Hiv testing and counselling for women attending child health clinics: An opportunity for entry to prevent mother-to-child transmission and hiv treatment. Author



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Methods:

Variables for input into a simple model of HIV prevention, AVERT, were derived from a study of hot spots of transactional sex on the trans-Africa highway. Diaries were completed by a sample of sex workers at selected sites of transactional sex for a period of 28 consecutive days. Key information elicited included numbers, types and occupations of clients, numbers of liaisons, sexual acts in each liaison, and condom use. 857 diaries were distributed and 578 received and usable in 30 sites. A sexual patterning matrix was completed by 202 truckers at the Malaba border point as part of a health seeking behaviour survey. Two methods were employed to estimate female sex worker (FSW) numbers on the highway. FSW focus group discussions (FGDs) at 15 sites were carried out and included questioning on the number of sex workers at the site. As most transactional sex on the highway is centred on bars and lodgings, a patron census and survey of 1007 bars and lodgings was carried out which included questions on the presence and proportions of FSWs among the clientele.


Results:

There are an estimated 8000 FSWs on the trans-Africa highway from Mombasa to Kampala. Annual numbers of different sexual partners per FSW were 129, annual numbers of sexual acts per FSW were 634, percentage of sexual acts protected by condom use was 77.7%. Using these input data an estimated 3200-4148 new HIV infections occur on this portion of the trans-Africa highway in 1 year. Having a 90% condom use programme in place could prevent almost two thirds of these infections and cumulative incidence would decline from 1.29% to 0.42%.


Conclusions:

In generalised epidemics there has been a debate as to the place of targeted interventions. In the current east African epidemic we show that a targeted intervention could have significant impact in averting HIV infections related to the trans-Africa highway.


Sexual and treatment-seeking behaviour for sexually transmitted infection in long-distance transport workers of East Africa.
Source: Sex Transm Infect. 2007 Jun; 83(3):242-5.
Abstract: Objective:

To investigate the sexual and treatment-seeking behaviour for sexually transmitted infection (STI) in long-distance transport workers of East Africa.


Methods:

A health-seeking behaviour survey was carried out at four sites on the Mombasa-Kampala trans-Africa highway (n = 381). The questionnaires probed details of STI knowledge, symptoms and care-seeking behaviour. In one site at the Kenya-Uganda border, a sexual patterning matrix was used (n = 202) to measure sexual behaviour in truck drivers and their assistants over the 12-month period before the interview.


Results:

Over half of the sexual acts of long-distance transport workers over 12 months were with female sex workers, with an annual average of 2.8 sexual partners. Condom use was reported at 70% for liaisons with casual partners. 15% of truckers had had a self-reported STI and one-third exhibited high-risk sexual behaviour in the previous year. Of those with an STI, 85% had symptoms when on the road and 77.2% sought treatment within 1 week of onset of symptoms. 94% of drivers and 56% of assistants sought treatment for STI in a private health facility or pharmacy. The cost of private facilities and pharmacies was not significantly higher than in the public sector. Waiting times were three times longer in the public sector. Only 28.9% of patients completed their medication courses as prescribed.


Conclusions:

Truck drivers and their assistants in East Africa have high rates of reported STIs and many continue to exhibit high-risk sexual behaviour. The transport workers studied here favoured private health facilities because of convenience and shorter waiting times.



Sexual Behavior of Female Sex Workers and Access to Condoms in Kenya and Uganda on the trans-Africa Highway.
Author: Morris, C. N.; Morris, S. R., and Ferguson, A. G.
Source: AIDS Behav. 2008 Jul 30.
Abstract: Female sex workers and their clients remain a high risk core group for HIV in Africa. We measured sexual behavior of a snowball sample of female sex workers (FSW) along the Trans Africa highway from Mombasa, Kenya to Kampala, Uganda and surveyed the availability of male condoms at 1,007 bars and lodgings in Kenya along the highway trucking stops where transactional sex occurs. There were 578 FSW one month sex diaries analyzed, 403 from Kenya and 175 from Uganda. Kenyan FSW had a median of 45 sexual acts per 28 days compared to 39 sex acts per 28 days by Ugandan FSW (P < 0.05). Condom use by FSW for all sexual liaisons was 79% in Kenya compared to 74% in Uganda. In multivariate analysis, adjusting for repeated measures, Kenyan FSW were more likely to use a condom by an adjusted odds ratio of 2.54 (95% confidence interval 1.89-3.41) compared to Ugandan FSW. Condom use with regular clients was 50.8% in Uganda compared with 68.7% in Kenya (P < 0.01). The number of sex workers reporting 100% condom use was 26.8% in Kenya and 18.9% in Uganda (P < 0.01). Bars and lodges in Kenya compared to Uganda were more likely to: have condom dispensers, 25% versus 1%, respectively (P < 0.01); distribute or sell condoms, 73.9% versus 47.6% (P < 0.01); and have more weekly condom distribution, 4.92 versus 1.27 condoms per seating capacity (P < 0.01). Our data indicate that in both countries condom use for FSW is suboptimal, particularly with regular partners, and greater condom use by Trans African highway FSW in Kenya compared to Uganda may be related to availability. Targeted interventions are warranted for FSW and truck drivers to prevent transmission in this important core group.

