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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Participants:

Potential HIV/AIDS clinical trial participants, clinician researchers, and administrators. RESULTS: Eighty nine individuals participated in a total of 11 focus groups over a four month period. The desire for continued drug therapy, most often life long, following an HIV/AIDS clinical trial was the most common priority expressed in all focus groups. Patients with and without HIV/AIDS also thought subsidizing of drug therapies and education were critical forms of compensation for clinical trial participation. Financial incentives were considered important primarily for purchasing drug therapy as well as obtaining food. Patients noted a concern for the potential mismanagement of any money offered. Clinician researchers and administrators felt strongly that researchers have a moral obligation to participants following a trial to provide continued drug therapy, adverse event monitoring, and primary care. Finally, clinician researchers and administrators stressed the need for thorough informed consent to avoid coercion of study participants.


Conclusions:

Kenyan patients, clinician researchers, and administrators believe that it would be unfair to stop antiretroviral therapy following an HIV/AIDS clinical trial and that researchers have a long term obligation to participants.



HIV immunosuppression and antimalarial efficacy: sulfadoxine-pyrimethamine for the treatment of uncomplicated malaria in HIV-infected adults in Siaya, Kenya.
Author: Shah, S. N.; Smith, E. E.; Obonyo, C. O.; Kain, K. C.; Bloland, P. B.; Slutsker, L., and Hamel, M. J.
Source: J Infect Dis. 2006 Dec 1; 194(11):1519-28.
Abstract: Background:

The altered immune response of persons with human immunodeficiency virus (HIV) infection could result in increased rates of antimalarial treatment failure. We investigated the influence of HIV infection on the response to sulfadoxine-pyrimethamine treatment.


Methods:

Febrile adults with Plasmodium falciparum parasitemia were treated with sulfadoxine-pyrimethamine and were monitored for 28 days. HIV status and CD4 cell count were determined at study enrollment.


Results:

Of the adults enrolled in the study, 508 attended all follow-up visits, including 130 HIV-uninfected adults, 256 HIV-infected adults with a high CD4 cell count (> or =200 cells/ micro L), and 122 HIV-infected adults with a low CD4 cell count (<200 cells/ micro L). The hazard of treatment failure at day 28 of follow-up was significantly higher for HIV-infected adults with a low CD4 cell count (20.5%) than for HIV-uninfected adults (7.7%). Anemia (hemoglobin level, <110 g/L) modified the effect of HIV status on treatment failure. When we controlled for fever and parasite density, the hazard of treatment failure for HIV-infected adults with a low CD4 cell count and anemia was 3.4 times higher than that for HIV-uninfected adults (adjusted hazard ratio, 3.38; 95% confidence interval, 1.56-7.34).


Conclusions:

HIV-infected persons with a low CD4 cell count and anemia have an increased risk of antimalarial treatment failure. The response to malaria treatment in HIV-infected persons must be carefully monitored. Proven measures for the control and prevention of malaria must be incorporated into the basic package of services provided by HIV/acquired immunodeficiency syndrome care and treatment programs in malarious areas



Mucosal Neisseria gonorrhoeae coinfection during HIV acquisition is associated with enhanced systemic HIV-specific CD8 T-cell responses.
Author: Sheung, A.; Rebbapragada, A.; Shin, L. Y.; Dobson-Belaire, W.; Kimani, J.; Ngugi, E.; MacDonald, K. S.; Bwayo, J. J.; Moses, S.; Gray-Owen, S., and Kaul, R.
Source: AIDS. 2008 Sep 12; 22(14):1729-37.
Abstract: Background:

The host immune response against mucosally acquired pathogens may be influenced by the mucosal immune milieu during acquisition. As Neisseria gonorrhoeae can impair dendritic cell and T-cell immune function, we hypothesized that coinfection during HIV acquisition would impair subsequent systemic T-cell responses.


Methods:

Monthly screening for sexually transmitted infections was performed in high risk, HIV seronegative Kenyan female sex workers as part of an HIV prevention trial. Early HIV-specific CD8 T-cell responses and subsequent HIV viral load set point were assayed in participants acquiring HIV, and were correlated with the presence of prior genital infections during HIV acquisition.


Results:

Thirty-five participants acquired HIV during follow-up, and 16 out of 35 (46%) had a classical sexually transmitted infection at the time of acquisition. N. gonorrhoeae coinfection was present during HIV acquisition in 6 out of 35 (17%), and was associated with an increased breadth and magnitude of systemic HIV-specific CD8 T-cell responses, using both interferon-gamma gamma and MIP-1 beta as an output. No other genital infections were associated with differences in HIV-specific CD8 T-cell response, and neither N. gonorrhoeae nor other genital infections were associated with differences in HIV plasma viral load at set point.


Conclusion:

Unexpectedly, genital N. gonorrhoeae infection during heterosexual HIV acquisition was associated with substantially enhanced HIV-specific CD8 T-cell responses, although not with differences in HIV viral load set point. This may

have implications for the development of mucosal HIV vaccines and adjuvants.

