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Neonatal sepsis contributes to increased rates of mortality among newborns during their first month of life. Chlorhexidine (CHX) has proven effective in the prevention of neonatal sepsis due to umbilical stump infection after birth. Despite shifting from dry cord care techniques to CHX use, there is still a high prevalence of improper cord care in low-resource settings in Kenya. This study sought to explore barriers and enablers to CHX use in Kwale, Vihiga and Machakos counties in Kenya. We adopted mixed methods cross-sectional survey with 582 women of reproductive age with a young child less than one year as respondents to the quantitative survey. Qualitative data entailed thirty (30) key informant interviews with healthcare workers and national policymakers. Six (6) focus group discussions with mothers, caregivers, community health volunteers (CHVs) and traditional birth attendants were conducted. An observation checklist was used to assess the availability of CHX services and supplies in fourteen (14) health facilities was conducted. Results indicated variation in umbilical cord care practices for newborns across counties. Of 582 caregivers, only 1.3% reported having ever used CHX. Majority mentioned using methylated spirits (41.6%), other antiseptics (23.3%) and salty water (11.3%). Other substances used for cord care included plain water, herbal extracts, cow dung, soil, and breast milk. Despite 100% awareness of CHX among health workers, only a third of caregivers (38.7%) had heard of CHX. About 76.9% of participants preferred the gel formulation and 8.9% did not know where to get the product. Drivers of CHX use included faster cord healing, infection control in hospitals, ease of use, cost implications, ease of access, influence from key decision makers and preferred CHX formulation. Barriers included minimal awareness among caregivers, cultural practices and taboos on cord care, inadequate capacity building of CHVs on CHX, unclear CHX user guidelines for caregivers, prolonged stockouts and inadequate knowledge of CHX in communities. Healthcare workers highlighted poor dissemination of CHX guidelines by the Ministry of Health, unavailability in the Kenya Medical Supplies Authority (KEMSA) and Mission for Essential Drugs and Supplies logistic management information system making it difficult to procure. There is a need for advocacy to promote the uptake of CHX in facilities and increase knowledge of communities on CHX as well as manage the supply chain to increase CHX availability

Introduction: Kenya adopted the World Health Organization’s recommendation of community case management of malaria (CCMM) in 2012. Trained community health volunteers (CHVs) provide CCMM but information on quality of services is limited. This study aimed to establish determinants of quality of service of CCMM conducted by CHVs. Methodology: A cross-sectional survey was conducted in November 2016 in Bungoma County, Kenya. Data were collected through observing CHVs perform routine CCMM and through interviews of CHVs using structured questionnaires. A ≥ 75% score was considered as quality provision. Descriptive statistics were performed to describe basic characteristics of the study, followed by Chi-Square test and binary logistic regression to examine the differences and associations between the categorical variables. Results: A total of 147 CHVs participated; 62% of CHVs offered quality services. There was a direct association between quality of services and stock-outs of artemether-lumefantrine (AL), stock-outs of malaria rapid diagnostic tests (RDT) and support supervision. CHVs who were supervised during the year preceding the assessment were four times more likely to perform better than those not supervised (uOR 4.2, 95% CI: 1.38-12.85). CHVs with reliable supplies of AL and RDT kits performed three times better than those who experienced stock outs (uOR = 3.2, 95% CI: 1.03-10.03 and 3.3, 95% CI: 1.63-6.59 respectively). Biosafety and documentation were the most poorly performed. Conclusions: The majority of CHVs offered quality CCMM services despite safety gaps. Safety, continuous supplies of RDT, AL and supervision are essential for quality performance by CHV in delivering CCMM.

Background: Attendance rates for eye clinics are low across low- and middle-income countries (LMICs) and exhibit marked sociodemographic (SD) inequalities. We aimed to quantify the association between a range of SD domains and attendance rates from vision screening in programmes launching in Botswana, Kenya and Nepal. Methods: We will develop a set of sociodemographic questions and introduce them into routine community-based eye screening programmes in Kenya, Botswana and Nepal, targeting children aged 5-18 years and adults. Our study design is a rolling survey, embedded within the Peek screening programme. The sociodemographic questions will be asked of 10% of all those presenting to be screened, and 100% of those identified with an eye problem. We will also collect data on whether people referred to ophthalmic clinic for treatment or further assessment attended, and we will use logistic regression to report odds ratios for this outcome attendance) for each socioeconomic domain in each country. We hypothesise that attendance rates will be lowest among marginalised sociodemographic groups such as older, less educated, less wealthy women. To identify the most appropriate sociodemographic items we will perform a literature review, and then hold workshops with researchers, academics, programme implementers, and programme designers in each country to tailor the domains and response options to the national context. We will report outcome data at 6 and 12 months, identifying the groups facing the highest barriers to access. Discussion: This low-risk, embedded, pragmatic, observational data collection will enable eye screening programme managers to accurately identify which sociodemographic groups are facing the highest systematic barriers to accessing care at any point in time. This information will be used to inform the development of service improvements to improve equity.

