School of Public Health in Toronto, Canada, and Moi University, College of Health Sciences, School of Public Health in Eldoret, Kenya. Target audiences were scientists, students, and educators in public health, environmental studies, agriculture, agroecology, civil society, non-government organisations, and government stakeholders. Symposium organisers did a literature review to develop a background paper that helped inform the selection of five planetary health subthemes of the symposium: (1) agriculture, nutrition, and agro-biodiversity; (2) water security; (3) renewable and sustainable cooking fuels; (4) nutrition and food security issues affecting vulnerable populations; and (5) human rights and sustainable development. The symposium format consisted of keynote and oral abstract presentations, plenary discussions, small group work, poster viewing sessions, and networking opportunities. A final report was produced to highlight key outcomes and recommendations. Findings: There were 121 attendees at the symposium from 26 institutions in Kenya, Uganda, Canada, USA, and elsewhere; most were from academic and community organisations. Participants' reasons for attending were met: personal growth and development, networking, research, course and training ideas, and potential collaborations. There was consensus on the need to invest in innovative, context-specific, climate-smart agricultural practices that support sustainable livelihoods and development, and improve food security at the household level throughout east Africa. Interpretation: Multisectoral, transdisciplinary, community-based, and population health research and interventions are needed to address the complex and interconnected issues of climate change, nutrition, and food security. Within east Africa, participatory initiatives that engage vulnerable populations (such as women, pastoral populations, and the urban poor), and those that integrate indigenous food system practices are crucial. Training priorities should be in the areas of integration of climate change topics into existing public health curriculums, and novel interdisciplinary courses on planetary health. Funding: Canadian Institutes of Health Research.

BACKGROUND:Orphaned and vulnerable adolescents (OVA) in sub-Saharan Africa are at greater risk for adverse psychological outcomes compared with their non-OVA counterparts. Social interventions that provide cash transfers (CTs) have been shown to improve health outcomes among young people, but little is known about their impact on the psychological wellbeing of OVA. OBJECTIVE:Among OVA in western Kenya, we assessed the association between living in a household that received monthly unconditional government CTs and psychological wellbeing. METHODS:We examined the likelihood of depression, anxiety, post-traumatic stress symptoms (PTSS) and positive future outlook among 655 OVA aged between 10 and 18 years who lived in 300 randomly selected households in western Kenya that either received or did not receive unconditional monthly CTs. RESULTS:The mean age was 14.0 (SD 2.4) years and 329 (50.2%) of the participants were female while 190 (29.0%) were double orphans whose biological parents were both deceased. After adjusting for socio-demographic, caregiver, and household characteristics and accounting for potential effects of participant clustering by sub-location of residence, OVA living in CT households were more likely to have a positive future outlook (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.08, 1.99), less likely to be anxious (OR 0.57, 95% CI 0.42, 0.78), and less likely to have symptoms of post-traumatic stress (OR 0.50, 95% CI 0.29, 0.89). We did not find statistically significant differences in odds of depression by CT group. CONCLUSION:OVA in CT households reported better psychological wellbeing compared to those in households not receiving CTs. CT interventions may be effective for improving psychological wellbeing among vulnerable adolescents in socioeconomically deprived households.

After the publication of the original article [1], it was highlighted that Fig. 1 was incorrectly labeled.