Assessment of utilisation of PMTCT services at Nyanza Provincial Hospital, Kenya.
Author: Moth, I. A.; Ayayo, A. B., and Kaseje, D. O.
Source: SAHARA J. 2005 Jul; 2(2):244-50.
Abstract: The main objective of the study was to assess the utilisation of prevention of mother-to-child transmission (PMTCT) services among mothers registered for services at Nyanza Provincial Hospital in Kenya. A crosssectional exploratory study was conducted, using both quantitative and qualitative approaches to collect primary and secondary data.The study population was 133 clients registered for PMTCT services. The study revealed that 52.4% of clients received PMTCT information at the health facility without prior knowledge about intervention, 96% waited for more than 90 minutes, and 89% took less than 10 minutes for post-test counselling. Knowledge of MTCT and PMTCT was inadequate even after counselling, as participants could not recall the information divulged during counselling. In addition, 80% of clients did not present for follow-up counselling irrespective of HIV status, and 95%, did not disclose positive HIV status to spouses/relatives for fear of stigma, discrimination and violence. Inadequate counselling services delivered to clients affected service utilisation, in that significant dropout occurred at the stages of HIV result (31.5%), enrollment (53.6%), and delivery (80.7%). Reasons for dropout included fear of positive HIV result, chronic illness, stigma and discrimination, unsupportive spouse and inability to pay for the services

Promoting female condoms in HIV voluntary counselling and testing centres in Kenya.
Author: Mung'ala, L.; Kilonzo, N.; Angala, P.; Theobald, S., and Taegtmeyer, M.
Source: Reprod Health Matters. 2006 Nov; 14(28):99-103.
Abstract: Promotion of male condoms and voluntary counselling and testing for HIV (VCT) have been cornerstones of Kenya's fight against the HIV epidemic. This paper argues that there is an urgent need to promote the female condom in Kenya through VCT centres, which are rapidly being scaled-up across the country and are reaching increasingly large numbers of people. Training of counsellors using a vaginal demonstration model is needed, as well an adequate supply of free female condoms. In a study in five VCT centres, however, counsellors reported that most people they counselled believed female condoms were "not as good" as male condoms. In fact, many clients had little or no knowledge or experience of female condoms. Counsellors' knowledge too was largely based on hearsay; most felt constrained by lack of experience and had many doubts about female condoms, which need addressing. Additional areas that require attention in training include how to re-use female condoms and the value of female condoms for contraception. VCT counsellors in Kenya already promote male condoms as a routine part of risk reduction counselling alongside HIV testing. This cadre, trained in client-centred approaches, has the potential to champion female condoms as well, to better support the right to a healthy and safe sex life.