Background: As in other developing countries, sexual and reproductive ill-health continues to mostly affect adolescents and youths. Samburu and Turkana counties in Kenya have some of the highest levels of total fertility rates (TFR) at 6.3 and 6.9 respectively placing them well above the national TFR of 3.9. Establishing factors that influence utilization of SRH services among adolescent and youth aged 10 - 24 years is critical in developing an effective program. Method: We used primary data from qualitative and purposeful study design. Data collection used Focus group discussions (FGD), In-depth interviews (IDIs) and Key informant interviews (IDIs). The target groups were adolescents and youth aged 10 - 24 years, health care providers, community health volunteers (CHVs), chemist assistants, parents of adolescents and youth, teachers, spiritual leaders and traditional activists. Findings and Conclusion: Socio-cultural factors were found to influence utilization of SRH services and information. Early marriage, being youth, male only decisions on sexuality matters and fear of family contribute to unprotected sex while myths and misconceptions on contraceptives affected utilization. The findings revealed that youth needs to know sources, how contraceptives work and how to use them. The findings suggest capacity building of health care providers, CHVs, teachers, parents and community leaders on adolescence, sexuality needs of adolescents and disadvantages of female genital mutilation (FGM) including early marriage.

Background: Female Genital Mutilation/Cutting (FGM/C) often has lifelong negative consequences for a woman’s physical and mental health but is still practiced in some parts of Kenya including Kajiado County. We aimed to estimate the current prevalence as well as the socio-cultural beliefs and power relations that are in favor of or against the practice in Kajiado, Kenya. Methods: A mixed method cross-sectional study was conducted in Kajiado County. The study targeted: women of reproductive age (15 to 49 years); community health volunteers (CHVs); opinion leaders; health care workers; officials from the ministries of Education, Health, Culture, Gender and Social Services; Community Health Assistants (CHAs); Traditional Birth Attendants (TBAs); teachers; morans and adolescent boys and girls aged 10 to 24 years. Data were collected both quantitatively through a household questionnaire and qualitatively through the focus group discussions and key informant interviews. Factors influencing Female Genital Mutilation/Cutting (FGM/C) were classified as either social, cultural beliefs or economic. Results: From the study, quantitative results revealed that the prevalence of FGM/C in Kajiado County was 91%, with most of them (96.7%) practicing type 2 (excision) circumcisions. From the interviews, girls undergo the cut as a rite of passage to womanhood and thus a prerequisite for marriage. It is also believed that girls who are uncircumcised cannot be helped by TBAs in delivery. It is believed that their blood is poisonous and can cause bad omen to whoever comes in contact with dirty blood. Additionally, it is believed that girls go through the cut to avoid conflict and natural phenomena; for instance, drought and outbreaks of diseases that kill many people. Finally, it is a practice that earns respect for the parents of the girls and incentives as dowry to the father of the girl. TBAs that perform FGM/C get paid in cash and kind. Conclusion: Female genital mutilation/cutting practice in Kajiado County is still high. Efforts to end the practice will need to have an integrated approach to include all the players. Suggested alternatives to the cut must, therefore, be inclusive so as to address the myths/beliefs, misconceptions, socio-cultural and economic factors in favor of the vice. The alternatives must be inclusive for the beneficiaries, supporters, and practitioners.

