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

Eighteen maternity care providers, including 14 nurse/midwives, 2 physician assistants, and 2 physicians (ob/gyn specialists).

The HIV/AIDS epidemic has had numerous adverse effects and a few positive effects on maternity care providers in this setting. Adverse effects include reductions in the number of health care providers, increased workload, burnout, reduced availability of services in small health facilities when workers are absent due to attending HIV/AIDS training programs, difficulties with confidentiality and unwanted disclosure, and maternity care providers' fears of becoming HIV infected and the resulting stigma and discrimination. Positive effects include improved infection control procedures on maternity wards and enhanced maternity care provider knowledge and skills.

A multifaceted package including policy, infrastructure, and training interventions is needed to support maternity care providers in these settings and ensure that they are able to perform their critical roles in maternal healthcare and prevention of HIV/AIDS transmission.

To improve uptake in a program to prevent mother-to-child HIV transmission and describe lessons relevant for prevention of mother-to-child transmission programs in resource-poor settings.

Implementation of a pilot project that evaluates approaches to increase program uptake at health facility level at New Nyanza Provincial General Hospital, a public hospital in western Kenya, an area with high HIV prevalence. Client flow was revised to integrate counseling, HIV testing, and dispensing of single-dose nevirapine into routine antenatal services. The number of facilities providing PMCT services was expanded to increase district-wide coverage. Main outcome measures were uptake of counseling, HIV testing, nevirapine, and estimated program impact.

Uptake of counseling and testing improved from 55 to 68% (P < 0.001), nevirapine uptake from 57% to 70% (P < 0.001), and estimated program impact from 15% to 23% (P = 0.03). Aggregate reports compare well with computer-entered data.

Addressing institutional factors can improve uptake, but expected program impact remains low for several reasons, including relatively low efficacy of the intervention and missed opportunities in the labor room

Health facilities providing tuberculosis (TB) treatment in two districts in rural western Kenya with a high TB and human immunodeficiency virus (HIV) burden.

To evaluate TB and HIV/acquired immune-deficiency syndrome (AIDS) services at the facilities and identify barriers to providing quality diagnostic HIV testing and counseling (DTC) and HIV treatment for TB patients in anticipation of the introduction of TB-HIV collaborative services.

We performed a standard interview with health workers responsible for TB care, inspected the facilities and collected service delivery data. A self-administered questionnaire on training attended was given to all health workers. Results were shared with stakeholders and plans for implementation were developed.

Of the 59 facilities, 58 (98%) provided TB treatment, 19 (32%) offered sputum microscopy and 24 (41%) HIV testing. Most facilities (72%) advised HIV testing only if TB patients were suspected of having AIDS. Barriers identified included unaccommodating TB clinic schedules and lack of space, which was an obstacle to holding confidential discussions. The need to refer for HIV testing and/or HIV care was a perceived barrier to recommending these services. Activities implemented following the assessment aimed 1) to provide HIV testing and cotrimoxazole prophylaxis at all TB treatment clinics, 2) to increase availability of HIV treatment services, and 3) to address structural needs at each facility.

This evaluation identified barriers to the implementation of HIV testing and care services within facilities providing TB treatment.

Pre-exposure prophylaxis (PrEP) is a promising new HIV prevention method, especially for women. An urgent demand for implementation of PrEP is expected at the moment efficacy has been demonstrated in clinical trials. We explored the long-term impact of PrEP on HIV transmission in different HIV epidemics.

We used a mathematical model that distinguishes the general population, sex workers and their clients. PrEP scenarios varying in effectiveness, coverage and target group were modeled in the epidemiological settings of Botswana, Nyanza Province in Kenya, and Southern India. We also studied the effect of condom addition or condom substitution during PrEP use. Main outcome was number of HIV infections averted over ten years of PrEP use. PrEP strategies with high effectiveness and high coverage can have a substantial impact in African settings. In Southern India, by contrast, the number of averted HIV infections in different PrEP scenarios would be much lower. The impact of PrEP may be strongly diminished or even reversed by behavioral disinhibition, especially in scenarios with low coverage and low effectiveness. However, additional condom use during low coverage and low effective PrEP doubled the amount of averted HIV infections.