Communication for HIV/AIDS prevention in Kenya: social-cultural considerations.
Author: Muturi, N.
Source: J Health Commun. 2005 Jan-2005 Feb 28; 10(1):77-98.
Abstract: The acquired immune deficiency syndrome (AIDS) epidemic is spreading fast in Africa in spite of the various efforts and resources put in place to prevent it. In Kenya, reproductive health programs have used the mass media and other communication interventions to inform and educate the public about the disease and to promote behavior change and healthy sexual practices. This effort has led to a discrepancy between awareness and behavioral change among people of reproductive age. In this article I examine the discrepancy in Kenya from a communications perspective addressing social cultural and related factors contributing to the lack of change in behavior and sexual practices. I draw on the theoretical framework of Grunig's model of excellence in communication, the importance of understanding and relationship building between programs and their stakeholders. Data were gathered qualitatively using focus groups and in-depth interviews among men and women in rural Kenya. Key findings indicate that although awareness of sexually transmitted diseases (STDs) including human immunodeficiency virus (HIV)/AIDS is high in Kenya, a majority of the population, particularly those in the rural communities, lack understanding of the communicated messages. They also lack the knowledge of other ways of transmitting HIV particularly among those not sexually involved. Cultural beliefs, values, norms, and myths have played a role in the rapidly increasing epidemic in the rural communities and yet HIV/AIDS communication programs have not addressed these factors adequately. I conclude that successful behavior change communication must include strategies that focus on increasing understanding of the communicated messages and understanding of the audience through application of appropriate methodologies. Building a relationship with the audience or stakeholders through dialogues and two-way symmetrical communication contributes toward this understanding and the maintenance of the newly adopted behaviors and practices.

Validation of a new clinical scoring system for acute bronchitis.
Author: Mwachari, C.; Nduba, V.; Nguti, R.; Park, D. R.; Sanguli, L., and Cohen, C. R.
Source: Int J Tuberc Lung Dis. 2007 Nov; 11(11):1253-9.
Abstract: Introduction:

Although several clinical prediction rules exist for lower respiratory tract infection (LRTI), few are for acute bronchitis (acute bronchitis) and most have not been validated in high human immunodeficiency virus (HIV) prevalence settings.


Methods:

An Acute Bronchitis Severity Score (ABSS) was developed and validated during a randomized trial of antibiotic treatment for acute bronchitis. Ambulatory adults with productive cough of < or =2 weeks at out-patient respiratory disease clinics in Nairobi, Kenya, were recruited and assessed for clinical response to therapy. The ABSS quantitative ratings of LRTI-associated symptoms, physical signs and sputum Gram stain purulence were assessed using standard psychometric tests.


Results:

The ABSS was evaluated among 649 cases of acute bronchitis; 129 (20%) were HIV-seropositive. The ABSS had small floor and ceiling effects (1.8/0.2) and demonstrated high internal consistency (alpha-coefficient of 0.66) and internal validity, with a mean inter item total correlation of > or =0.25. Effect sizes from baseline to subsequent follow-up visits were large (>0.5). Wheezing and chest pain were associated with higher ABSS values, whereas irrelevant clinical variables were not.


Conclusion:

The ABSS demonstrated good responsiveness, high internal consistency, good correlation with common respiratory signs and symptoms and high discriminatory validity among patients with acute bronchitis in a high HIV-seroprevalence setting.



Modelling the public health impact of male circumcision for HIV prevention in high prevalence areas in Africa.
Author: Nagelkerke, N. J.; Moses, S.; de Vlas, S. J., and Bailey, R. C.
Source: BMC Infect Dis. 2007; 7:16.
Abstract: Background:

Recent clinical trials in Africa, in combination with several observational epidemiological studies, have provided evidence that male circumcision can reduce HIV female-to-male transmission risk by 60% or more. However, the public health impact of large-scale male circumcision programs for HIV prevention is unclear.


Methods:

Two mathematical models were examined to explore this issue: a random mixing model and a compartmental model that distinguishes risk groups associated with sex work. In the compartmental model, two scenarios were developed, one calculating HIV transmission and prevalence in a context similar to the country of Botswana, and one similar to Nyanza Province, in western Kenya.


Results:

In both models, male circumcision programs resulted in large and sustained declines in HIV prevalence over time among both men and women. Men benefited somewhat more than women, but prevalence among women was also reduced substantially. With 80% male circumcision uptake, the reductions in prevalence ranged from 45% to 67% in the two "countries", and with 50% uptake, from 25% to 41%. It would take over a decade for the intervention to reach its full effect.


Conclusion:

Large-scale uptake of male circumcision services in African countries with high HIV prevalence, and where male circumcision is not now routinely practised, could lead to substantial reductions in HIV transmission and prevalence over time among both men and women.


