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Involving both partners of a couple in HIV prevention can improve maternal and child health outcomes in sub-Saharan Africa. Using data from 96 couples, we explored the actor and partner effects of perceived relationship dynamics on a couple's confidence and ability to reduce HIV risk together. Perceived relationship quality altered perceived confidence and ability to reduce HIV threat. One's own ability to confidently act together with their spouse appeared to be stronger for husbands than wives with respect to relationship commitment. A partner's confidence to communicate with their spouse about HIV risk reduction appeared to be stronger from husbands to wives for relationship satisfaction and trust. Gender differences in perceived relationship quality and effects on communal coping may exist and requires further study for applicability in intervention development in this setting. Efficacious couple-oriented interventions for HIV prevention should incorporate evidence on how partners mutually influence each other's health beliefs and behaviors.

Purpose: Early cervical cancer screening (CCS) and treatment is effective method of controlling the disease, however its uptake is poor. Women only screen for cervical cancer when they experience symptoms or when advised by healthcare workers. Main objective of the study was to assess knowledge, attitude and practices of cervical cancer screening among women in Kakamega County. Methodology: The target population was 208,905 women of reproductive age residing in Kakamega County. This was a quantitative research approach utilizing descriptive study design. An interviewer administered questionnaire was used to collect data. Multi-stage sampling was used to select 872 women aged 25-49 from 16 community units of Kakamega County. Participants were assured of confidentiality, voluntary participation and freedom to exit the study at any point. Descriptive statistics were used to analyze knowledge and attitude levels towards cervical cancer screening. Logistic regression along with odds ratios at 95% confidence intervals was used to analyze factors affecting uptake of screening. Findings: Majority (81%) of participants had heard of cervical cancer screening mainly from media and Health Care workers. Only 16 % and 13% had good knowledge about signs of and risk factors of cervical cancer respectively. More than 78% had positive attitude towards cervical cancer screening. Less than 22% of participants had been screened for cervical cancer previously. Uptake of cervical cancer screening was low, and there was poor knowledge on aspects of cervical cancer. Poor to average knowledge is not sufficient to enable women make decisive actions on CCS. Unique Contribution to Theory, Practice and Policy: Women should be encouraged to seek for more information about CCS through the various sources of media available to them. Healthcare providers need to be empowered further on delivering key information about CCS. The Ministry of Health should consider and strengthen alternative sources of information on CCS by use of Community Health Volunteers to complement health care providers. The government should further initiate a monitoring and evaluation program to track trends of factors barring uptake of CCS. A qualitative research need to be conducted to establish deeper factors associated with poor knowledge and uptake of CCS despite positive attitude.

Main objective was to describehealth facility and human resource related factors supporting uptake of cervical cancer screening in Kakamega County.Design; descriptive cross-sectional study adopting quantitative methods. Setting; Kakamega County within 16 community units in 8 sub counties.Sampling;multistage sampling was used to sample 48 community health volunteers and 16 health facilities.Interviewer administered questionnaire was used to collect data from Community Health Volunteers and the heads of link health facilities.Validity and reliability of questionnaire was ensured through expert review.Analysiswasby use of descriptive statistics. Results;Majority of participants were female (91.7%) aged between 30-50 years (75%), with primary level of education(47%) and had worked for more than five years as Community Health Volunteers (60%). More than 95% ofCommunity Health Volunteers visited clients’ homeson monthly schedule(77%).Regarding cervical cancer screening,60% of Community Health Volunteers agreed that they were involved in referring women for cervical cancer screening.Almost all(92%)of Community Health Volunteers had not been trained on aspects of cervical cancer screening. Further, 94% of Community Health Volunteers confirmed that cervical cancer screening was part of the health education package they discuss with women. Approximately 81% of health facilities were health centers and offeredcervical cancer screening services weekly (75%).Conclusion;Health facilities offer cervical cancer screening adequately. Community Health Volunteers have established network to reach women but lack capacity to sensitize women on cervical cancer screening. Recommendation: Community Health Volunteersshould be empowered to mobilize women for cervical cancer screening.

Mobility is linked to negative HIV care continuum outcomes. We sought to understand factors associated with short and long term mobility among women in fishing communities in Kenya, Tanzania, and Uganda. From 2018 through 2019 we conducted a cross-sectional survey of women aged 15 years and above, randomly selected from a census of six fishing villages, around Lake Victoria. Data collected included: demographics, risky sexual behaviour on the most recent trip, and travel behaviour in the previous 4 months. Mobility was recorded as any overnight trip outside the participant's village. A two-level multinomial logistic regression model was used to determine the associated factors. A total of 901 participants were enrolled, of whom 645 (71.6%) reported travelling (53.4%; short and 18.2% long term trips). Five factors were associated with long term travel: age, travel purpose, frequency of travel, sexual behaviour while travelling, and destination. Trips made by women aged 46-75 years were less likely to be long term. Long term trips were more common if the trip was to visit, rather than to trade, and more common for women who reported one or two trips rather than three or more trips. Women who made long term trips were more likely to engage in unprotected sex while on a trip. Women who travelled to a regional town/district or another town/district were more likely to take long term trips. The factors associated with travel duration among women living in fishing communities could inform planning of future health care interventions in these communities.