The public health impact of PrEP can be substantial. However, this impact may be diminished, or even reversed, by changes in risk behavior. Implementation of PrEP strategies should therefore come on top of current condom campaigns, not as a substitution.

To compare the sexual behaviour of female sex workers in urban and rural areas in Nyanza province in Kenya, and to compare their unsafe sex with clients and with regular partners.

In a cross-sectional study among 64 sex workers (32/32 in urban/rural areas), sex workers kept a sexual diary for 14 days after being interviewed face-to-face.

Most sex workers were separated/divorced and had one or two regular partners, who were mostly married to someone else. Sex workers in Kisumu town were younger, had started sex work at an earlier age, and had more clients in the past 14 days than rural women (6.6 vs. 2.4). Both groups had an equal number of sex contacts with regular partners (4.7). With clients, condom use was fairly frequent (75%) but with regular partners, it was rather infrequent (<40%). For both urban and rural areas, the mean number of sex acts in which no condom was used was greater for regular partners (3.2 and 2.8 respectively) than for clients (1.9 and 1.0 respectively).

Sex workers in urban and rural areas of Nyanza province practise more unsafe sex with regular partners than with clients. Interventions for sex workers should also focus on condom use in regular partnerships

Much of the burden of morbidity affecting women of childbearing age in sub-Saharan Africa occurs in the context of HIV-1 infection. Understanding patterns of illness and determinants of disease in HIV-1-infected mothers may guide effective interventions to improve maternal health in this setting.

We describe the incidence and cofactors of comorbidities affecting peripartum and postpartum HIV-1-infected women in Kenya. Women were evaluated by clinical examination and standardized questionnaires during pregnancy and for up to 2 years after delivery.

Five hundred thirty-five women were enrolled in the cohort (median CD4 count of 433 cells/mm) and accrued 7736 person-months of follow-up. During 1-year follow-up, the incidence of upper respiratory tract infections was 161 per 100 person-years, incidence of pneumonia was 33 per 100 person-years, incidence of tuberculosis (TB) was 11 per 100 person-years, and incidence of diarrhea was 63 per 100 person-years. Immunosuppression and HIV-1 RNA levels were predictive for pneumonia, oral thrush, and TB but not for diarrhea; CD4 counts <200 cells/mm(3) were associated with pneumonia (relative risk [RR] = 2.87, 95% confidence interval [CI]: 1.71 to 4.83), TB (RR = 7.14, 95% CI: 2.93 to 17.40) and thrush. The risk of diarrhea was significantly associated with crowding (RR = 1.86, 95% CI: 1.19 to 2.92) and breast-feeding (RR = 1.71, 95% CI: 1.19 to 2.44). Less than 10% of women reported hospitalization during 2-year follow-up; mortality risk in the cohort was 1.9% and 4.8% for 1 and 2 years, respectively.

Mothers with HIV-1, although generally healthy, have substantial morbidity as a result of common infections, some of which are predicted by immune status or by socioeconomic factors. Enhanced attention to maternal health is increasingly important as HIV-1-infected mothers transition from programs targeting the prevention of mother-to-child transmission to HIV care clinics.

Several co-infections have been shown to impact the progression of HIV-1 infection. We sought to determine if treatment of helminth co-infection in HIV-1-infected adults impacted markers of HIV-1 disease progression.

To date, there have been no randomized trials to examine the effects of soil-transmitted helminth eradication on markers of HIV-1 progression.

A randomized, double-blind, placebo-controlled trial of albendazole (400 mg daily for 3 days) in antiretroviral-naive HIV-1-infected adults (CD4 cell count >200 cells/microl) with soil-transmitted helminth infection was conducted at 10 sites in Kenya (Clinical Trials.gov NCT00130910). CD4 and plasma HIV-1 RNA levels at 12 weeks following randomization were compared in the trial arms using linear regression, adjusting for baseline values.