Background Conflict regions bear the heaviest brunt of food insecurity and undernutrition. South Sudan is one of the fragile countries following years of conflict that led to large displacements. Moderate to severe undernutrition among under-five children has been associated with elevated morbidity and mortality. This study, therefore, was conducted to assess the magnitude and factors influencing undernutrition (wasting, underweight and stunting) among children aged 6 to 59 months in Yambio County, South Sudan. Methods A cross-sectional study was conducted from 26 October to 6 November 2018 in Yambio County, South Sudan among 630 children aged 6–59 months from the 348 households surveyed in 39 clusters using two-stage cluster sampling design. Data were collected using questionnaires and nutritional anthropometric measurements. The Standardized Monitoring and Assessment of Relief and Transitions (SMART) Methodology was followed to obtain the prevalence of wasting, underweight and stunting based on respective z scores and according to the 2006 world health organization child growth standards. Data were exported to Stata version 16 for further analysis. Bivariate analysis of independent variables and undernutrition was done using binary logistic regression. Mixed effects logistic regression analysis was conducted to control for possible confounders and account for random effects at household and cluster levels. Unadjusted and adjusted odds ratios (cOR and aOR) with 95% confidence intervals (CI) and p-values were computed. P-values of ≤0.05 were considered statistically significant. Results The prevalence of undernutrition explained by wasting (weight-for-height Z-score (WHZ) p-value: 5.6 [1.10–30.04], p = 0.038), older child’s age (aOR [95% CI], p-value: 30.4 [2.65–347.60], p = 0.006) and non-residents (cOR [95% CI], p-value: 4.2 [1.4–12.2] p = 0.009) were associated with increased risk of wasting. Household size (cOR [95% CI], p-value: 1.09 [1.01–1.18] p = 0.029) and younger child age (cOR [95% CI], p-value: 4.2 [1.34–13.23] p = 0.014) were significantly associated with underweight. Younger child age (aOR [95% CI], p-value: 5.4 [1.82–16.44] p = 0.003) and agricultural livelihood (aOR [95% CI], p-value: 3.4 [1.61–7.02] p = 0.001) were associated with stunting. Conclusion Based on a cut off of less than − 2 standard deviations for 2006 World Health Organization (WHO) child growth standards, the wasting prevalence was very low, underweight prevalence was low while stunting prevalence was high. The county lies in the only livelihood region in South Sudan with bimodal reliable rainfall pattern and it seems that the impact of the 2016 conflicts that lead to large displacements may not have greatly affected under-five undernutrition. Interventions targeted at improving food diversity, increasing nutrition knowledge and enhancing resilience in male children might reduce undernutrition. In the short-term, investment in continued surveillance of nutritional status should be a main focus.

Background Cases of the Corona Virus Disease of 2019 (COVID-19) in Kenya have continued to increase rapidly, since the first case in the country was confirmed in March 2020. In the wake of the pandemic, the health and socio-economic challenges experienced by the youth in Kenya are likely to be elevated. We assessed knowledge, practices, perceived risk of infection, adoption of recommended behaviour and the effects of COVID-19 among the youth in Kenya. Methods A cross sectional descriptive study was conducted between April 30th to May 7th, 2020 through a combined online survey and phone interviews. A total of 2156 youth across all 47 counties in Kenya completed the responses to the study questions. All survey responses analyzed using Stata version 15 were tabulated by gender, age, and education level to generate basic descriptive tables and tested for differences by category using chi-square tests. Where applicable, linear and logistic regression analysis model was conducted using covariates such as employment status, gender, and education level. Results Knowledge on symptoms of COVID-19 was generally high. Female respondents were more likely to identify more symptoms correctly compared to men (p Conclusion There was high knowledge of COVID-19 symptoms, preventive strategies, and high adoption of preventive practices. Strategies to sustain behaviors positively adopted among young people will be critical to reduce the spread of COVID-19. Despite the low reported rates of inability to access sexual and reproductive health, response measures should include strategies that facilitate continuity of services among young people. The reported social effects of the pandemic show the need for interventions to meet the health and socio-economic needs of the youth and minimize the long-term consequences of the pandemic.

Introduction In Kenya, Female Genital Mutilation/Cutting (FGM/C) is highly prevalent in specific communities such as the Maasai and Somali. With the intention of curtailing FMG/C prevalence in Maasai community, Amref Health Africa, designed and implemented a novel intervention—community-led alternative rite of passage (CLARP) in Kajiado County in Kenya since 2009. The study: a) determined the impact of the CLARP model on FGM/C, child early and forced marriages (CEFM), teenage pregnancies (TP) and years of schooling among girls and b) explored the attitude, perception and practices of community stakeholders towards FGM/C. Methods We utilised a mixed methods approach. A difference-in-difference approach was used to quantify the average impact of the model with Kajiado as the intervention County and Mandera, Marsabit and Wajir as control counties. The approach relied on secondary data analysis of the Kenya Demographic and Health Survey (KDHS) 2003, 2008–2009 and 2014. A qualitative approach involving focus group discussions, in-depth interviews and key informant interviews were conducted with various respondents and community stakeholders to document experiences, attitude and practices towards FGM/C. Results The CLARP has contributed to: 1) decline in FGM/C prevalence, CEFM rates and TP rates among girls by 24.2% (p Conclusion This study demonstrated that CLARP has been positively received by the Maasai community and has played a significant role in attenuating FGM/C, CEFM and TP in Kajiado, while contributing to increasing girls’ schooling years. CLARP is replicable as it is currently being implemented in Tanzania. We recommend scaling it up for adoption by stakeholders implementing in other counties that practice FGM/C as a rite of passage in Kenya and across other sub Saharan Africa countries.