Bronchoscopic study on aetiology of chronic cough in HIV-infected adults with negative sputum smears for Mycobacterium tuberculosis.
Author: Siika, A. M.; Chakaya, J. M.; Revathi, G.; Mohamed, S. S., and Bhatt, K. M.
Source: Kenyatta National Hospital, Nairobi. East Afr Med J. 2006 Jun; 83(6):295-305.
Abstract: objective:

To establish the aetiology of chronic cough in HIV-infected patients with negative sputum smears for Acid Fast Bacilli (AFB).


Design: A cross-sectional descriptive study.
Setting: Kenyatta National Hospital, a tertiary referral centre in Kenya
Subjects:

Sixty five HIV-infected adults presenting with chronic cough and negative sputum smears for AFBs.


Results:

Sixty-two patients were included in the final analysis. Aetiology of chronic cough was established in 42 (68%) patients. Pneumocystis jiroveci, bacterial pneumonia and Mycobacterium tuberculosis were diagnosed in 22 (35.5%), 17 (27.4%) and 14 (22.5%) patients respectively. Majority (98%) of patients with a diagnosis had multiple causes established in them. Ciprofloxacin had activity against 91% of the isolated organisms while Penicillin was active against 35% only.


Conclusion:

This study documents Pneumocystis jiroveci pneumonia as a common cause of morbidity in a subset of HIV infected patients with chronic cough and negative sputum smears for AFB in Kenya.



An electronic medical record system for ambulatory care of HIV-infected patients in Kenya.
Author: Siika, A. M.; Rotich, J. K.; Simiyu, C. J.; Kigotho, E. M.; Smith, F. E.; Sidle, J. E.; Wools-Kaloustian, K.; Kimaiyo, S. N.; Nyandiko, W. M.; Hannan, T. J., and Tierney, W. M.
Source: Int J Med Inform. 2005 Jun; 74(5):345-55.
Abstract: Administering and monitoring therapy is crucial to the battle against HIV/AIDS in sub-Saharan Africa. Electronic medical records (EMRs) can aid in documenting care, monitoring drug adherence and response to therapy, and providing data for quality improvement and research. Faculty at Moi University in Kenya and Indiana and University in the USA opened adult and pediatric HIV clinics in a national referral hospital, a district hospital, and six rural health centers in western Kenya using a newly developed EMR to support comprehensive outpatient HIV/AIDS care. Demographic, clinical, and HIV risk data, diagnostic test results, and treatment information are recorded on paper encounter forms and hand-entered into a central database that prints summary flowsheets and reminders for appropriate testing and treatment. There are separate modules for monitoring the Antenatal Clinic and Pharmacy. The EMR was designed with input from clinicians who understand the local community and constraints of providing care in resource poor settings. To date, the EMR contains more than 30,000 visit records for more than 4000 patients, almost half taking antiretroviral drugs. We describe the development and structure of this EMR and plans for future development that include wireless connections, tablet computers, and migration to a Web-based platform.

Building Upendo Village: a global effort.
Author: Sister Beatrice Hernandez; Sister Sheila Kinsey, and Rocole, T.
Source: Health Prog. 2006 Jul-2006 Aug 31; 87(4):33-6.
Abstract: What began as a conversation in 2000 between two women religious on how to help Kenyans affected by HIV/AIDS has evolved into a far-reaching ministry supported by the Wheaton Franciscan sisters. Inspired by the parable of the Good Samaritan, Sr. Florence Muia, ASN, a native of Kenya, explored with Sr. Marge Zulaski, OSF, a Wheaton Franciscan sister, how to offer assistance and support to Kenyans with HIV/AIDS. The two began by establishing a partnership involving the Wheaton, IL, congregation; the Assumption Sisters of Nairobi; and community members in Kenya. These partners have worked together closely to secure local community members' buy-in for a care program, study models for success, build a program infrastructure, secure funds, staff up, and interact with government agencies. The result? Upendo Village, a program that helps ensure the physical, economic, and emotional safety of people suffering from HIV/AIDS. This partnership has enabled the Wheaton Franciscans, the Assumption Sisters, and the Kenyan community to live out a simple principle: We are called to help each other.

A reverse transcriptase assay for early diagnosis of infant HIV infection in resource-limited settings.
Author: Sivapalasingam, S.; Patel, U.; Itri, V.; Laverty, M.; Mandaliya, K.; Valentine, F., and Essajee, S.
Source: J Trop Pediatr. 2007 Oct; 53(5):355-8.
Abstract: Early diagnosis of pediatric HIV infection is confounded by persistence of maternal antibodies until 18 months, necessitating the use of expensive assays such as HIV-1 DNA PCR, an untenable option in resource-limited settings. This is the first report of a low-cost, commercial, reverse transcriptase (RT) assay for the diagnosis of HIV-1 infection in infants. RT assays were performed on 42 samples from 30 HIV-exposed Kenyan infants under 15 months of age. When correlated with serologic testing conducted after 18 months, the sensitivity, specificity, positive and negative predictive values of the RT assay were 92%, 93%, 87% and 96%. A low-cost assay for infant HIV diagnosis is urgently needed, and these results merit further evaluation.