Given shortages of health care providers and a rise in the number of people living with both communicable and non-communicable diseases, Community Health Workers (CHWs) are increasingly incorporated into health care programs. We sought to explore community perceptions of CHWs including perceptions of their roles in chronic disease management as part of the Academic Model Providing Access to Healthcare Program (AMPATH) in western Kenya. In depth interviews and focus group discussions were conducted between July 2012 and August 2013. Study participants were purposively sampled from three AMPATH sites: Chulaimbo, Teso and Turbo, and included patients within the AMPATH program receiving HIV, tuberculosis (TB), and hypertension (HTN) care, as well as caregivers of children with HIV, community leaders, and health care workers. Participants were asked to describe their perceptions of AMPATH CHWs, including identifying the various roles they play in engagement in care for chronic diseases including HIV, TB and HTN. Data was coded and various themes were identified. We organized the concepts and themes generated using the Andersen-Newman Framework of Health Services Utilization and considering CHWs as a potential enabling resource. A total of 207 participants including 110 individuals living with HIV (n = 50), TB (n = 39), or HTN (n = 21); 24 caregivers; 10 community leaders; and 34 healthcare providers participated. Participants identified several roles for CHWs including promoting primary care, encouraging testing, providing education and facilitating engagement in care. While various facilitating aspects of CHWs were uncovered, several barriers of CHW care were raised, including issues with training and confidentiality. Suggested resources to help CHWs improve their services were also described. Our findings suggest that CHWs can act as catalysts and role models by empowering members of their communities with increased knowledge and support.

OBJECTIVE:To describe the uptake of and factors associated with HIV prevalence among pregnant women in a large-scale home-based HIV counseling and testing (HBCT) program in western Kenya. METHODS:In 2007, the Academic Model Providing Access to Healthcare Program (AMPATH) initiated HBCT to all individuals aged ≥13 years and high-risk children

Losses to follow-up (LTFU) remain an important programmatic challenge. While numerous patient-level factors have been associated with LTFU, less is known about facility-level factors. Data from the East African International epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium was used to identify facility-level factors associated with LTFU in Kenya, Tanzania and Uganda. Patients were defined as LTFU if they had no visit within 12 months of the study endpoint for pre-ART patients or 6 months for patients on ART. Adjusting for patient factors, shared frailty proportional hazard models were used to identify the facility-level factors associated with LTFU for the pre- and post-ART periods. Data from 77,362 patients and 29 facilities were analyzed. Median age at enrolment was 36.0 years (Interquartile Range: 30.1, 43.1), 63.9% were women and 58.3% initiated ART. Rates (95% Confidence Interval) of LTFU were 25.1 (24.7-25.6) and 16.7 (16.3-17.2) per 100 person-years in the pre-ART and post-ART periods, respectively. Facility-level factors associated with increased LTFU included secondary-level care, HIV RNA PCR turnaround time >14 days, and no onsite availability of CD4 testing. Increased LTFU was also observed when no nutritional supplements were provided (pre-ART only), when TB patients were treated within the HIV program (pre-ART only), and when the facility was open ≤4 mornings per week (ART only). Our findings suggest that facility-based strategies such as point of care laboratory testing and separate clinic spaces for TB patients may improve retention.

OBJECTIVE:Little is known about the reproductive health or family planning needs of street-connected children and youth in resource-constrained countries. The study objective was to describe how street-connected children and youth (SCCY) in Eldoret, Kenya, perceive pregnancy. METHODS:This qualitative study was conducted between August 2013 and February 2014. A total of 65 SCCY aged 11-24 years were purposively sampled from the three referral points: 1) A dedicated study clinic for vulnerable children and youth at Moi Teaching and Referral Hospital (MTRH); 2) Primary locations in which street children reside known as "bases/barracks"; and 3) Street youth community-based organizations. In-depth interviews and focus group discussions were audio recorded, transcribed, and translated into English. Content analysis was performed after thematic coding by 4 independent coders. RESULTS:The majority of SCCY interviewed were male (69%) and sexually active (81.5%). None had gone beyond primary level of education. The strong desire for SCCY to go through conventional life experiences including marriage and child bearing was evident. Sub-themes around desired pregnancies included: sense of identity with other SCCY, sense of hope, male ego, lineage, source of income, and avoiding stigmatization. The desire for children was highly gendered with male SCCY more focused on their social status in the street community, while for females it was primarily for survival on the street. Female SCCY generally lacked agency around reproductive health issues and faced gender-based violence. Abortions (either assisted or self-induced), infanticide, and child abandonment were reported. Respondents described a lucrative market for babies born to SCCY and alleged that healthcare workers were known to abduct these babies following hospital deliveries. CONCLUSION:Our findings indicate gender differences in the reasons why SCCY become pregnant and have children. We also noted gender inequalities in reproductive health decisions. SCCY friendly interventions that provide tailored reproductive health services are needed.