Background: Cases of the Corona Virus Disease of 2019 (COVID-19) in Kenya have continued to increase rapidly, since the first case in the country was confirmed in March 2020. In the wake of the pandemic, the health and socio-economic challenges experienced by the youth in Kenya are likely to be elevated. We assessed knowledge, practices, perceived risk, adoption of recommended behaviour and the effect of COVID-19 on health seeking behaviour related to sexual and reproductive health and social economic status among the youth.Methods: A cross sectional descriptive study was conducted between April 30th to May 7th, 2020 among 2,153 youth across all 47 counties in Kenya, through a combined online survey and phone interviews. All survey responses analyzed using STATA v15 were tabulated by gender, age, and education level to generate basic descriptive tables and tested for differences by category using chi-square tests. Where applicable, linear and logistic regression analysis model was conducted using covariates such as employment status, gender, and education level. Results: Knowledge on symptoms of COVID-19 was generally high. Female respondents were more likely to identify more symptoms correctly compared to men; pConclusion: There was high knowledge of COVID-19 symptoms, preventive strategies, and adoption of preventive practices. Despite the low reported inability to access health services related to sexual and reproductive health, response measures should include continuity of services. The reported adverse socioeconomic effects of the pandemic show the need for interventions to meet the health and socioeconomic needs of the youth and minimize the long term consequences of the pandemic. Strategies to sustain behaviors positively adopted among young people will be critical to reduce the spread of COVID-19.

Background: The cases of Corona Virus Disease of 2019 (COVID-19) in Kenya have been increasing rapidly, since the first case was confirmed in early March, 2020. In the wake of the crisis around COVID-19, the health and socio-economic challenges experienced by Kenya’s largest demography, the youth, are likely to elevated. This study sought to establish knowledge levels, gaps and attitude of the youth with regards to COVID-19 and identify the effects of the pandemic on health seeking behaviour and socio-economic status of youth.Methods: A cross sectional descriptive study was conducted among 2,153 youth across 47 counties in Kenya, through a combined online survey and phone interviews. All survey responses analyzed using STATA v15 were tabulated by gender, age, education level to generate basic descriptive tables and tested for differences by category using chi-square tests with a significance level of 0.05. Where applicable linear and logistic regression analysis model was conducted with covariates such as employment status, gender and education level were used.Results: Knowledge on symptoms of COVID-19 was generally high. Female respondents were more likely to name more symptoms correctly compared to men; pConclusion: Our study revealed considerably high knowledge of COVID-19 symptoms, preventive strategies and most commonly sources of information that are instructive for the pandemic response. Findings suggest messaging campaigns should focus on reaching clarifying risk groups. The need to track health service use among youth is essential to lay longer term strategies towards minimizing potential long-term consequences of the pandemic. Strategies to sustain behaviors positively adopted and leverage the vast network of youth as champions of behavior change will be critical to reduce the spread of COVID-19.

Summary Background Retention of patients in HIV care is crucial to ensure timely treatment initiation, viral suppression, and to avert AIDS-related deaths. We did a randomised trial to determine whether a text-messaging intervention improved retention during the first year of HIV care. Methods This unmasked, randomised parallel-group study was done at two clinics in informal settlements in Nairobi, Kenya. Eligible participants were aged 18 years or older, HIV-positive, had their own mobile phone or access to one, and were able to use simple text messaging (or have somebody who could text message on their behalf). Participants were randomly assigned (1:1), with random block sizes of 2, 4, and 6, to the intervention or control group. Participants in the intervention group received a weekly text message from the automated WelTel service for 1 year and were asked to respond within 48 h. Participants in the control group did not receive text messages. Participants in both groups received usual care, which comprised psychosocial support and counselling; patient education; CD4 cell count; treatment; screening for tuberculosis, opportunistic infections, and sexually transmitted infections; prevention of mother-to-child transmission and family planning services; and up to two telephone calls for missed appointments. The primary outcome was retention in care at 12 months (ie, clinic attendance 10–14 months after the first visit). Participants who did not attend this 12-month appointment were traced, and we considered as retained those who were confirmed to be active in care elsewhere. The data analyst and clinic staff were masked to the group assignment, whereas participants and research nurses were not. We analysed the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT01630304. Findings Between April 4, 2013, and June 4, 2015, we screened 1068 individuals, of whom 700 were recruited. 349 people were allocated to the intervention group and 351 to the control group. Participants were followed up for a median of 55 weeks (IQR 51–60). At 12 months, 277 (79%) of 349 participants in the intervention group were retained, compared with 285 (81%) of 351 participants in the control group (risk ratio 0·98, 95% CI 0·91–1·05; p=0·54). There was one mild adverse event related to the intervention, a domestic dispute that occurred when a participant's partner became suspicious of the weekly messages and follow-up calls. Interpretation This weekly text-messaging service did not improve retention of people in early HIV care. The intervention might have a modest role in improving self-perceived health-related quality of life in individuals in HIV care in similar settings. Funding National Institutes of Health and Canadian Institutes of Health Research Canadian HIV Trials Network