Modified vaccinia Ankara expressing HIVA antigen stimulates HIV-1-specific CD8 T cells in ELISpot assays of HIV-1 exposed infants.
Author: Slyker, J. A.; Lohman, B. L.; Mbori-Ngacha, D. A.; Reilly, M.; Wee, E. G.; Dong, T.; McMichael, A. J.; Rowland-Jones, S. L.; Hanke, T., and John-Stewart, G.
Source: Vaccine. 2005 Sep 7; 23(38):4711-9.
Abstract: Recombinant modified vaccinia virus Ankara expressing HIV-1 antigens (MVA.HIVA) was used in ELISpot assays to monitor HIV-1-specific T cell responses in infants. Responses to MVA.HIVA and HIV-1 peptides were examined in 13 infected and 81 exposed uninfected infants in Nairobi, Kenya. Responses to MVA.HIVA (38%) and peptide stimulation (38%) were similar in frequency (p=1.0) and magnitude (mean 176 versus 385 HIVSFU/10(6), p=0.96) in HIV-1 infected infants. In exposed uninfected infants, MVA.HIVA detected more positive responses and higher magnitude responses as compared to peptide. MVA.HIVA ELISpot is a sensitive method for quantification of HIV-1-specific CD8+ T cell responses in HIV-1 exposed infants. These results demonstrate the relevance of HIV-1 clade A consensus-derived immunogen HIVA for the viruses currently circulating in Nairobi.

Should rapid tests for HIV infection now be mandatory during pregnancy? Global differences in scarcity and a dilemma of technological advance.
Author: Smith, C. B.; Battin, M. P.; Francis, L. P., and Jacobson, J. A.
Source: Dev World Bioeth. 2007 Aug; 7(2):86-103.
Abstract: Since testing for HIV infection became possible in 1985, testing of pregnant women has been conducted primarily on a voluntary, 'opt-in' basis. Faden, Geller and Powers, Bayer, Wilfert, and McKenna, among others, have suggested that with the development of more reliable testing and more effective therapy to reduce maternal-fetal transmission, testing should become either routine with 'opt-out' provisions or mandatory. We ask, in the light of the new rapid tests for HIV, such as OraQuick, and the development of antiretroviral treatment that can reduce maternal-fetal transmission rates to <2%, whether that time is now. Illustrating our argument with cases from the United States (US), Kenya, Peru, and an undocumented Mexican worker in the US, we show that when testing is accompanied by assured multi-drug therapy for the mother, the argument for opt-out or mandatory testing for HIV in pregnancy is strong, but that it is problematic where testing is accompanied by adverse events such as spousal abuse or by inadequate intrapartum or follow-up treatment. The difference is not a 'double standard', but reflects the presence of conflicts between the health interests of the mother and the fetus--conflicts that would be abrogated by the assurance of adequate, continuing multi-drug therapy. In light of these conflicts, where they still occur, careful processes of informed consent are appropriate, rather than opt-out or mandatory testing.

An evaluation of intravaginal rings as a potential HIV prevention device in urban Kenya: behaviors and attitudes that might influence uptake within a high-risk population.
Author: Smith, D. J.; Wakasiaka, S.; Hoang, T. D.; Bwayo, J. J.; Del Rio, C., and Priddy, F. H.
Source: J Womens Health (Larchmt). 2008 Jul-2008 Aug 31; 17(6):1025-34.
Abstract: Purpose:

We sought to assess the potential acceptability of intravaginal rings (IVRs) as an HIV prevention method among at-risk women and men.


Methods:

We conducted a qualitative assessment of initial attitudes toward IVRs, current HIV prevention methods, and common behavioral practices among female sex workers (FSWs) and men who frequent FSWs in Mukuru, an urban slum community in Nairobi, Kenya. Nineteen women and 21 men took part in six focus group discussions.


Results:

Most participants, both male and female, responded positively to the concept of an IVR as a device for delivering microbicides. Women particularly liked the convenience offered by its slow-release capacity. Some female respondents raised concerns about whether male customers would discover the ring and respond negatively, whereas others thought it unlikely that their clients would feel the ring. Focus groups conducted with male clients of FSWs suggested that many would be enthusiastic about women, and particularly sex workers, using a microbicide ring, but that women's fears about negative responses to covert use were well founded. Overall, this high-risk population of FSWs and male clients in Nairobi was very open to the IVR as a potential HIV prevention device.


Conclusion:

Themes that emerged from the focus groups highlight the importance of understanding attitudes toward IVRs as well as cultural practices that may impact IVR use in high-risk populations when pursuing clinical development of this potential HIV prevention device.