Of 1551 HIV-1-infected individuals screened for helminth infection, 299 were helminth infected. Two hundred and thirty-four adults were enrolled and underwent randomization and 208 individuals were included in intent-to-treat analyses. Mean CD4 cell count was 557 cells/microl and mean plasma viral load was 4.75 log10 copies/ml at enrollment. Albendazole therapy resulted in significantly higher CD4 cell counts among individuals with Ascaris lumbricoides infection after 12 weeks of follow-up (+109 cells/microl; 95% confidence interval +38.9 to +179.0, P = 0.003) and a trend for 0.54 log10 lower HIV-1 RNA levels (P = 0.09). These effects were not seen with treatment of other species of soil-transmitted helminths.

Treatment of A. lumbricoides with albendazole in HIV-1-coinfected adults resulted in significantly increased CD4 cell counts during 3-month follow-up. Given the high prevalence of A. lumbricoides infection worldwide, deworming may be an important potential strategy to delay HIV-1 progression.

To describe the early response to World Health Organization (WHO)-recommended nonnucleoside reverse transcriptase inhibitor (NNRTI)-based first-line highly active antiretroviral therapy (HAART) in HIV-1-infected Kenyan children unexposed to nevirapine. DESIGN: Observational prospective cohort.

HIV-1 RNA level, CD4 lymphocyte count, weight for age z score, and height for age z score were measured before the initiation of HAART and every 3 to 6 months thereafter. Children received no nutritional supplements.

Sixty-seven HIV-1-infected children were followed for a median of 9 months between August 2004 and November 2005. Forty-seven (70%) used zidovudine, lamivudine (3TC), and an NNRTI (nevirapine or efavirenz), whereas 25% used stavudine (d4T), 3TC, and an NNRTI. Nevirapine was used as the NNRTI by 46 (69%) children, and individual antiretroviral drug formulations were used by 63 (94%), with only 4 (6%) using a fixed-dose combination of d4T, 3TC, and nevirapine (Triomune; Cipla, Mumbai, India). In 52 children, the median height for age z score and weight for age z score rose from -2.54 to -2.17 (P<0.001) and from -2.30 to -1.67 (P=0.001), respectively, after 6 months of HAART. Hospitalization rates were significantly reduced after 6 months of HAART (17% vs. 58%; P<0.001). The median absolute CD4 count increased from 326 to 536 cells/microL (P<0.001), the median CD4 lymphocyte percentage rose from 5.8% before treatment to 15.4% (P<0.001), and the median viral load fell from 5.9 to 2.2 log10 copies/mL after 6 months of HAART (P<0.001). Among 43 infants, 47% and 67% achieved viral suppression to less than 100 copies/mL and 400 copies/mL, respectively, after 6 months of HAART.

Good early clinical and virologic response to NNRTI-based HAART was observed in HIV-1-infected Kenyan children with advanced HIV-1 disease.

Understanding infant feeding practices in the context of HIV and factors that put mothers at risk of HIV infection is an important step towards prevention of mother to child transmission of HIV (PMTCT). Face-to-face (FTF) interviewing may not be a suitable way of ascertaining this information because respondents may report what is socially desirable. Audio computer-assisted self-interviewing (ACASI) is thought to increase privacy, reporting of sensitive issues and to eliminate socially desirable responses. We compared ACASI with FTF interviewing and explored its feasibility, usability, and acceptability in a PMTCT program in Kenya.

A graphic user interface (GUI) was developed using Macromedia Authorware and questions and instructions recorded in local languages Kikuyu and Kiswahili. Eighty mothers enrolled in the PMTCT program were interviewed with each of the interviewing mode (ACASI and FTF) and responses obtained in FTF interviews and ACASI compared using McNemar's chi2 for paired proportions. A paired Student's t-test was used to compare means of age, marital-time and parity when measuring interview mode effect and two-sample Student's t-test to compare means for samples stratified by education level - determined during the exit interview. A Chi-Square (chi2test) was used to compare ability to use ACASI by education level.