Background: Women in Africa face disproportionate risk of human immunodeficiency virus (HIV) acquisition, accounting for more than half of new infections in Africa and similarly face a disproportionate burden of sexually transmitted infections (STIs). Very high STI prevalence is being observed globally, especially among people taking pre-exposure prophylaxis (PrEP) for HIV prevention. Doxycycline post-exposure prophylaxis (dPEP) has been proposed as an STI prevention strategy to reduce chlamydia, syphilis, and possibly gonorrhea, and trials are ongoing among cisgender men who have sex with men (MSM) and transgender women who are taking PrEP in high-income settings. We designed and describe here the first open label trial to determine the effectiveness of dPEP to reduce STI incidence among cisgender women.Methods: We are conducting an open-label 1:1 randomized trial of dPEP versus standard of care (STI screening and treatment and risk-reduction counselling without dPEP) among 446 Kenyan women aged ³18 and £30 years old women taking PrEP. Women are followed for 12 months, with quarterly STI testing, treatment, and adherence counselling. The primary trial outcome will be the combined incidence of Chlamydia trachomatis, Neisseria gonorrhoeae, and Treponema pallidum, compared between the randomized groups. We will also assess dPEP acceptability, tolerability, safety, impact on sexual behavior, adherence, and occurrence of antimicrobial resistance (AMR) in N. gonorrhoeae and C. trachomatis isolates. Finally, we will estimate cost per incident STI case and complications averted accounting for nonadherence and benefits relative AMR or side effects.Discussion: The results of this trial may have immediate implications for the global epidemic of STIs and sexual health. If effective, dPEP could put STI prevention into women’s hands. While dPEP may be able to prevent STIs, it carries important risks that could counter its benefits; global debate about the balance of these potential risks and benefits requires data to inform policy and implementation and our study aims to fill this gap.Trial registration: https://clinicaltrials.gov/ct2/show/NCT04050540

As countries scale up pre-exposure prophylaxis (PrEP) for HIV prevention, diverse PrEP delivery models are needed to expand access to populations at HIV risk that are unwilling or unable to access clinic-based PrEP care. To identify factors that may influence implementation of retail pharmacy-based PrEP delivery in Kenya, we conducted in-depth interviews with 40 pharmacy clients, 16 pharmacy providers, 16 PrEP clients, and 10 PrEP providers from two provinces. Most participants expressed strong support for expanding PrEP to retail pharmacies, though conditioned their acceptance on assurances that care would be private, respectful, safe, and affordable. Participant-reported determinants of feasibility centered primarily on ensuring that the intervention is compatible with retail pharmacy operations (e.g., staffing levels, documentation requirements). Future research is needed to develop and test tailored packages of implementation strategies that are most effective at integrating PrEP delivery into routine pharmacy practice in Kenya and other high HIV prevalence settings.Ya que varios países están ampliando sus programas de profilaxis previa a la exposición al VIH (PrEP, por sus siglas en inglés), se necesitan modelos diversos para ampliar el acceso a poblaciones que no están dispuestos a acceder, o que no pueden acceder, a los servicios de PrEP que se ofrecen en las instalaciones de salud. Para identificar los factores que pueden influir en la prestación de servicios de PrEP a través de farmacias privadas, realizamos entrevistas en profundidad con 40 clientes de farmacia, 16 proveedores de servicios de farmacia, 16 usuarios de PrEP, y 10 proveedores de PrEP. La mayoría de los participantes manifestó su firme apoyo a la propuesta de expandir la provisión de PrEP a las farmacias privadas, aunque condicionó su aceptación a la garantía de que la atención sea privada, respetuosa, segura, y asequible. Según los participantes, los factores determinantes de la viabilidad de ofrecer PrEP en las farmacias privadas se centran en asegurar de que la intervención sea compatible con las operaciones de las farmacias privadas (p. ej., el número de personal, los requisitos de documentación). Se necesitan investigaciones adicionales para desarrollar y evaluar diferentes paquetes de estrategias de implementación para descubrir cuáles son los más eficaces para integrar los servicios de PrEP en la prestación rutinaria de servicios de farmacia tanto en Kenia como en otros lugares de alta prevalencia del VIH.

We estimated effects of maternal depressive symptoms, utilizing the Patient Health Questionnaire-8 (PHQ-8), on women’s HIV prevention behaviors in Migori County, Kenya. Pregnant women ≥ 18 years old, with gestational age of

INTRODUCTION Repeat HIV testing among pregnant and postpartum women enables incident HIV infection identification for targeted interventions. We evaluated oral HIV self-testing (HIVST) for repeat HIV testing among pregnant and postpartum women attending busy public clinics in East Africa. METHODS Between October 2018 and January 2019, we conducted a pilot mixed methods study to evaluate the acceptability of oral-based HIVST among pregnant and postpartum women within 3 public health facilities in Kisumu County, Kenya. We invited 400 seronegative pregnant and postpartum women to choose between clinic-based oral HIVST and the standard finger prick provider-initiated testing and counseling for repeat HIV testing. We measured the frequency of each choice and described the participants' experiences with the choices, including data from 3 focus group discussions. RESULTS Slightly over half of the women [53.8%, 95% confidence interval (CI): 48.7 to 58.7] chose oral HIVST. Unmarried women were more likely to use HIVST (prevalence ratio: 1.26, 95% CI: 1.01 to 1.57, P < 0.05). The most frequent reason for oral HIVST selection was the fear of the needle prick (101/215, 47.0%). More HIVST than provider-initiated testing and counseling users indicated lack of pain (99.1% vs 34.6%, P < 0.001) and the need for assistance (18.1% vs 1.1%, P < 0.001) as reflective of their HIV testing experiences. Participants choosing HIVST cited privacy, ease, and speed of the procedure as the main reasons for their preference. CONCLUSIONS The use of HIVST in Kenyan antenatal and postpartum settings seems to be feasible and acceptable for repeat HIV testing. Future work should explore the practical mechanisms for implementing such a strategy.