Plasma and mucosal fluid from HIV type 1-infected patients but not from HIV type 1-exposed uninfected subjects prevent HIV type 1-exposed DC from infecting other target cells.
Author: Soderlund, J.; Hirbod, T.; Smed-Sorensen, A.; Johansson, U.; Kimani, J.; Plummer, F.; Spetz, A. L.; Andersson, J.; Kaul, R., and Broliden, K.
Source: AIDS Res Hum Retroviruses. 2007 Jan; 23(1):101-6.
Abstract: Highly exposed persistently seronegative (HEPS) individuals have previously been shown to mount HIV-1-specific humoral and cellular immune responses in the mucosa, despite their uninfected status. It is thus possible that HEPS individuals are protected from HIV-1 infection at the mucosal level. Recent work supports the hypothesis that dendritic cells are involved in the establishment of a mucosal HIV-1 infection as well as the dissemination to other target cells. However, no previous study has investigated if samples collected from HEPS individuals have the capacity to prevent HIV-1 infection in the presence of dendritic cells in vitro. We therefore established an assay that measures HIV-1 neutralization in cocultures of HIV-1-exposed dendritic cells (DC) and PBMC. Plasma and cervicovaginal lavage (CVL) samples from HIV-1-infected patients and HEPS individuals, enrolled in a well-characterized sex worker cohort in Kenya, were evaluated. Most plasma and CVL samples of HIV-1-infected patients neutralized HIV-1 in the DC/PBMC cocultures. Neither plasma nor CVL samples of most HEPS individuals had this capacity. However, they readily neutralized HIV-1 infection of PBMC alone. This may suggest that protection against HIV-1 infection in HEPS individuals occurs prior to interaction between HIV-1-exposed DC and other target cells.

Efficacy of highly active antiretroviral therapy in HIV-1 infected children in Kenya.
Author: Song, R.; Jelagat, J.; Dzombo, D.; Mwalimu, M.; Mandaliya, K.; Shikely, K., and Essajee, S.
Source: Pediatrics. 2007 Oct; 120(4):e856-61.
Abstract: Objective:

Few studies have investigated the efficacy of antiretroviral therapy among HIV-infected children in resource-poor settings. This observational, retrospective analysis describes the clinical, immunologic, and virologic effects of highly active antiretroviral therapy in treatment-naive, HIV-infected children in Mombasa, Kenya. In keeping with a public health approach, all children were treated by using a simplified, nationally approved, triple-drug regimen.


Methods:

Clinical data and stored plasma samples from 29 children who were followed prospectively between April 2003 and October 2004 were analyzed. All children received generic formulations of nevirapine, zidovudine, and lamivudine and were evaluated at baseline and at 3, 6, 9, 12, and 15 months. At each visit, weight and CD4 lymphocyte counts were measured and plasma samples were stored for analysis. HIV RNA load was determined retrospectively at baseline and 9 months after initiation of therapy.


Results:

The mean age of the children was 8.5 years (range: 2-16 years). At baseline, the mean CD4 count (+/-SD) was 182.3 x 10(6) cells per microL (+/-145.6). On treatment, CD4 counts increased step-wise by a mean of 187 x 10(6) cells per microL at 3 months, 293 cells per microL at 6 months, 308 cells per microL at 9 months, 334 cells per microL at 12 months, and 363 cells per microL at 15 months. The mean plasma viral load decreased from a baseline level of 622,712 to 35,369 copies per mL, and at 9 months was undetectable in 55% of the patients. Mean z scores for weight for age increased from a baseline of -1.61 to -1.12 at 12 months into therapy.


Conclusions:

A public health approach using 1 treatment regimen in generic form showed excellent efficacy among treatment-naive, HIV-infected children in a resource-limited country. Clinical and immunologic improvement occurred in all patients, but 9 months after the start of therapy, only 55% of the children had an undetectable viral load.



Implementation of an antiretroviral access program for HIV-1-infected individuals in resource-limited settings: clinical results from 4 African countries.
Author: Sow, P. S.; Otieno, L. F.; Bissagnene, E.; Kityo, C.; Bennink, R.; Clevenbergh, P.; Wit, F. W.; Waalberg, E.; Rinke de Wit, T. F., and Lange, J. M.
Source: J Acquir Immune Defic Syndr. 2007 Mar 1; 44(3):262-7.
Abstract: Background:

We assessed the effectiveness and safety of highly active antiretroviral therapy (HAART) in HIV-1-infected patients in resource-limited African countries. HIV-1 screening, therapy, counseling, monitoring, training, and education were provided free of charge.


Methods:

In an open-label cohort program, 206 antiretroviral-naive HIV-1-infected patients who could not afford HAART were recruited in 4 urban clinics in Senegal, Cote d'Ivoire, Uganda, and Kenya and were treated with saquinavir boosted with ritonavir (1600/100 mg once daily), lamivudine (150 mg twice daily), and zidovudine (300 mg twice daily). The primary outcome was a plasma viral load (pVL) of <400 copies/mL after 96 weeks of treatment. Secondary analyses included CD4 cell count changes and the occurrence of treatment-emergent adverse events.