Factors leading to self-disclosure of a positive HIV diagnosis in Nairobi, Kenya: people living with HIV/AIDS in the Sub-Sahara.
Author: Neville Miller, A. and Rubin, D. L.
Source: Qual Health Res. 2007 May; 17(5):586-98.
Abstract: Understanding why, how, and to whom people living with HIV/AIDS disclose their diagnosis to others is a critical issue for HIV prevention and care efforts, but previous investigations of those issues in sub-Saharan Africa have been limited to one or two questions included in quantitative studies of social support or stigma. Instruments and findings on serostatus disclosure based on U.S. populations are likely to be at best only partially relevant because of Africa's primarily heterosexual transmission vectors and highly communalistic social structures. This qualitative analysis of two male and two female focus groups comprised of persons living with HIV/AIDS (PLWHAs) in Nairobi, Kenya, revealed several HIVstatus disclosure patterns that appear distinctive to Africa. These include (a) intermediaries as vehicles for disclosure to family, (b) indirectness as a communication strategy, and (c) church pastors as common targets for disclosure.

Sustained changes in sexual behavior by female sex workers after completion of a randomized HIV prevention trial.
Author: Ngugi, E. N.; Chakkalackal, M.; Sharma, A.; Bukusi, E.; Njoroge, B.; Kimani, J.; MacDonald, K. S.; Bwayo, J. J.; Cohen, C. R.; Moses, S., and Kaul, R.
Source: J Acquir Immune Defic Syndr. 2007 Aug 15; 45(5):588-94.
Abstract: Introduction:

Behavioral interventions in female sex workers (FSWs) are associated with changes in sexual behavior and reduced rates of sexually transmitted infections (STIs) and HIV We examined the sustainability of such interventions.


Methods:

HIV-uninfected Kenyan FSWs were enrolled in a clinical trial that provided free male condoms, community and clinic-based counseling, and STI management. After trial completion, scaled-back community-based resources remained in place. More than a year later, women were invited to complete a follow-up behavioral questionnaire and to undergo STI/HIV counseling and testing. Individual changes in sexual behavior were assessed by paired analysis.


Results:

One hundred seventy-two women participated in the resurvey 1.2 years after trial termination. Client numbers had risen (paired t test, P < 0.001), but condom use had also increased (P < 0.001); both remained substantially lower than at enrollment. Regular partners accounted for a greater proportion of unprotected FSW sexual encounters (35% vs. 10%; P < 0.001). Only 9 (5.2%) of 172 women had a conventional STI, and the follow-up HIV incidence of 1.6 per 100 person-years (PYs) was similar to that during the trial period (3.7 per 100 PYs). Incident STIs and HIV were associated with the frequency of unprotected sex and younger age.


Conclusions:

Less intensive community-based risk reduction services after clinical trial termination may support ongoing reductions in STIs and HIV among high-risk FSWs.



Ethical dilemmas of social science research on AIDS and orphanhood in Western Kenya.
Author: Nyambedha, E. O.
Source: Soc Sci Med. 2008 Sep; 67(5):771-9.
Abstract: This paper is based on the experiences drawn from a long-term social science research programme on the impact of the AIDS pandemic on orphanhood in western Kenya. It discusses the ethical dilemma of maintaining a delicate balance between research ethics, the expectations of the study population and negotiating the community's vested interests in a health related research project in a low-income society. I argue that informed consent and the intended benefits of the study to the participants continue to be major challenges facing the justification of social research with people affected by or living with AIDS in low-income societies. The paper underscores the importance of community feedback sessions as a way of enhancing chances of acceptability of research efforts and obtaining informed consent. It further shows how community feedback sessions contribute to local knowledge of the problem being studied, creating opportunities for advocacy. This discussion adds to the existing ethical debate on the wider contexts within which research on vulnerable people affected by AIDS is conducted by arguing that research practice is inseparable from epistemological concerns of knowledge production. I suggest that ethnographers should enhance efforts to innovatively design action research projects to serve the twin purposes of data collection and deal with ethical challenges that are experienced when doing long-term research on vulnerable groups.

Sexual and demographic determinants for herpes simplex virus type 2 among fishermen along Lake Victoria, Kenya.
Author: O Ng'ayo, M.; Bukusi, E.; A Morrow, R.; Rowhani-Rahbar, A.; A Obare, B.; Friedrich, D., and Holmes, K. K.
Source: Sex Transm Infect. 2008 Apr; 84(2):140-2.
Abstract: Objectives:

To determine the prevalence and correlates of herpes simplex virus type 2 (HSV-2) seropositivity among fishermen along the shores of Lake Victoria in Kisumu district, Kenya.