To develop a patient-centred financial incentive delivery strategy to improve antiretroviral treatment adherence in adolescents and young adults (AYA) living with HIV in Kisumu, Kenya, we conducted a mixed methods study exploring preferences.A discrete choice experiment (DCE) and focus group discussion (FGD) were conducted simultaneously to identify preferences for five incentive delivery strategy features: value, eligibility, recipient, format and disbursement frequency. We used consecutive sampling to recruit AYA (14-24 years) living with HIV attending three health facilities in Kisumu, Kenya. We calculated mean preferences, willingness to trade, latent class membership and predictors of latent class membership. The FGD explored preferred incentive features, and, after deductive and inductive coding, qualitative findings were triangulated with DCE results.Two hundred and seven AYA living with HIV (46% 14-17 years, 54% 18-24 years; 33% male sex, 89% viral load50 copies/ml) were recruited to the study (28 October-16 November 2020). Two distinct preference phenotypes emerged from the DCE analysis (N = 199), 44.8% of the population fell into an "immediate reward" group, who wanted higher value cash or mobile money distributed at each clinic visit, and 55.2% fell into a "moderate spender" group, who were willing to accept lower value incentives in the form of cash or shopping vouchers, and accrued payments. The immediate reward group were willing to trade up to 200 Kenyan Shillings (KSH)-approximately 2 US dollars (USD)-of their 500 KSH (∼5 USD) incentive to get monthly as opposed to accrued yearly payments. The strongest predictor of latent class membership was age (RR 1.45; 95% CI: 1.08-1.95; p = 0.006). Qualitative data highlighted the unique needs of those attending boarding school and confirmed an overwhelming preference for cash incentives which appeared to provide the greatest versatility for use.Providing small financial incentives as cash was well-aligned with AYA preferences in this setting. AYA should additionally be offered a choice of other incentive delivery features (such as mobile money, recipient and disbursement frequency) to optimally align with the specific needs of their age group and life stage.

Despite the need, adolescents and young adults (AYAs) in resource-limited settings have limited access to sexual and reproductive health (SRH) care services for improved health outcomes. This is worse for AYAs living with HIV in resource-limited settings where much is unknown about contexts and issues inhibiting access to SRHs. We explored adolescents’, healthcare workers, and caregivers’ preferences for access to sexual and reproductive health services for adolescents and young adults living with HIV. We conducted 30 in-depth interviews and 8 focus group discussions among a subset of AYA aged 14–24 living with HIV, healthcare workers, and caregivers/parents. We recruited participants from Lumumba Sub-County Hospital (KLM) and Kisumu County Referral Hospitals in Kisumu County (KCH). Trained and experienced qualitative research assistants 5–10 years older than the adolescents conducted interviews and facilitated discussions using guides designed to elicit detailed views and perspectives on sex and sexuality, access to SRH services, challenges of AYA living with HIV, and potential interventions to improve access to SRH services. Audio files were transcribed verbatim and translated to English where necessary before coding and analysis. We applied constant comparative analysis for theme and content to arrive at our conclusions. Our analysis yielded two main themes: preferences for a venue for SRH services and choices for qualities of an SRH counsellor. We found that AYAs generally preferred receiving SRH services to be co-situated within clinical facilities. We also observed gender differences in the qualities of SRH providers, with male AYAs preferring older male service providers compared to females who preferred younger female providers close to their age. The study highlighted the preferences of AYAs for accessing SRH, which need to be considered when designing their health programs. Further, AYAs seem to endite health systems to individualize access to SRH for AYAs living with HIV by providing a combination of attributes that meet individual preferences.

Introduction Adolescents living with HIV (ALHIV, ages 10–19) experience complex challenges to adhere to antiretroviral therapy (ART) and remain in care, and may be vulnerable to wide-scale disruptions during the COVID-19 pandemic. We assessed for a range of effects of the pandemic on ALHIV in western Kenya, and whether effects were greater for ALHIV with recent histories of being lost to program (LTP). Methods ALHIV were recruited from an ongoing prospective study at 3 sites in western Kenya. The parent study enrolled participants from February 2019–September 2020, into groups of ALHIV either 1) retained in care or 2) LTP and traced in the community. Phone interviews from July 2020–January 2021 assessed effects of the pandemic on financial and food security, healthcare access and behaviors, and mental health. Responses were compared among the parent study groups. Results Phone surveys were completed with 334 ALHIV or their caregivers, including 275/308 (89.3%) in the retained group and 59/70 (84.3%) among those LTP at initial enrollment. During the pandemic, a greater proportion of LTP adolescents were no longer engaged in school (45.8% vs. 36.4%, p = 0.017). Over a third (120, 35.9%) of adolescents reported lost income for someone they relied on. In total, 135 (40.4%) did not have enough food either some (121, 36.2%) or most (14, 4.2%) of the time. More LTP adolescents (4/59, 6.8% vs. 2/275, 0.7%, p = 0.010) reported increased difficulties refilling ART. Adolescent PHQ-2 and GAD-2 scores were ≥3 for 5.6% and 5.2%, respectively. Conclusions The COVID-19 pandemic has had devastating socioeconomic effects for Kenyan ALHIV and their households. ALHIV with recent care disengagement may be especially vulnerable. Meanwhile, sustained ART access and adherence potentially signal resilience and strengths of ALHIV and their care programs. Findings from this survey indicate the critical need for support to ALHIV during this crisis.