Results:

The median age of the patient group was 36 years, 38% were male, 35% of the patients had AIDS, the median CD4 count was 119 cells/microL, and the median pVL was 304,210 copies/mL. Overall, 65%/52% (on treatment [OT]/intent to treat [ITT]) of the patients had a pVL <400 copies/mL after 96 weeks of follow-up. This proportion varied significantly between sites, however; although in Nairobi and Dakar, 51%/40% and 56%/46% (OT/ITT) were found, respectively, Abidjan and Kampala showed proportions of 69%/54% and 83%/69% (OT/ITT), respectively. The median increase in the CD4 count was 198 cells/microL (interquartile range: 86-319 cells/microL), ranging from 191 to 292 cells/microL between the sites. Fourteen patients (6.8%) died between 8 and 96 weeks of follow-up, whereas 18 (9%) developed an AIDS-defining event between 8 and 96 weeks of follow-up. Non-HIV-related serious adverse events occurred in 55 patients (26.7%), of whom 13 were diagnosed with severe anemia. Thirty-five patients (17%) changed treatment for toxicity reasons.


Conclusions:

Although a statistically significant difference was observed between sites with respect to virologic success, overall virologic and immunologic responses to HAART in resource-limited African settings can be as good as in Western settings. There were some difficulties (eg, laboratory, logistics, proper training) during the early phase of the program. Therefore, provision of adequate medical care, counseling, proper instruction, and education of patients and medical staff during the entire study is warranted in such programs, with special care in the early phase.



Piloting post-exposure prophylaxis in Kenya raises specific concerns for the management of childhood rape.
Author: Speight, C. G.; Klufio, A.; Kilonzo, S. N.; Mbugua, C.; Kuria, E.; Bunn, J. E., and Taegtmeyer, M.
Source: Trans R Soc Trop Med Hyg. 2006 Jan; 100(1):14-8.
Abstract: Thika District, Kenya, is the site of an operational research study on the provision of comprehensive post-rape care, including the free provision of HIV post-exposure prophylaxis (PEP). It is a typical rural Kenyan district in terms of resources and patient throughput. The high rate of children attending for post-rape services was unexpected and had significant programming implications. An age-disaggregated analysis of existing quantitative data from the first 8 months of service provision was conducted. Ninety-four case records were reviewed, of whom 48 (51%) were in the age range 1.5-17 years inclusive. All three cases of male rape were in children. Children were more likely to know their assailant than adults and were more likely to be HIV-negative at baseline. The majority (86%) of children presented in time for PEP, with adherence and completion rates similar to adults but lower rates of 6-week follow-up. The use of weight bands to determine drug dosages greatly simplified the appropriate and early administration of paediatric PEP. The high rates of childhood rape and demand for post-rape services were an enormous challenge for service providers and policy-makers.

Analysis of HIV-1 sequences vertically transmitted to infants in Kisumu, Kenya.
Author: Steain, M. C.; Wang, B., and Saksena, N. K.
Source: J Clin Virol. 2006 Aug; 36(4):298-302.
Abstract: Background:

HIV-1 prevalence in Kenya among women aged between 15-19 years is approximately 23%. These women are prospective mothers and therefore can play an important role in mother-to-child transmission of HIV. The risk of a seropositve mother transmitting the virus to her infant is 25-35% in developing countries, such as Kenya, where antiretroviral drugs are not readily available.


Objectives:

This study was undertaken to evaluate the molecular nature of HIV-1 strains, assess recombination and it's relevance in mother-to-child transmission in Kenya.


Study design:

HIV-1 gag and gp120 sequences were derived from peripheral blood mononuclear cells (PBMC) of 16 infected mothers and infants, from Kisumu, Kenya. PCR, cloning, and phylogenetic analyses were conducted to examine any sequence differences between HIV-1 strains derived from mother-infant pairs.


Results:

The cohort consisted of seven pairs harboring possible subtype A/D recombinants, eight pairs with apparent pure A or D strains and one possible dual infection. This dual infection comprised of a pure subtype A region and an A/D recombinant, and was detected in one of the mother's sample. Interestingly, only the recombinant virus was detected in the paired baby sample.


Conclusions:

This study shows that HIV-1 inter-subtype recombinants can be effectively transmitted vertically to infants, and could possibly be favored in this setting where multiple subtypes infect women. Together, dual infections and the co-existence of multiple HIV-1 subtypes is encouraging the emergence of recombinant HIV strains and their rapid dispersal.



HIV type 1 sequence diversity and dual infections in Kenya. AIDS Res Hum Retroviruses.
Author: Steain, M. C.; Wang, B.; Yang, C.; Shi, Y. P.; Nahlen, B.; Lal, R. B., and Saksena, N. K.
Abstract: As vertical transmission of HIV-1 is an ongoing problem in East Africa, we analyzed HIV-1 strains of infected mothers, from Kisumu, Kenya. We sequenced the gag and gp120 regions from peripheral blood mononuclear cells (PBMC) of 15 HIV-infected mothers attending an antenatal clinic. PCR, cloning, bootscanning, using the program Simplot, and phylogenetic analyses were conducted to assign subtypes and identify recombinants. Our analyses showed two dual infections from patients who had infections with pure subtypes and recombinants subtype D. In addition, we also noted the presence of subsubtype A1 and A2, as well as unique recombinants in this area. These results imply that the HIV epidemic in western Kenya is a dynamic one and is continually evolving. Therefore, continued monitoring of the epidemic in this region is necessary if a vaccine for the area is to be developed.