Methods:

Sera from a random sample of 250 fishermen from 18 beaches were collected after a detailed sociodemographic interview. HSV-2 infection was tested by Kalon HSV-2 ELISA.


Results:

The HSV-2 seroprevalence was 63.9%. In multivariate analysis, fishermen were more likely to be infected with HSV-2 if they were HIV positive (prevalence ratio (PR) 1.27; 95% CI 1.06 to 1.52) compared with those testing HIV negative, were aged 18-20 (PR 0.49; 95% CI 0.24 to 0.99) and older than 40 (PR 1.66; 95% CI 1.30 to 2.14) years compared with those aged 21-25 years, perceived their last two sexual partners to have a sexually transmitted infection (STI; PR 1.27; 95% CI 1.06 to 1.52) compared with those who did not and were more likely to be circumcised (PR 1.49; 95% CI 1.19 to 1.86).


Conclusions:

HSV-2 seroprevalence is high among this population and is associated with HIV serostatus, age, perception about partner's STI status and circumcision.



Viral load, CD4+ T-lymphocyte counts and antibody titres in HIV-1 infected untreated children in Kenya; implication for immunodeficiency and AIDS progression.
Author: Ochieng, W.; Ogoyi, D.; Mulaa, F. J.; Ogola, S.; Musoke, R., and Otsyula, M. G.
Source: Afr Health Sci. 2006 Mar; 6(1):3-13.
Abstract: Background:

There are limited reports on HIV-1 RNA load, CD4+ T-lymphocytes and antibody responses in relation to disease progression in HIV-1 infected untreated children in Africa.


Methods:

To describe the relationships between these parameters, we conducted a longitudinal cohort study involving 51 perinatally HIV-1 infected children aged between 1 and 13 years. HIV status was determined by ELISA and confirmed by western blot and PCR. Antibodies were quantified by limiting dilution ELISA, plasma HIV-1 RNA load by RT-PCR and CD4+ T-lymphocytes by FACSCount.


Results:

Asymptomatic and symptomatic disease had, respectively, a rise in median HIV-1 RNA load from 1,195 to 132,543 and from 42,962 to 1,109,281 copies/ml in children below 6 years. The increase in viral load was 10-fold higher for asymptomatic compared to other categories and 2-fold faster for children less than 6 years than those above. Similarly, symptomatic children below 6 years had initial median CD4+ T-lymphocyte counts of 647 (22%) cells/muL, declining to 378 (20%) while those above 6 years had initial values of below 335 (15%) but which increased to 428 (17%). Median viral load correlated significantly with median CD4+ T-lymphocyte percentage in children above 6 years (p=0.026) but not below.


Conclusions:

Viral load is lower in older than younger children and correlates significantly with percentage CD4+ T-lymphocytes. Survival by HIV-1 infected children requires a competent immune response early in infection to counter the rapidly replicating virus. Interventions aimed at boosting the naive immune system may prolong survival in these children.



Tuberculosis and oral Candida species surveillance in HIV infected individuals in Northern Kenya, and the implications on tuberculin skin test screening for DOPT-P.
Author: Ochieng, W.; Wanzala, P.; Bii, C.; Oishi, I.; Ichimura, H.; Lihana, R.; Mpoke, S.; Mwaniki, D., and Okoth, F. A.
Source: East Afr Med J. 2005 Dec; 82(12):609-13.
Abstract: Objective:

To determine the pattern of opportunistic infections such as TB and Candida species in HIV infected patients in Northern Kenya.


Design:

Cross-sectional study. SETTING: Five health facilities in Moyale (n=224), Mandera (n=121) and Turkana Kakuma; (n=83), Lopiding; (n=94) districts during different periods in 2003. SUBJECTS: Five hundred and fifty two patients.


Results:

In total 94 (18%) patients were found to be HIV positive (Moyale=42, Mandera=13, Turkana; Kakuma=8, Lopiding=31). Only 65 of 94 HIV positive patients provided saliva samples. Of these, 11 (17%) were TB smear positive and 19 (29.2%) were colonized by oral Candida species. The Candida isolates were as follows; Co-infection of Candida species and TB (n=4), C. albicans only (n=12), C. tropicalis only (n=1), C. albicans and C. glabarata (n=1) and C. albicans, C. glabarata and C. tropicalis. co-infection (n=1).



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