OBJECTIVE: To determine the incidence of loss to follow-up in a treatment programme for people living with human immunodeficiency virus (HIV) infection in Kenya and to investigate how loss to follow-up is affected by gender. METHODS: Between November 2001 and November 2007, 50275 HIV-positive individuals aged > 14 years (69% female; median age: 36.2 years) were enrolled in the study. An individual was lost to follow-up when absent from the HIV treatment clinic for 3 months if on combination antiretroviral therapy (cART) or for 6 months if not. The incidence of loss to follow-up was calculated using Kaplan-Meier methods and factors associated with loss to follow-up were identified by logistic and Cox multivariate regression analysis. FINDINGS: Overall, 8% of individuals attended no follow-up visits, and 54% of them were lost to follow-up. The overall incidence of loss to follow-up was 25.1 per 100 person-years. Among the 92% who attended at least one follow-up visit, the incidence of loss to follow-up before and after starting cART was 27.2 and 14.0 per 100 person-years, respectively. Baseline factors associated with loss to follow-up included younger age, a long travel time to the clinic, patient disclosure of positive HIV status, high CD4+ lymphocyte count, advanced-stage HIV disease, and rural clinic location. Men were at an increased risk overall and before and after starting cART. CONCLUSION: The risk of being lost to follow-up was high, particularly before starting cART. Men were more likely to become lost to follow-up, even after adjusting for baseline sociodemographic and clinical characteristics. Interventions designed for men and women separately could improve retention.

Guidelines for infant feeding options among HIV-positive mothers are changing with informative research. Cultural factors, socialisation processes, gender dimensions and socio-economic status within communities should be considered in recommending feasible and sustainable options. The objective of this study was to assess the knowledge, attitudes and practices with regards to infant feeding in the context of HIV. A cross-sectional study was conducted between November 2003 and January 2004. The study was carried out in Kosirai Division, Nandi-North District, in western Kenya. The target population was community members aged 18 – 45 years and key informants aged 18 years and above. Structured questionnaires and in-depth interviews were used to collect data. Multistage and snowball sampling methods were used to identify study participants. Quantitative data were analysed using the SPSS statistical package for social scientists (Version 12). Cross-tabulations were calculated and Pearson's chi-square test used to test significance of relationships between categorical variables. Recorded qualitative data were transcribed and coded. Themes were developed and integrated. A generation of concepts was used to organise the presentation into summaries, interpretations and text.A total of 385 individuals participated in the survey, 50% of whom were women. There were 30 key informants. Farming was the main source of income but half of the women (49.7%) had no income. Most of the respondents (85.5%) knew of breastfeeding as a route of HIV transmission with sex (p=0.003) and age (p=0.000) being highly associated with this knowledge. Breastfeeding was the norm although exclusive breastfeeding was not practised. Cow's milk, the main breast milk substitute, was reported as being given to infants as early as two weeks. It was the most popular (93.5%) infant feeding option in the context of HIV/AIDS. Heating expressed milk, wet nursing and milk banks were least preferred. Thus, the social, cultural and psychological complexity of infant feeding practices should be taken into account when advocating appropriate infant feeding options. Further research is required to determine the safety of using cow's milk as an infant feeding option. Community engagement, including education and awareness strategies, specific to the benefits of exclusive breastfeeding as a mechanism to reduce the risk of HIV transmission is urgently needed.