Evaluation of two commercially available alternatives for HIV-1 viral load testing in resource-limited settings.
Author: Steegen, K.; Luchters, S.; De Cabooter, N.; Reynaerts, J.; Mandaliya, K.; Plum, J.; Jaoko, W.; Verhofstede, C., and Temmerman, M.
Source: Virol Methods. 2007 Dec; 146(1-2):178-87.
Abstract: There is an urgent need for low-cost assays for HIV-1 quantitation to ensure adequate follow-up of HIV-infected patients on antiretroviral therapy (ART) in resource-limited countries. Two low-cost viral load assays are evaluated, a reverse transcriptase activity assay (ExavirLoad v2, Cavidi) and a real-time reverse transcriptase PCR assay (Generic HIV viral load, Biocentric). Both tests were compared with the ultrasensitive HIV Amplicor Monitor assay. Samples were collected in Mombasa, Kenya, from 20 HIV-1 seronegative and 150 HIV-1 seropositive individuals of whom 50 received antiretroviral treatment (ART). The ExavirLoad and the Generic HIV viral load assay were performed in a local laboratory in Mombasa, the Amplicor Monitor assay (version 1.5, Roche Diagnostics) was performed in Ghent, Belgium. ExavirLoad and Generic HIV viral load reached a sensitivity of 98.3% and 100% and a specificity of 80.0% and 90.0%, respectively. Linear regression analyses revealed good correlations between the Amplicor Monitor and the Generic HIV viral load (r=0.935, p<0.001) with high accuracy (100.1%), good precision (5.5%) and a low percent similarity coefficient of variation (5.4%). Bland-Altman analysis found 95% of the samples within clinically acceptable limits of agreement (-1.19 to 0.87logcopies/ml). Although, the ExavirLoad also showed a good linear correlation with the Amplicor Monitor (r=0.901, p<0.001), a problem with false positive results was more significant. The cost per test remains relatively high (US$ 30 for ExavirLoad and US$ 20 for the Generic HIV viral load). Hence, false positive results and the need for an expensive PCR instrument for the Generic HIV viral load assays still limit the implementation of these tests in less equipped, less experienced laboratories.

The ABCs of HIV prevention in men: associations with HIV risk and protective behaviors.
Author: Steele, M. S.; Bukusi, E.; Cohen, C. R.; Shell-Duncan, B. A., and Holmes, K. K.
Source: J Acquir Immune Defic Syndr. 2006 Dec 15; 43(5):571-6.
Abstract: Objective:

To elucidate associations between beliefs in abstinence, fidelity, and condom use (the "ABCs" of preventing HIV and other sexually transmitted infections) and associated self-reported risk behaviors among Kenyan men.


Methods:

We assessed associations of beliefs in the ABCs with sociodemographic characteristics and sexual risk behaviors in a respondent-driven sample of 500 men in Nairobi.


Results:

Younger age, single marital status, and higher education were associated with beliefs in abstinence and condom use as "best" prevention methods; and older age and marriage were associated with belief in fidelity. Many of these and other associations persisted in multivariate models. Men citing abstinence or fidelity belief less often reported sex with a female sex worker (FSW) ever or recent concurrent partnerships less often. Belief in fidelity was negatively associated with reported use of condoms ever. Belief in condom use to prevent HIV was most common among those having recent concurrent partnerships.


Conclusions:

Beliefs in abstinence, fidelity ("being faithful"), or condom use were associated, in plausible directions, with life stages and other demographic factors and with corresponding risk and preventive behaviors. Context-specific and selective educational promotion of individual ABC components rather than comprehensive education from an early age in a wide repertoire of prevention strategies ignores the evolution of sexual behaviors and the relative utility of different approaches throughout the life course.



A peer-led HIV counselling and testing programme for the deaf in Kenya.
Author: Taegtmeyer, M.; Hightower, A.; Opiyo, W.; Mwachiro, L.; Henderson, K.; Angala, P.; Ngare, C., and Marum, E.
Source: Disabil Rehabil. 2008 May 28; 1-7.
Abstract: Purpose. To describe and evaluate the establishment of the first VCT services for the Deaf in Africa. Method. Operational research methods were used to document programme establishment. The demographics of deaf VCT clients were compared with hearing clients at the same sites as well as where clients had learned of the service, HIV risks, and HIV test results. Univariate and multivariate analyses were used. Results. During the two year period (January 2004 to December 2005) 1709 Deaf and 1649 hearing clients were seen at three Deaf VCT sites. The majority of Deaf clients in this sample learned of the services through the peer education programme. Data indicate that Deaf VCT clients are as much at risk of HIV from sexual transmission as their hearing counterparts and that Deaf persons seeking VCT services have an HIV prevalence of 7%, similar to the national rate of 6.7%. Conclusions. The Deaf in Kenya are at risk of HIV and there is an urgent need for Deaf-friendly HIV services, supplemented by peer education programmes. This is the first published report describing HIV services run by the Deaf for the Deaf in the developing world.