Health-related quality of life (HRQoL) and health state utility value (HSUV) measurements are vital components of healthcare clinical and economic evaluations. Accurate measurement of HSUV and HRQoL require validated instruments. The 12-item Short-Form Health Survey (SF-12) is one of few instruments that can evaluate both HRQoL and HSUV, but its validity has not been assessed in people living with HIV/AIDS (PLWHA) in east Africa, where the burden of HIV is high. This cross-sectional study used baseline data from a randomized trial involving PLWHA in Kenya. Data included responses from a translated and adapted SF-12 survey as well as key demographic and clinical data. Construct validity of the survey was examined by testing the SF-12’s ability to distinguish between groups known in advance to have differences in their health based on their disease severity. We classified disease severity based on established definitions from the US Center for Disease Control (CDC) and WHO, as well as a previously studied viral load threshold. T-tests and ANOVA were used to test for differences in HRQoL and HSUV scores. Area under the receive operator curve (AUC) was used to test the discriminative ability of the HRQoL and HSUV instruments. Differences in physical component scores met the minimum clinically important difference among participants with more advanced HIV when defined by CD4 count (4.3 units) and WHO criteria (compared to stage 1, stages 2, 3 and 4 were 2.0, 7.2 and 9.8 units lower respectively). Mental score differences met the minimum clinically important difference between WHO stage 1 and stage 4 patients (4.4). Differences in the HSUV were statistically lower in more advanced HIV by all three definitions of severity. The AUC showed poor to weak discriminatory ability in most analyses, but had fair discriminatory ability between WHO clinical stage 1 and clinical stage 4 individuals (AUC = 0.71). Our findings suggest that the Kiswahili translated and adapted version of the SF-12 could be used as an assessment tool for physical health, mental health and HSUV for Kiswahili-speaking PLHWA. Clinical trials.gov identifier: NCT00830622 . Registered 26 January 2009.

Introduction HIV self-testing could add a new approach to scaling up HIV testing with potential of being high impact, low cost, confidential, and empowering for users. Methods Pregnant women attending antenatal clinics (ANC) and their male partners were recruited in 14 clinics in the eastern and central regions of Kenya and randomly allocated to intervention or control arms at a ratio of 1:1:1. Arm 1 received the standard of care, which involved invitation of the male partner to the clinic through word of mouth, arm 2 received an improved invitation letter, and arm 3 received the same improved letter and, two self-testing kits. Analysis was done using adjusted odds ratios (aOR) at 95% confidence intervals (CI) to calculate and determine effects of HIV self-testing in increasing uptake of male partner testing. Results A total of 1410 women and 1033 men were recruited; 86% (1217) women and 79% (1107) couples were followed up. In arm 3, over 80% (327) of male partners took HIV test, compared to only 37% (133) in arm 2 and 28% (106) in arm one. There was a statistical significance between arm one and two (p-value=0.01) while arm three was statistically significant compared to arm two (p-value