The aim of this study was to determine the impact of the domestic care environment on the prevalence of potentially traumatic events (PTEs) and posttraumatic stress disorder (PTSD) among orphaned and separated children in Uasin Gishu County, western Kenya.A total of 1565 (55.5% male) orphaned and separated adolescents aged 10-18 years (mean 13.8 years, sd 2.2), were assessed for PTSD and PTEs including bullying, physical abuse and sexual abuse. In this sample, 746 lived in extended family households, 746 in Charitable Children's Institutions (CCIs), and 73 on the street. Posttraumatic stress symptom (PTSS) scores and PTSD were assessed using the Child PTSD Checklist.Bullying was the commonest PTE in all domestic care environments, followed by physical and sexual abuse. All PTEs were commonest among the street youth followed by CCIs. However, sexual abuse was more prevalent in households than in CCIs. Prevalence of PTSD was highest among street youth (28.8%), then households (15.0%) and CCIs (11.5%). PTSS scores were also highest among street youth, followed by CCIs and households. Bullying was associated with higher PTSS scores and PTSD odds than either sexual or physical abuse.This study demonstrated differences in distribution of trauma and PTSD among orphaned and separated children in different domestic care environments, with street youth suffering more than those in CCIs or households. Interventions are needed to address bullying and sexual abuse, especially in extended family households. Street youth, a heretofore neglected population, are urgently in need of dedicated mental health services and support.

Street-connected youth are a neglected and vulnerable population, particularly in resource-constrained settings. The development of interventions and supports for this population requires insight into how they live. This study describes the social and economic characteristics of a convenience sample of street youth (SY) in Eldoret, Kenya.Participants were eligible if they were aged 12-21, living in Eldoret, spending days only (part-time), or nights and days on the street (full-time) and able and willing to consent or assent. Data were collected using a standardized interview conducted in English or Kiswahili. Binary dependent variables were having been arrested and/or jailed, and first priority for spending money (food vs. other). Nominal categorical dependent variables included major source of support, and major reason for being street-involved. Multivariable analysis used logistic regression models to examine the association of gender and level of street-involvement with social and economic factors of interest adjusting for age and length of time on the street. Data were analyzed using SAS 9.3.Of the 200 SY enrolled, 41% were female, mean age of 16.3 years; 71% were on the street full-time, and 29% part-time. Compared with part-time SY, full-time SY were more likely to have been arrested (Adjusted Odds Ratio [AOR]: 2.33, 95% Confidence Interval [95%CI]:1.01-5.35), name food as their first spending priority (AOR: 2.57, 95%CI:1.03-6.45), have left home due to violence (AOR: 5.54, 95%CI: 1.67-18.34), and more likely to report friends on the street as a major source of support (AOR: 3.59, 95% CI: 1.01-12.82). Compared with females, males were more likely to have ever been arrested (AOR: 2.66, 95%CI:1.14-6.18), and to have ever been jailed (AOR: 3.22, 95%CI:1.47-7.02).These results suggest a high degree of heterogeneity and vulnerability among SY in this setting. There is an urgent need for interventions taking into consideration these characteristics.

To describe the nutritional status of orphaned and separated children and adolescents (OSCA) living in households in the community (HH), on the street, and those in institutional environments in western Kenya.The study enrolled OSCA from 300 randomly selected households (HH), 19 Charitable Children's Institutions (CCIs), and 100 street-involved children. Measures of malnutrition were standardized with Z-scores using World Health Organization criteria; Z-scores ≤-2 standard deviations (sd) were moderate-severe malnutrition. Data were analyzed using multivariable logistic regression adjusting for child age, sex, HIV status, whether the child had been hospitalized in the previous year, time living with current guardian, and intra-household clustering for adequacy of diet and moderate-severe malnutrition.Included are data from 2862 participants (1337 in CCI's, 1425 in HH's, and 100 street youth). The population was 46% female with median age at enrolment of 11.1 years. Only 4.4% of households and institutions reported household food security; 93% of children in HH reported an adequate diet vs. 95% in CCI's and 99% among street youth. After adjustment, OSCA in HH were less likely to have an adequate diet compared to those in CCI's (AOR 0.4, 95% CI 0.2-1.0). After adjustment, there were no differences between the categories of children on weight-for-age, weight-for-height, or BMI-for-age. Children living in HH (AOR 2.6, 95% CI: 2.0-3.4) and street youth (AOR: 5.9, 95% CI: 3.6-9.5) were more likely than children in CCI's to be low height-for-age.OSCA in HH are less likely to have an adequate diet compared to children in CCI's. They and street children are more likely to be moderately-severely low height-for-age compared to children in CCI's, suggesting chronic malnutrition among them.