Introduction HIV is a leading cause of morbidity and mortality among youth in sub Saharan Africa. This study explores the adaptation of an adult social network intervention for adolescents, entitled Kanyakla. Methods The study was conducted in Kisumu, Kenya from July to November 2016. Data was collected from: (1) semi-structured interviews (n = 32) with adolescents living with HIV aged 15–19; and (2) two focus group discussions (n = 21). Transcripts were coded using thematic analysis through the lens of an Adolescent Development Model. Results Participants were interested in joining a Kanyakla to build social support, learn new skills, and partake in recreational activities. Many participants feared inadvertent disclosure related to stigma. Certain dichotomous themes emerged including the need for privacy versus the need for social support; and the desire for inclusion of elders versus preference for same-aged peers in the Kanyaklas. Conclusions With this study, we have key information that can be applied to developing the Kanyakla intervention for adolescents. Further study is needed to reconcile the dichotomies that emerged.

Background HIV-related maternal deaths and HIV infection among infants remain unacceptably high across sub-Saharan Africa despite increased antenatal care attendance and provision of antiretroviral therapy to pregnant women. In the Jamii Bora (“Better Family” in Swahili) Study, we seek to test the efficacy of an interdependence theory-based couple intervention. The intervention reaches pregnant women and male partners through home visits by male-female pairs of lay health workers. The aim is to increase access to home-based couples’ HIV testing and counseling services to improve family health. Methods This is a three-arm randomized control trial among 1080 pregnant women 15 years of age or older, living with their male partners, and who have not undergone couples’ HIV testing and counseling in Kisumu and Migori Counties in Kenya. Couples will be randomized into three groups: home-based couple visits, HIV self-testing kits for couple use, or standard care (male partner clinic invitation letters). Participants will be followed up to 18 months postpartum. The study has three aims: in aim 1, we will determine the effects of the intervention on our primary outcome of couple HIV testing, compared to HIV self-testing kits and standard care; in aim 2, we will examine the intervention impact on HIV prevention behaviors, facility delivery, and postnatal healthcare utilization, as well as secondary health outcomes of maternal viral suppression and HIV-free child survival up to 18 months for couples living with HIV; and in aim 3, we will compare the cost-effectiveness of the home-based couple intervention to the less resource-intensive strategies used in the other two study arms. Assessments with couples are conducted at baseline, late pregnancy, and at months 3, 6, 12, and 18 after birth. Discussion The results from this study will inform decision-makers about the cost-effective strategies to engage pregnant couples in the prevention of mother-to-child transmission and family health, with important downstream benefits for maternal, paternal, and infant health. Trial registration ClinicalTrials.gov NCT03547739. Registered on May 9, 2018

Pregnancy is a time of heightened HIV risk, but also a phase when a couple can prioritize family health. We conducted secondary analysis of a home-based intervention in rural Kenya to explore couple-level adherence to HIV prevention behaviors. The intervention included health education, relationship-building skills, and Couples HIV Testing and Counseling. Pregnant women were randomized to the intervention (n = 64) or standard care (n = 63) along with male partners. Of 96 couples, 82 (85.0%) were followed to 3 months postpartum, when 31.0% of couples reported perfect adherence to HIV prevention. In logistic regression, intervention condition couples had three-fold higher odds of perfect adherence (AOR = 3.07, 95% CI = 1.01–9.32). A structural equation model found the intervention had moderate effects on couple communication, large effects on couple efficacy to take action around HIV, which in turn improved HIV prevention behaviors (CFI = 0.969; TLI = 0.955; RMSEA = 0.049). Strengthening couple communication and efficacy may help prevent the spread of HIV to infants or partners around the time of pregnancy.

Background HIV-prevalence and incidence is high in many fishing communities around Lake Victoria in East Africa. In these settings, mobility among women is high and may contribute to increased risk of HIV infection and poor access to effective prevention and treatment services. Understanding the nature and patterns of this mobility is important for the design of interventions. We conducted an exploratory study to understand the nature and patterns of women’s mobility to inform the design of HIV intervention trials in fishing communities of Lake Victoria. Methods This was a cross-sectional formative qualitative study conducted in six purposively selected fishing communities in Kenya, Tanzania and Uganda. Potential participants were screened for eligibility on age (18+ years) and having stayed in the fishing community for more than 6 months. We collected data using introductory and focus group discussions, and in-depth interviews with key informants. Data focused on: history and patterns of mobility, migration in and out of fishing communities and the relationship between mobility and HIV infection. Since the interviews and discussions were not audio-recorded, detailed notes were taken and written up into full scripts for analysis. We conducted a thematic analysis using constant comparison analysis. Results Participants reported that women in fishing communities were highly mobile for work-related activities. Overall, we categorized mobility as travels over long and short distances or periods depending on the kind of livelihood activity women were involved in. Participants reported that women often travelled to new places, away from familiar contacts and far from healthcare access. Some women were reported to engage in high risk sexual behaviour and disengaging from HIV care. However, participants reported that women often returned to the fishing communities they considered home, or followed a seasonal pattern of work, which would facilitate contact with service providers. Conclusion Women exhibited circular and seasonal mobility patterns over varying distances and duration away from their home communities. These mobility patterns may limit women’s access to trial/health services and put them at risk of HIV-infection. Interventions should be tailored to take into account mobility patterns of seasonal work observed in this study.