Background In response to poor maternal, newborn, and child health indicators in Magadi sub-county, the “Boma” model was launched to promote health facility delivery by establishing community health units and training community health volunteers (CHVs) and traditional birth attendants (TBAs) as safe motherhood promoters. As a result, health facility delivery increased from 14% to 24%, still considerably below the national average (61%). We therefore conducted this study to determine factors influencing health facility delivery and describe barriers and motivators to the same. Methods A mixed methods cross-sectional study involving a survey with 200 women who had delivered in the last 24 months, 3 focus group discussions with health providers, chiefs and CHVs and 26 in-depth interviews with mothers, key decision influencers and TBAs. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) using logistic regression were calculated to identify predictive factors for health facility delivery. Thematic analysis was done to describe barriers and motivators to the same. Results Of the women interviewed, 39% delivered at the health facility. Factors positively associated with health facility deliveries included belonging to the highest wealth quintiles [aOR 4.9 (95%CI 1.5–16.5)], currently not married [aOR 2.4 (95%CI 1.1–5.4)] and living near the health facility [aOR 2.2 (95%CI 1.1 = 4.4)]. High parity [aOR 0.7 (95%CI 0.5–0.9)] was negatively associated with health facility delivery. Barriers to health facility delivery included women not being final decision makers on place of birth, lack of a birth plan, gender of health provider, unfamiliar birthing position, disrespect and/or abuse, distance, attitude of health providers and lack of essential drugs and supplies. Motivators included proximity to health facility, mother’s health condition, integration of TBAs into the health system, and health education/advice received. Conclusion Belonging to the highest wealth quintile, currently not married and living near a health facility were positively associated with health facility delivery. Gender inequity and cultural practices such as lack of birth preparedness should be addressed. Transport mechanisms need to be established to avoid delay in reaching a health facility. The health systems also need to be functional with adequate supplies and motivated staff. Electronic supplementary material The online version of this article (10.1186/s12884-017-1632-x) contains supplementary material, which is available to authorized users.

OBJECTIVES: To assess biological and behavioral factors in HIV-uninfected female sex workers (FSWs) accessing postexposure prophylaxis (PEP) and to characterize the circumstances preceding PEP time to access and adherence. METHODS: Participants were HIV-uninfected FSWs enrolled in an HIV care and prevention program in Nairobi Kenya. Those accessing PEP between 2009 and 2010 were enrolled and compared with controls. Multiple logistic regression models were used to compare PEP-related biological and behavioral parameters. RESULTS: PEP users (n = 326) had been involved in sex work for a shorter duration than nonusers [n = 2570; 3.3 vs. 5.1 yrs AOR: 0.92 95% confidence interval (CI): 0.89 to 0.95] and were less likely to report a regular partner (54.9% vs. 72.5% AOR: 0.52 0.39 to 0.68). PEP use was associated with gonorrhea infection (6.9% vs. 2.6% AOR: 2.37 95% CI: 1.34 to 4.21) and alcohol use (84.3% vs. 76.1% AOR: 1.58 95% CI: 1.09 to 2.31) but with increased condom use (85.1% vs. 68.2% AOR 1.80 95% CI: 1.38-2.35) and a history of prior HIV testing (89.2 vs. 76.2% AOR: 2.22 95% CI: 1.45 to 3.40). Reasons for PEP access centered on issues of client mistrust. The median time from exposure to PEP was 18 hours with an estimated adherence of 49%. Precise PEP efficacy could not be calculated but HIV incidence was 0.6% in users (2/326) compared with 2.1% (30/1417) in nonusers (Cox regression P = 0.35). CONCLUSIONS: "PEP services were accessed by 10% of FSWs during the study period and were not implicated in any incident HIV cases." Users had indicators of increased sexual risk and higher health care literacy. Increasing PEP access and compliance in FSWs may be an important HIV prevention strategy.

Mobile (cell) phone communication has been suggested as a method to improve delivery of health services. However, data on the effects of mobile health technology on patient outcomes in resource-limited settings are limited. We aimed to assess whether mobile phone communication between health-care workers and patients starting antiretroviral therapy in Kenya improved drug adherence and suppression of plasma HIV-1 RNA load.WelTel Kenya1 was a multisite randomised clinical trial of HIV-infected adults initiating antiretroviral therapy (ART) in three clinics in Kenya. Patients were randomised (1:1) by simple randomisation with a random number generating program to a mobile phone short message service (SMS) intervention or standard care. Patients in the intervention group received weekly SMS messages from a clinic nurse and were required to respond within 48 h. Randomisation, laboratory assays, and analyses were done by investigators masked to treatment allocation; however, study participants and clinic staff were not masked to treatment. Primary outcomes were self-reported ART adherence (95% of prescribed doses in the past 30 days at both 6 and 12 month follow-up visits) and plasma HIV-1 viral RNA load suppression (400 copies per mL) at 12 months. The primary analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT00830622.Between May, 2007, and October, 2008, we randomly assigned 538 participants to the SMS intervention (n=273) or to standard care (n=265). Adherence to ART was reported in 168 of 273 patients receiving the SMS intervention compared with 132 of 265 in the control group (relative risk [RR] for non-adherence 0·81, 95% CI 0·69-0·94; p=0·006). Suppressed viral loads were reported in 156 of 273 patients in the SMS group and 128 of 265 in the control group, (RR for virologic failure 0·84, 95% CI 0·71-0·99; p=0·04). The number needed to treat (NNT) to achieve greater than 95% adherence was nine (95% CI 5·0-29·5) and the NNT to achieve viral load suppression was 11 (5·8-227·3).Patients who received SMS support had significantly improved ART adherence and rates of viral suppression compared with the control individuals. Mobile phones might be effective tools to improve patient outcome in resource-limited settings.US President's Emergency Plan for AIDS Relief.