Introduction. There have been no scales specifically developed to assess physician-patient communication behaviors (PPCB) in the sub-Saharan population. Aim. We revised an existing PPCB scale and tested its psychometric properties for HIV patients in Kenya. Methods. 17 items (five-point scale) measuring PPCB were initially adopted from the Matched Pair Instrument (MPI). Between July and August 2011, we surveyed a convenient sample of 400 HIV adult patients, attending three Academic Model Providing Healthcare program (AMPATH) clinics in Eldoret, Kenya. Of these 400, eight also participated in cognitive interviews, and 200 were invited to return after one week for follow-up interviews; 134 (67%) returned and were interviewed. Construct and content validity were established using an exploratory factor analysis, bivariate analyses, internal consistency, test-retest reliability and cognitive interviews. Results. Construct and content validity supported a one-dimensional measure of 13 PPCB items. Items assessed physicians’ effort to promote a favorable atmosphere for interaction with HIV patients. Biases associated with encoding and comprehension of specific terms, such as “discussion, involvement or concerns,” were noted. Internal consistency (Cronbach’s alpha = .81) and one-week retest reliability scores (.82) supported the reliability of the 13-item scale. Discussion. The revised PPCB scale showed acceptable validity and reliability in Kenya.

This mixed-methods study examined barriers to and facilitators of street children's drug use cessation in Eldoret, Kenya utilizing a cross-sectional survey and focus group discussions with a community-based sample of street-involved children and youth. The primary objective of this study was to describe factors that may assist or impede cessation of drug use that can be utilized in developing substance use interventions for this marginalized population. In 2011, 146 children and youth ages 10-19 years, classified as either children on the street or children of the street were recruited to participate in the cross-sectional survey. Of the 146 children that participated in the survey 40 were invited to participate in focus group discussion; 30 returned voluntarily to participate in the discussions. Several themes were derived from children's narratives that described the barriers to and facilitators of drug cessation. Specifically, our findings reveal the strength of the addiction to inhalants, the dual role that peers and family play in substance use, and how the social, cultural, and economic context influence or impede cessation. Our findings demonstrate the need to integrate community, family and peers into any intervention in addition to traditional medical and psychological models for treatment of substance use dependence.

Background. There was a 6-month shortage of antiretrovirals (cART) in Kenya. Methods. We assessed morbidity, mortality, and loss to follow-up (LTFU) in this retrospective analysis of adults who were enrolled during the six-month period with restricted cART (cap) or the six months prior (pre-cap) and eligible for cART at enrollment by the pre-cap standard. Cox models were used to adjust for potential confounders. Results. 9009 adults were eligible for analysis: 4,714 pre-cap and 4,295 during the cap. Median number of days from enrollment to cART initiation was 42 pre-cap and 56 for the cap (P

Monitoring and evaluation (M&E) of HIV care and treatment programs is impacted by losses to follow-up (LTFU) in the patient population. The severity of this effect is undeniable but its extent unknown. Tracing all lost patients addresses this but census methods are not feasible in programs involving rapid scale-up of HIV treatment in the developing world. Sampling-based approaches and statistical adjustment are the only scaleable methods permitting accurate estimation of M&E indices.In a large antiretroviral therapy (ART) program in western Kenya, we assessed the impact of LTFU on estimating patient mortality among 8,977 adult clients of whom, 3,624 were LTFU. Overall, dropouts were more likely male (36.8% versus 33.7%; p = 0.003), and younger than non-dropouts (35.3 versus 35.7 years old; p = 0.020), with lower median CD4 count at enrollment (160 versus 189 cells/ml; p