Using gender analysis to build voluntary counselling and testing responses in Kenya.
Author: Taegtmeyer, M.; Kilonzo, N.; Mung'ala, L.; Morgan, G., and Theobald, S.
Source: Trans R Soc Trop Med Hyg. 2006 Apr; 100(4):305-11.
Abstract: The rapid expansion of voluntary counselling and testing (VCT) for HIV in sub-Saharan Africa has led to concerns over the quality and equity of the services. Kenya has seen an unprecedented scale-up of VCT, and valuable lessons have been learnt at national as well as at district and community levels. We combined quantitative and qualitative research methodology and showed how the results of gender analysis can be used to develop equity in VCT scale-up. A gender-disaggregated analysis of VCT client data was conducted for the first 8 months of 2003. These quantitative data revealed that despite an increased vulnerability to HIV, women are underrepresented in VCT sites in all settings in Kenya. Our data also showed that women were also less likely to use condoms or to take home condoms after a VCT visit than their male counterparts. Further exploration through in-depth qualitative work with women and men allowed a better understanding of the reasons behind gender differences in Kenyan VCT sites and helped to develop strategies to address gender inequity. We conclude that there is an ongoing need to mainstream gender in monitoring and evaluation strategies to ensure services meet the needs and priorities of all groups.

Working with risk: occupational safety issues among healthcare workers in Kenya.
Author: Taegtmeyer, M.; Suckling, R. M.; Nguku, P. M.; Meredith, C.; Kibaru, J.; Chakaya, J. M.; Muchela, H., and Gilks, C. F.
Source: AIDS Care. 2008 Mar; 20(3):304-10.
Abstract: The objective of this study was to explore knowledge of, attitudes towards and practice of post-exposure prophylaxis (PEP) among healthcare workers (HCWs) in the Thika district, Kenya. We used site and population-based surveys, qualitative interviews and operational research with 650 staff at risk of needlestick injuries (NSIs). Research was conducted over a 5-year period in five phases: (1) a bio-safety assessment; (2) a staff survey: serum drawn for anonymous HIV testing; (3) interventions: biosafety measures, antiretrovirals for PEP and hepatitis B vaccine; (4) a repeat survey to assess uptake and acceptability of interventions; in-depth group and individual interviews were conducted; and (5) health system monitoring outside a research setting. The main outcome measures were bio-safety standards in clinical areas, knowledge, attitudes and practice as regards to PEP, HIV-sero-prevalence in healthcare workers, uptake of interventions, reasons for poor uptake elucidated and sustainability indicators. Results showed that HCWs had the same HIV sero-prevalence as the general population but were at risk from poor bio-safety. The incidence of NSIs was 0.97 per healthcare worker per year. Twenty-one percent had had an HIV test in the last year. After one year there was a significant drop in the number of NSIs (OR: 0.4; CI: 0.3-0.6; p<0.001) and a significant increase in the number of HCWs accessing HIV testing (OR: 1.55; CI: 1.2-2.1; p=0.003). In comparison to uptake of hepatitis B vaccination (88% of those requiring vaccine) the uptake of PEP was low (4% of those who had NSIs). In-depth interviews revealed this was due to HCWs fear of HIV testing and their perception of NSIs as low risk. We concluded that Bio-safety remains the most significant intervention through reducing the number of NSIs. Post-exposure prophylaxis can be made readily available in a Kenyan district. However, where HIV testing remains stigmatised uptake will be limited - particularly in the initial phases of a programme.

A prospective study assessing the effects of introducing the female condom in a sex worker population in Mombasa, Kenya.
Author: Thomsen, S. C.; Ombidi, W.; Toroitich-Ruto, C.; Wong, E. L.; Tucker, H. O.; Homan, R.; Kingola, N., and Luchters, S.
Source: Sex Transm Infect. 2006 Oct; 82(5):397-402.
Abstract: Objective:

To assess the impact and costs of adding female condoms to a male condom promotion and distribution peer education programme for sex workers in Mombasa, Kenya.


Design: A 12 month, prospective study of 210 female sex workers.
Methods:

We interviewed participants about their sexual behaviour every 2 months for a total of seven times and introduced female condoms after the third interview. We also collected cost data and calculated the cost and cost effectiveness of adding the female condom component to the existing programme.


Results:

Introduction of the female condom in an HIV/AIDS prevention project targeting sex workers led to small, but significant, increases in consistent condom use with all sexual partners. However, there was a high degree of substitution of the female condom for male condoms. The cost per additional consistent condom user at a programme level is estimated to be 2160 dollars (1169 pounds sterling, 1711 euros) (95% CI: 1338 to 11 179).