Engaging both partners of a pregnant couple can enhance prevention of mother-to-child transmission of HIV and promote family health. We developed and piloted an intervention to promote couple collaboration in health during pregnancy and postpartum in southwestern Kenya. We utilized formative data and stakeholder input to inform development of a home-based couples intervention. Next, we randomized pregnant women to intervention (n = 64) or standard care (n = 63) arms, subsequently contacting their male partners for enrollment. In the intervention arm, lay health workers conducted couple home visits, including health education, couple relationship and communication skills, and offers of couple HIV testing and counseling (CHTC) services. Follow-up questionnaires were conducted 3 months postpartum (n = 114 women, 86 men). Baseline characteristics and health behaviors were examined by study arm using t-tests, chi-square tests, and regression analyses. Of the 127 women randomized, 96 of their partners participated in the study. Of 52 enrolled couples in the intervention arm, 94% completed at least one couple home visit. Over 93% of participants receiving couple home visits were satisfied and no adverse social consequences were reported. At follow-up, intervention couples had a 2.78 relative risk of having participated in CHTC during the study period compared with standard care couples (95% confidence interval: 1.63–4.75), and significant associations were observed in other key perinatal health behaviors. This pilot study revealed that a home-based couples intervention for pregnant women and male partners is acceptable, feasible, and has the potential to enhance CHTC and perinatal health behaviors, leading to improved health outcomes.

Introduction To improve retention on HIV treatment in Africa, public health programs are promoting a family of innovations to service delivery—referred to as “differentiated service delivery” (DSD) models—which seek to better meet the needs of both systems and patients by reducing unnecessary encounters, expanding access, and incorporating peers and patients in patient care. Data on the relative desirability of different models to target populations, which is currently sparse, can help guide prioritization of specific models during scale-up. Methods We conducted a discrete choice experiment to assess patient preferences for various characteristics of treatment services. Clinically stable people living with HIV were recruited from an HIV clinic in Kisumu, Kenya. We selected seven attributes of DSD models drawn from literature review and previous qualitative work. We created a balanced and orthogonal design to identify main term effects. A total of ten choice tasks were solicited per respondent. We calculated relative utility (RU) for each attribute level, a numerical representation of the strength of patient preference. Data were analyzed using a Hierarchical Bayesian model via Sawtooth Software. Results One hundred and four respondents (37.5% men, 41.1 years mean age) preferred receiving care at a health facility, compared with home-delivery or a community meeting point (RU = 69.3, -16.2, and -53.1, respectively; p << 0.05); receiving those services from clinicians and pharmacists—as opposed to lay health workers or peers (RU = 21.5, 5.9, -24.5; p < 0.05); and preferred an individual support system over a group support system (RU = 15.0 and 4.2; p < 0.05). Likewise, patients strongly preferred longer intervals between both clinical reviews (RU = 40.1 and -50.7 for 6- and 1-month spacing, respectively; p < 0.05) and between ART collections (RU = 33.6 and -49.5 for 6- and1-month spacing, respectively; p < 0.05). Conclusion Although health systems find community- and peer-based DSD models attractive, clinically stable patients expressed a preference for facility-based care as long as clinical visits were extended to biannual. These data suggest that multi-month scripting and fast-track models best align with patient preferences, an insight which can help prioritize use of different DSD models in the region.

Men desire to be involved in their partner's decision-making about vaginal microbicide use. This coincides with women's desire to inform male partners about their microbicide use. Educating men about microbicides may enhance acceptability and generate critical support for the female participants of microbicide trials. In this multiphase mixed-methods study, we adapted an educational intervention on vaginal microbicides and tested it among men (n = 45) to determine its effect on men's knowledge regarding HIV/STI, vaginal microbicides and microbicide trials. We also conducted focus group discussions (FGDs) with the female partners (K = 3, n = 43) of the study participants and community representatives (K = 2, n = 24) to obtain their views on male partner microbicide education. We analysed FGD data for key themes using content analysis. HIV and vaginal microbicide knowledge scores increased significantly among men after the educational intervention. Both women and men highly supported male partner microbicide education, in the context of existing gender relations, to increase men's understanding about microbicides, promote adherence and help women gain their partners' trust. Complex gender dynamics should be considered when designing male partner educational interventions to improve acceptability and the use of microbicides and other female-initiated HIV prevention methods.

BACKGROUND: We sought to understand whether women’s empowerment and male partner engagement were associated with use of antenatal care (ANC). METHODS: Women presenting for ANC in Nyanza province of Kenya during June 2015-May 2016, were approached for participation. A total of 137 pregnant women and 96 male partners completed baseline assessments. Women’s empowerment was measured using the modified Sexual Relationship Power Scale. ANC use measures included timing of the first ANC visit and number of visits. Male engagement was based on whether a husband reported accompanying his wife to one or more antenatal visits during the pregnancy. Multiple linear and logistic regression analyses were used to identify factors independently related to use and timing of ANC. RESULTS: Women with higher mean empowerment scores were likely to have more than one ANC visit in the index pregnancy (Adjusted Odds Ratio (AOR)=2.8, 95% Confidence Interval (CI): 1.1–7.3), but empowerment was not associated with early ANC use. Women who were more empowered were less likely to have a husband who reported attending an ANC visit with his wife (AOR=0.1, 95% CI: 0.03–0.8). CONCLUSIONS: Women’s empowerment is important and may be related to ANC use and engagement of male partners in complex ways.