Many people newly diagnosed with HIV are lost to follow-up before timely initiation of antiretroviral therapy (ART). A randomised controlled trial (RCT), WelTel Kenya1, demonstrated the effectiveness of the WelTel text messaging intervention to improve clinical outcomes among patients initiating ART. In preparation for WelTel Retain, an RCT that will evaluate the effect of the intervention to retain patients in care immediately following HIV diagnosis, we conducted an informative qualitative study with people living with HIV (n = 15) and healthcare providers (HCP) (n = 5) in October 2012. Study objectives included exploring the experiences of people living with HIV who have attempted to engage in HIV care, the use of cell phones in everyday life, and perceptions of communicating via text message with HCP. Participants were recruited through convenience sampling. Semi-structured, qualitative interviews were conducted and recorded, transcribed verbatim and analysed using NVivo software. Analysis was guided by the Theory of Reasoned Action and the Technology Acceptance Model. Results indicate that while individuals have many motivators for engaging in care after diagnosis, structural and individual barriers including poverty, depression and fear of stigma prevent them from doing so. All participants had access to a mobile phone, and most were comfortable communicating through text messages, or were willing to learn. Both people living with HIV and HCP felt that increased communication via the text messaging intervention has the potential to enable early identification of problems, leading to timely problem solving that may improve retention and engagement in care during the first year after diagnosis.Keywords: engagement in care, HIV, mobile health, sub-Saharan Africa

Background: With a dramatic increase in mobile phone use in low- and middle-income countries, mobile health (mHealth) has great potential to connect health care services directly to participants enrolled and improve engagement of care. Rural and remote global settings may pose both significant challenges and opportunities. Objective: The objective of our study was to understand the demographics, phone usage and ownership characteristics, and feasibility among patients in rural and remote areas of Kenya of having text messaging (short messaging service, SMS)-based mHealth intervention for improvements in antenatal care attendance and routine immunization among children in Northern Kenya. Methods: A survey-based descriptive study was conducted between October 2014 and February 2015 at 8 health facilities in Northern Kenya as part of a program to scale up an mHealth service in rural and remote regions. The study was conducted at 6 government health facilities in Isiolo, Marsabit, and Samburu counties in remote and northern arid lands (NAL). Two less remote health facilities in Laikipia and Meru counties in more populated central highlands were included as comparison sites. Results: A total of 284 participants were surveyed; 63.4% (180/284) were from NAL clinics, whereas 36.6% (104/284) were from adjacent central highland clinics. In the NAL, almost half (48.8%, 88/180) reported no formal education and 24.4% (44/180) self-identified as nomads. The majority of participants from both regions had access to mobile phone: 99.0% (103/104) of participants from central highlands and 82.1% (147/180) of participants from NAL. Among those who had access to a phone, there were significant differences in network challenges and technology literacy between the 2 regions. However, there was no significant difference in the proportion of participants from NAL and central highlands who indicated that they would like to receive a weekly SMS text message from their health care provider (90.0% vs 95.0%; P=.52). Overall, 92.0% (230/250) of participants who had access to a telephone said that they would like to receive a weekly SMS text message from their health care provider. Most phone users already spent the equivalent of 626 SMS text messages on mobile credit for personal use. Conclusions: Despite the remoteness of northern Kenya’s NAL, the results indicate that the majority of pregnant women or care givers attending the maternal, newborn, and child health clinics have access to mobile phone and would like to receive text messages from their health care provider. mHealth programs, if designed appropriately for these settings, may be an innovative way for engaging women in care for improved maternal and newborn child health outcomes in order to achieve sustainable development goals. [JMIR Public Health Surveill 2017;3(1):e5]