Mean ages for intended time for breastfeeding as reported by ACASI were 11 months by ACASI and 19 months by FTF interviewing (p < 0.001). Introduction of complementary foods at
Conclusion:

ACASI seems to improve quality of information by increasing response to sensitive questions, decreasing socially desirable responses, and by preventing null responses and was suitable for collecting data in a setting where formal education is low.

Female sex workers (FSWs) often lack the ability to negotiate safer sex and are at high risk for HIV-1 infection and sexually transmitted infections (STIs).

Seronegative FSWs were enrolled in an STI/HIV-1 prevention trial in Nairobi, Kenya. Demographics and sexual risk taking were assessed every 3 months. Predictors of reduced risk taking were defined using multivariate logistic regression.

Four hundred sixty-six FSWs were enrolled and followed for just over 2 years each. A spectrum of sex work was apparent: FSWs working in night clubs were younger, charged more for sex, and used condoms more frequently; FSWs working from home were older, charged less, and used condoms the least; and those working in bars were intermediate. Increases in reported condom use were most significant and sustained for FSWs working from home and charging less for sex and were poorly maintained for bar-based FSWs. Self-reported lower condom use, higher client numbers, and alcohol use were associated with higher STI rates.

Home-based FSWs and those charging less for sex used condoms the least at baseline but showed the greatest and most sustained improvements over time. Potential response heterogeneity in FSW subgroups should be considered in the design of HIV-1 prevention programs.

To determine the clinical and immunological outcomes of a cohort of HIV-infected patients receiving antiretroviral therapy.

Retrospective study of prospectively collected data from consecutively enrolled adult HIV-infected patients in eight HIV clinics in western Kenya.

CD4 cell counts, weight, mortality, loss to follow-up and adherence to antiretroviral therapy were collected for the 2059 HIV-positive non-pregnant adult patients treated with antiretroviral drugs between November 2001 and February 2005.

Median duration of follow-up after initiation of antiretroviral therapy was 40 weeks (95% confidence interval, 38-43); 111 patients (5.4%) were documented as deceased and 505 (24.5%) were lost to follow-up. Among 1766 (86%) evaluated for adherence to their antiretroviral regimen, 78% reported perfect adherence at every visit. Although patients with and without perfect adherence gained weight, patients with less than perfect adherence gained 1.04 kg less weight than those reporting perfect adherence (P = 0.059). CD4 cell counts increased by a mean of 109 cells/microl during the first 6 weeks of therapy and increased more slowly thereafter, resulting in overall CD4 cell count increases of 160, 225 and 297 cells/microl at 12, 24, and 36 months respectively. At 1 year, a mean increase of 170 cells/microl was seen among patients reporting perfect adherence compared with 123 cells/microl among those reporting some missed doses (P < 0.001).

Antiretroviral treatment of adult Kenyans in this cohort resulted in significant and persistent clinical and immunological benefit. These findings document the viability and effectiveness of large-scale HIV treatment initiatives in resource-limited settings.

With all the resources to combat the scourge in the country, women leaders are needed at every level to unite and counter the spread of the virus.

It is imperative that prevention information, confidential counselling and testing, treatment for sexually transmitted diseases and comprehensive drug and anti-retroviral treatment be available to men and women equally.

This presentation will examine the experiences of Liverpool VCT in providing prevention and care services to MSM in Kenya. As the only organization in East Africa actively undertaking this work, LVCT has insights and experience that other organizations may benefit from.

Specifically, this presentation will examine lessons learnt in the provision of prevention and care services for MSM in Kenya, as well as presenting national VCT data on MSM, prevalence rates and related challenges.

The presentation will recommend increased access for MSM to VCT, care and RH services as well as creating targeted interventions that are acceptable to MSM.