Male involvement in antenatal care has been shown to improve health outcomes for women and infants. However, little is known about how best to encourage male partners to support essential perinatal health activities. We explored men's perceptions of facilitators and barriers to involvement in antenatal care and HIV prevention including fears, hopes and challenges. Forty in-depth interviews were conducted with the male partners of HIV-positive and HIV-negative pregnant women in southwest Kenya. Most male partners believed engaging in pregnancy health-related activities was beneficial for keeping families healthy. However, thematic analysis revealed several obstacles that hindered participation. Poor couple relationship dynamics seemed negatively to influence male engagement. Some men were apprehensive that clinic staff might force them to test for HIV and disclose the results; if HIV-positive, men feared being labelled as 'victimisers' in situations of serodiscordancy, and described fears of abandonment by their wives. Some men avoided accompanying their wives, citing local culture as rationale for avoiding the 'effeminate' act of antenatal care attendance. Amidst these obstacles, some men chose to use their partners' HIV status as proxy for their own. Findings suggest that improving male engagement in essential maternal and child health-related activities will require addressing both structural and interpersonal barriers.

Background The role of migration in the spread of HIV in sub-Saharan Africa is well-documented. Yet migration and HIV research have often focused on HIV risks to male migrants and their partners, or migrants overall, often failing to measure the risks to women via their direct involvement in migration. Inconsistent measures of mobility, gender biases in those measures, and limited data sources for sex-specific population-based estimates of mobility have contributed to a paucity of research on the HIV prevention and care needs of migrant and highly mobile women. This study addresses an urgent need for novel methods for developing probability-based, systematic samples of highly mobile women, focusing on a population of female traders operating out of one of the largest open air markets in East Africa. Our method involves three stages: 1.) identification and mapping of all market stall locations using Global Positioning System (GPS) coordinates; 2.) using female market vendor stall GPS coordinates to build the sampling frame using replicates; and 3.) using maps and GPS data for recruitment of study participants. Results The location of 6,390 vendor stalls were mapped using GPS. Of these, 4,064 stalls occupied by women (63.6%) were used to draw four replicates of 128 stalls each, and a fifth replicate of 15 pre-selected random alternates for a total of 527 stalls assigned to one of five replicates. Staff visited 323 stalls from the first three replicates and from these successfully recruited 306 female vendors into the study for a participation rate of 94.7%. Mobilization strategies and involving traders association representatives in participant recruitment were critical to the study’s success. Conclusion The study’s high participation rate suggests that this geospatial sampling method holds promise for development of probability-based samples in other settings that serve as transport hubs for highly mobile populations.

Author(s): Rogers, Anna J; Akama, Eliud; Weke, Elly; Blackburn, Justin; Owino, George; Bukusi, Elizabeth A; Oyaro, Patrick; Kwena, Zachary A; Cohen, Craig R; Turan, Janet M | Abstract: IntroductionRepeat HIV testing during the late antenatal period is crucial to identify and initiate treatment for pregnant women with incident HIV infection to prevent perinatal HIV transmission and keep mothers alive. In 2012, the Kenya Ministry of Health adopted international guidelines suggesting that pregnant women be offered retesting three months after an initial negative HIV test. Our objectives were to determine the current rate of antenatal repeat HIV testing; identify successes, missed opportunities and factors associated with retesting; and estimate the incidence of HIV during pregnancy.MethodsRetrospective analysis of longitudinal data was conducted for a cohort of 2145 women attending antenatal care clinic at a large district hospital in southwestern Kenya. Data were abstracted from registers for all women who attended the clinic from the years 2011 to 2014.ResultsAlthough 90.2% of women first came to clinic prior to their third trimester and 27.5% had at least four clinic visits, 58.0% of all women went to delivery without a retest. Missed opportunities for retesting included not returning to clinic at all, not returning when eligible, or late gestational age (g28 weeks) at first clinic visit making them ineligible for retesting (accounting for 14.2%, 26.8% and 9.6% of all clinic attendees respectively); and failure to be retested even when eligible at one or more visits (accounting for 73.2% of eligible returnees). Being unmarried and aged 20 or younger was associated with an increase in mean gestational age of first visit by 2.52 weeks (95% CI: 1.56, 3.48) and a 2.59 increased odds (95% CI: 1.90, 3.54) of failing to return to clinic, compared to those who were married and over 20 years of age. On retest, two women tested HIV positive, suggesting an incidence rate of 4.4 per 100 person-years. After adjusting for potential confounders, only later year of last menstrual period (2013 vs. 2012 and 2011) was associated with retesting.ConclusionsAdoption of retesting guidelines in 2012 appears to have successfully increased retesting rates, but missed opportunities to identify incident HIV infection during pregnancy may contribute to continuing high rates of perinatal HIV transmission in southwestern Kenya.