Introduction Interventions to improve retention in care after HIV diagnosis are necessary to optimise the timely initiation of antiretroviral therapy (ART) and HIV/AIDS control outcomes. Widespread mobile phone use presents new opportunities to engage patients in care. A randomised controlled trial (RCT), WelTel Kenya1, demonstrated that weekly text messages led to improved ART adherence and viral load suppression among those initiating ART. The aim of this study was to determine whether the WelTel intervention is an effective and cost-effective method of improving retention in care in the first year of care following HIV diagnosis. Methods and analysis WelTel Retain is an open, parallel group RCT that will be conducted at the Kibera Community Health Centre in Nairobi, Kenya. Over a 1-year period, we aim to recruit 686 individuals newly diagnosed with HIV who will be randomly allocated to an intervention or control arm (standard care) at a 1:1 ratio. Intervention arm participants will receive the weekly WelTel SMS ‘check-in’ to which they will be instructed to respond within 48 h. An HIV clinician will follow-up and triage any problems that are identified. Participants will be followed for 1 year, with a primary endpoint of retention in care at 12 months. Secondary outcomes include retention in stage 1 HIV care (patients return to the clinic to receive their first CD4 results) and timely ART initiation. Cost-effectiveness will be analysed through decision-analytic modelling. Ethics and dissemination Ethical approval has been obtained from the University of British Columbia and the African Medical and Research Foundation. This trial will test the effectiveness and cost-effectiveness of the WelTel intervention to engage patients during the first year of HIV care. Trial results and economic evaluation will help inform policy and practice on the use of WelTel in the early stages of HIV care. Trial registration ClinicalTrials.gov NCT01630304.

Background: The WelTel Kenya1 trial demonstrated that text message support improved adherence to antiretroviral therapy (ART) and suppression of HIV-1 RNA load. The intervention involved sending weekly messages to patients inquiring how they were doing; participants were required to respond either that they were well or that there was a problem. Objectives: 1) Describe problems participants identified through mobile phone support and reasons why participants did not respond to the messages; 2) investigate factors associated with indicating a problem and not responding; and 3) examine participant perceptions of the intervention. Design: Secondary analysis of WelTel Kenya1 trial data. Methods: Reasons participants indicated a problem or did not respond were extracted from the study log. Negative binomial regression was used to determine participant characteristics associated with indicating a problem and nonresponse. Data from follow-up questionnaires were used to describe participant perceptions of the intervention. Results: Between 2007 and 2009 271 participants generated 11873 responses; 377 of which indicated a problem. Health issues were the primary reason for problem responses (72%). Rural residence (adjusted incidence rate ratio [IRR] 1.96; 95%CI 1.19-3.25; p = 0.009 and age were associated with indicating a problem (adjusted IRR 0.63 per increase in age group category; 95%CI 0.50-0.80; p

Background: The objectives are to compare the effectiveness of cell phone-supported SMS messaging to standard care on adherence, quality of life, retention, and mortality in a population receiving antiretroviral therapy (ART) in Nairobi, Kenya. Methods and Design: A multi-site randomized controlled open-label trial. A central randomization centre provided opaque envelopes to allocate treatments. Patients initiating ART at three comprehensive care clinics in Kenya will be randomized to receive either a structured weekly SMS ('short message system' or text message) slogan (the intervention) or current standard of care support mechanisms alone (the control). Our hypothesis is that using a structured mobile phone protocol to keep in touch with patients will improve adherence to ART and other patient outcomes. Participants are evaluated at baseline, and then at six and twelve months after initiating ART. The care providers keep a weekly study log of all phone based communications with study participants. Primary outcomes are self-reported adherence to ART and suppression of HIV viral load at twelve months scheduled follow-up. Secondary outcomes are improvements in health, quality of life, social and economic factors, and retention on ART. Primary analysis is by 'intention-to-treat'. Sensitivity analysis will be used to assess per-protocol effects. Analysis of covariates will be undertaken to determine factors that contribute or deter from expected and determined outcomes. Discussion: This study protocol tests whether a novel structured mobile phone intervention can positively contribute to ART management in a resource-limited setting. Trial Registration: Trial Registration Number: NCT00830622

The Leading Edge in the August 2008 issue questioned "Does HIV/AIDS still require an exceptional response" in relation to the potential imbalance of global health-care resources? In the midst of the unchecked and deadly pandemic the answer is yes; especially if local resources are used and management of other endemic health problems can also benefit. Perhaps one of the most promising emerging health systems tools which can build capacity around the HIV/AIDS response and filter into the global health response lies increasingly in the palms of our hands. Mobile telephones are reaching people in Africas cities towns villages and countrysides more rapidly than anywhere else in the world (figure 1). The overlap with the global health-care crisis does not go unnoticed. We previously reported that despite very low incomes most clients attending two University of Nairobi clinics (serving sex workers and providing HIV services for the general population in Pumwani district) had access to mobile phones and knew how to use them. Surprisingly mobile phone communication featured in most aspects of patients personal lives and business but not their health management. (excerpt)