Conclusions:

The female condom has some potential for reducing unprotected sex among sex workers. However, given its high cost, and the marginal improvements seen here, governments should limit promotion of the female condom in populations that are already successfully using the male condom. More research is needed to identify effective methods of encouraging sex workers to practise safer sex with their boyfriends.



The AMPATH medical record system: creating, implementing, and sustaining an electronic medical record system to support HIV/AIDS care in western Kenya.
Author: Tierney, W. M.; Rotich, J. K.; Hannan, T. J.; Siika, A. M.; Biondich, P. G.; Mamlin, B. W.; Nyandiko, W. M.; Kimaiyo, S.; Wools-Kaloustian, K.; Sidle, J. E.; Simiyu, C.; Kigotho, E.; Musick, B.; Mamlin, J. J., and Einterz, R. M.
Source: Stud Health Technol Inform. 2007; 129(Pt 1):372-6.
Abstract: Providing high-quality HIV/AIDS care requires high-quality, accessible data on individual patients and visits. These data can also drive strategic decision-making by health systems, national programs, and funding agencies. One major obstacle to HIV/AIDS care in developing countries is lack of electronic medical record systems (EMRs) to collect, manage, and report clinical data. In 2001, we implemented a simple primary care EMR at a rural health centre in western Kenya. This EMR evolved into a comprehensive, scalable system serving 19 urban and rural health centres. To date, the AMPATH Medical Record System contains 10 million observations from 400,000 visit records on 45,000 patients. Critical components include paper encounter forms for adults and children, technicians entering/managing data, and modules for patient registration, scheduling, encounters, clinical observations, setting user privileges, and a concept dictionary. Key outputs include patient summaries, care reminders, and reports for program management, operating ancillary services (e.g., tracing patients who fail to return for appointments), strategic planning (e.g., hiring health care providers and staff), reports to national AIDS programs and funding agencies, and research.

Anti-viral activity of the extracts of a Kenyan medicinal plant Carissa edulis against herpes simplex virus.
Author: Tolo, F. M.; Rukunga, G. M.; Muli, F. W.; Njagi, E. N.; Njue, W.; Kumon, K.; Mungai, G. M.; Muthaura, C. N.; Muli, J. M.; Keter, L. K.; Oishi, E., and Kofi-Tsekpo, M. W.
Source: J Ethnopharmacol. 2006 Mar 8; 104(1-2):92-9.
Abstract: Herpes simplex virus (HSV) infection is a major opportunistic infection in immunosuppressed persons. It is therefore a serious disease in high HIV/AIDS prevalence areas as in sub-Saharan Africa where infections due to HSV have risen significantly. The development of resistant strains of HSV to the available drugs for infection management, as is evident in the first drug of choice acyclovir, has further compounded this situation. There is therefore an urgent need to identify and develop new alternative agents for management of HSV infections, more so, for those due to resistant strains. We report here on an aqueous total extract preparation from the roots of Carissa edulis (Forssk.) Vahl (Apocynaceae), a medicinal plant locally growing in Kenya that has exhibited remarkable anti-HSV activity in vitro and in vivo for both wild type and resistant strains of HSV. The extract significantly inhibited formation of plaques in Vero E6 cells infected with 100PFU of wild type strains of HSV (7401H HSV-1 and Ito-1262 HSV-2) or resistant strains of HSV (TK(-) 7401H HSV-1 and AP(r) 7401H HSV-1) by 100% at 50 microg/ml in vitro with minimal cell cytotoxicity (CC(50)=480 microg/ml). When the extract was examined for in vivo efficacy in a murine model using Balb/C mice cutaneously infected with wild type or resistant strains of HSV, the extract at an oral dose of 250 mg/kg significantly delayed the onset of HSV infections by over 50%. It also increased the mean survival time of treated infected mice by between 28 and 35% relative to the infected untreated mice (p<0.05 versus control by Student's t-test). The mortality rate for mice treated with extract was also significantly reduced by between 70 and 90% as compared with the infected untreated mice that exhibited 100% mortality. No acute toxicity was observed in mice at the oral therapeutic dose of 250 mg/kg. These results suggest that this herbal extract has potent anti-viral agents against herpes simplex viruses that can be exploited for development of an alternative remedy for HSV infections.

Effects of HIV/AIDS on maternity care providers in Kenya.
Author: Turan, J. M.; Bukusi, E. A.; Cohen, C. R.; Sande, J., and Miller, S.
Source: J Obstet Gynecol Neonatal Nurs. 2008 Sep-2008 Oct 31; 37(5):588-95.
Abstract: Objective:

To explore the impact of HIV/AIDS on maternity care providers in labor and delivery in a high HIV-prevalence setting in sub-Saharan Africa.


Design:

Qualitative one-on-one in-depth interviews with maternity care providers.


Setting:

Four health facilities providing labor and delivery services (2 public hospitals, a public health center, and a small private maternity hospital) in Kisumu, Nyanza Province, Kenya.




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