IntroductionMultimorbidity, coexistence of two or more chronic conditions, is becoming more common across different demographic groups in sub-Saharan Africa. We investigate the nature and prevalence of multimorbidity in fishing communities on Lake Victoria in Kenya.MethodsWe conducted a cross-sectional survey enrolling 679’participants in the fishing communities to establish the’prevalence of HIV and non-communicable diseases (NCDs)’and associated risk factors. The NCDs targeted included diabetes mellitus detected by random blood glucose (RBG) and kidney dysfuction detected by serum creatinine level and proteniuria. Hypertension was defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg. Diabetes mellitus was defined as RBG >7.8 mmol/L and renal dysfunction was defined as estimated glomerular filtration rate (eGFR) ResultsOverall, HIV prevalence was 36% while 15%, 12% and 8% of the participants were suspected to have kidney dysfuction, hypertension and diabetes mellitus, respectively. Overall, 12% of the participants had multimorbidity. The most common multimorbidity among those with any of the four chronic conditions was HIV and kidney dysfunction (29%), followed by hypertension and kidney dysfuction (22%), HIV and hypertension (20%), HIV and diabetes (18%), diabetes and kidney disease (6%) and, lastly, diabetes and hypertension (5%). Apart from HIV, we observed no statistically significant gender differences for any of the NCDs or various multimorbidity conditions.ConclusionThese fishing communities have a high burden of both HIV and NCDs resulting in high prevalence of different multimorbidities.

In Nyanza Province, Kenya, HIV incidence is highest (26.2%) in the beach communities along Lake Victoria. Prior research documented high mobility and HIV risks among fishermen; mobility patterns and HIV risks faced by women in fishing communities are less well researched. This study aimed to characterize forms of mobility among women in the fish trade in Nyanza; describe the spatial and social features of beaches; and assess characteristics of the “sex-for-fish” economy and its implications for HIV prevention. We used qualitative methods, including participant observation in 6 beach villages and other key destinations in the Kisumu area of Nyanza that attract female migrants, and we recruited individuals for in-depth semi-structured interviews at those destinations. We interviewed 40 women, of whom 18 were fish traders, and 15 men, of whom 7 were fishermen. Data were analyzed using Atlas.ti software. We found that female fish traders are often migrants to beaches; they are also highly mobile. They are at high risk of HIV acquisition and transmission via their exchange of sex for fish with jaboya fishermen.

Despite the recognized need for structural HIV prevention interventions, few scientific programs have integrated women's property and inheritance rights with HIV prevention and treatment. The current study focused on a community-led land and property rights intervention that was implemented in two rural areas of Western Kenya with high HIV prevalence rates (24-30%). The program was designed to respond to women's property rights violations in order to reduce HIV risk at the local level. Through in-depth interviews with twenty program leaders, we identified several facilitators to program implementation, including the leadership of home-based HIV caregivers and involvement of traditional leaders in mediating property rights disputes. We also identified the voluntary basis of the intervention and its lack of integration with the formal justice system as implementation barriers. Our findings can guide future research and design of structural HIV prevention strategies that integrate women's economic empowerment through property and inheritance rights.

In sub-Saharan Africa, high burdens of HIV and unmet need for contraception often coexist. Research emphasises the need to engage men and couples in reproductive health, yet couples’ negotiations around fertility and family planning in the context of HIV have been sparsely studied. This study examined the gendered power dynamics that frame women’s and couples’ negotiations of contraceptive use in western Kenya. We conducted 76 in-depth interviews with 38 couples, of whom 22 couples were concordant HIV-positive. Qualitative data were analysed using a grounded theory approach. Direct communication around contraception with men was often challenging due to perceived or expressed male resistance. A substantial minority of women avoided male reproductive decision-making authority through covert contraceptive use, with concern for severe consequences when contraceptive use was discovered. Many men assumed that family planning use signified female promiscuity and that infidelity motivated covert use. Men were more willing to use condoms to avoid HIV re-infection or at the recommendation of HIV care providers, which allowed some women leverage to insist on condom use. Our findings highlight the tension between male-dominated reproductive decision-making and women’s agency and point to the need for gender transformative approaches seeking to challenge masculinities that negatively impact health.

Despite innovations in HIV counseling and testing (HCT), important gaps remain in understanding linkage to care. We followed a cohort diagnosed with HIV through a community-based HCT campaign that trained persons living with HIV/AIDS (PLHA) as navigators. Individual, interpersonal, and institutional predictors of linkage were assessed using survival analysis of self-reported time to enrollment. Of 483 persons consenting to follow-up, 305 (63.2%) enrolled in HIV care within 3 months. Proportions linking to care were similar across sexes, barring a sub-sample of men aged 18–25 years who were highly unlikely to enroll. Men were more likely to enroll if they had disclosed to their spouse, and women if they had disclosed to family. Women who anticipated violence or relationship breakup were less likely to link to care. Enrolment rates were significantly higher among participants receiving a PLHA visit, suggesting that a navigator approach may improve linkage from community-based HCT campaigns. Vestergaard Frandsen

Attitudes and beliefs about antiretroviral therapy (ART) may affect sexual risk behaviors among the general population in sub-Saharan Africa. We performed a cross-sectional population-based study in Kisumu, Kenya to test this hypothesis in October 2006. A total of 1655 participants were interviewed regarding attitudes and beliefs about ART and their sexual risk behaviors. The majority of participants, (71%) men and (70%) women, had heard of ART. Of these, 20% of men and 29% of women believed ART cures HIV. Among women, an attitude that “HIV is more controllable now that ART is available” was associated with sex with a non-spousal partner, increased lifetime number of sexual partners as well as a younger age at sexual debut. No significant associations with this factor were found among men. The belief that “ART cures HIV” was associated with younger age of sexual debut among women. The same belief was associated with an increased likelihood of exchanging sex for money/gifts and decreased likelihood of condom use at last sex among men. These findings were most significant for people aged 15–29 years. In high HIV seroprevalence populations with expanding access to ART, prevention programs must ensure their content counteracts misconceptions of ART in order to reduce high risk sexual behaviors, especially among youth.

Research on hygiene has been relatively limited in the current era of rigorous observational studies and clinical trials. We set out to investigate the perception and practices of genital hygiene among fishermen working on the beaches along Lake Victoria, targeted for a topical male microbicide hygiene intervention. We conducted 12 focus group discussions involving fishermen ( n = 130), recording the discussions in Dholuo (the local language) and transcribing them verbatim before translating into English. Transcripts were double-coded and analysed using constant comparative analysis. Despite easy access to lake water and recognition of a link that may exist between poor genital hygiene and the risk of penile infection and poor sexual relationships, few fishermen regularly washed their genitalia due to fear/embarrassment from cleaning their genitalia in public, traditional Luo beliefs such as that washing with soap would reduce the fish catch, lack of time because of their busy schedules, laziness and lack of responsibility, and excessive consumption of alcohol and illicit drugs. Hygiene practices of the fishermen were poor and could contribute to genital infections including sexually transmitted infections. Given the fishermen's poor genital hygiene practices, they may benefit from hygiene intervention, including that provided by penile microbicides, which can be applied in the privacy of their bedrooms.

Background Repeat HIV testing in late pregnancy has the potential to decrease rates of mother-to-child transmission of HIV by identifying mothers who seroconvert after having tested negative for HIV in early pregnancy. Despite being national policy in Kenya, the available data suggest that implementation rates are low. Methods We conducted 20 in-depth semi-structured interviews with healthcare providers and managers to explore barriers and enablers to implementation of repeat HIV testing guidelines for pregnant women. Participants were from the Nyanza region of Kenya and were purposively selected to provide variation in socio-demographics and job characteristics. Interview transcripts were coded and analyzed in Dedoose software using a thematic analysis approach. Four themes were identified a priori using Ferlie and Shortell’s Framework for Change and additional themes were allowed to emerge from the data. Results Participants identified barriers and enablers at the client, provider, facility, and health system levels. Key barriers at the client level from the perspective of providers included late initial presentation to antenatal care and low proportions of women completing the recommended four antenatal visits. Barriers to offering repeat HIV testing for providers included heavy workloads, time limitations, and failing to remember to check for retest eligibility. At the facility level, inconsistent volume of clients and lack of space required for confidential HIV retesting were cited as barriers. Finally, at the health system level, there were challenges relating to the HIV test kit supply chain and the design of nationally standardized antenatal patient registers. Enablers to improving the implementation of repeat HIV testing included client dissemination of the benefits of antenatal care through word-of-mouth, provider cooperation and task shifting, and it was suggested that use of an electronic health record system could provide automatic reminders for retest eligibility. Conclusions This study highlights some important barriers to improving HIV retesting rates among pregnant women who attend antenatal clinics in the Nyanza region of Kenya at the client, provider, facility, and health system levels. To successfully implement Kenya’s national repeat HIV testing guidelines during pregnancy, it is essential that these barriers be addressed and enablers capitalized on through a multi-faceted intervention program.

Since the discovery of HIV, the advent of anti-retrovirals in the late 80s heralded an era of medicalization of HIV and fostered major advancements in the management of the disease. Africa, despite its high HIV burden, lagged behind in the adoption of these advancements due to major resource and logistical constraints. Innovative responses such as family-centered models of care, community systems strengthening, integration of HIV care with existing health services, and economic and mobile phone- based approaches have been critical in the successful roll-out of evidence-based HIV/AIDS treatment even in the most resource- limited settings.

Extramarital partnerships exacerbate high HIV prevalence rates in many communities in sub-Saharan Africa. We explored contextual risk factors and suggested interventions to reduce extramarital partnerships among couples in the fishing communities on Lake Victoria, Kenya. We conducted 12 focus group discussions with 9–10 participants each (N = 118) and 16 in-depth interviews (N = 16) with fishermen and their spouses. Couples who participated were consented and separated for simultaneous gender-matched discussions/interviews. Interview topics included courtship and marriage, relationship and sexual satisfaction, extramarital relationships and how to intervene on HIV risks. Coding, analysis, and interpretation of the transcripts followed grounded theory tenets that allow analytical themes to emerge from the participants. Our results showed that extramarital partnerships were perceived to be widespread and were attributed to factors related to sexual satisfaction such as women needing more foreplay before intercourse, discrepancies in sexual desire, and boredom with the current sexual repertoire. Participants also reported that financial and sociophysical factors such as family financial support and physical separation, contributed to the formation of extramarital partnerships. Participants made suggestions for interventions that reduce extramarital partnerships to minimize HIV risks at the community, couple, and individual level. These suggestions emphasized improving community education, spousal communication, and self-evaluation for positive behavior change. Future studies can draw upon these findings as a basis for designing community-owned interventions that seek to reduce community-level HIV risk through a reduction in the number of sexual partners.