The Deaf community numbers approximately 650,000 out of about 32,000,000 people in Kenya. It is most concentrated in the urbane regions and also spread out in the rural areas in lesser but significant numbers. In the Deaf community, access to education and services is more limited and employment either is lower or reaps less per capita income than the rest of the population. With its own linguistic culture based in Kenyan Sign Language, this community faces stigma and poverty at a more alarming level than general.

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  Implement high quality voluntary counseling and testing (VCT) and care services throughout Kenya
  
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  Provide technical assistance and support to GoK and partners
  
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  Develop research- and evidence-based practice to inform policy
  

Since October 2003, LVCT has trained 12 Deaf counselours and mobilizers and established three Deaf VCT stand-alone sites in Kisumu, Mombasa, and Nairobi, reinforced by monthly mobile VCT clinics in surrounding regions. After counseling and testing, Deaf clients who test positive for HIV are referred to local clinics that provide care and ART therapy. The objectives of the programme are two-fold:

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  To increase provision and quality of VCT and care services for Deaf clientele
  
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  To increase provision and quality of VCT services for the adjacent hearing population
  

In 2005, a coordinator position held by a Deaf professional was also established to run the programme.

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  Maintaining anonymity and confidentiality in Deaf community
  
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  Mobilization of rural Deaf communities requires more support, consistency, time, and creativity
  
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  Data on Deaf clientele is lacking
  
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  Limited Deaf involvement in professional development
  
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  Quality of care of Deaf PLWHA decreases after VCT service
  

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  Data collection of Deaf and physically challenged clientele needs to be incorporated in national data system
  
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  VCT & Care scale-up then must begin to reflect above data e.g. access ramps & lifts, sign language fluency and sensitivity training among care providers
  
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  Increase provision of Deaf counselors at rural stand alone sites near sizable Deaf communities and trim down over-reliance on costly mobile VCT activities
  

The study covered the period between Jan 2^nd and December 31^st 2006. The essence was to assess the HIV status and other related data of the clients who were attended in that VCT centre that year. The details of all the clients were documented and analyzed appropriately.

The results, conclusions and recommendations were there from extracted.

Objectives:

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  To relate the demographic data to the HIV status
  
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  To assess the purpose of attendance
  
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  To assess the sexual practices
  
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  To make some recommendations based on findings
  

Of the 846 clients who attended the number and the attendant percentage of those tested was documented. This was also done for those found to be seropositive. The demographic data of all the clients and the infected ones was analyzed and compared. The information on the services required and how the clients knew of their existence was documented and analyzed. Sexual history over the last twelve months and the use of the condom was analyzed as was couple discordance and the referral pattern.

Of the 846 clients who attended, 715(84.5%) were tested and 36(5.0%) found to be positive. Of these positive ones 25(69.4%) were females. The age-group most affected was 29-32 years. Although the students constituted 54.7% of the total population, they were the least affected. One the other hand the married monogamous were the most affected (36.1% of the seropositive). Plan for the future and the desire to know the serostatus were the key reasons for visiting the clinic. Information from a relative or friends was the key motivation for the visit. There was still a proposion of clients with multiple sexual partners yet condom use was mstill low. No couple discordance was noted and the referral was done appropriately.

The seropositivity and its female to ratio are similar to the National one. The age group distribution seems to peak at 29-32 years, decline rapidly thereafter and then plateau at between 34 and 44 years before a final gentle drop. This pattern would be expected. The students and the professionals had the lowest infection rates. It is possible they could have been more sensitized but there was a reasonable number of students who had not had sex and many also with one sexual partner. Of the educated, those with secondary education had the highest infection rate.

One would have expected the primary education level. Besides, those without education had the lowest rate. However, those without a job had the highest rate. The married monogamous comprised about 40% of those infected. It might help to investigate this cohort. Most clients wanted to know their status with a future in mind. Of concern are those with multiple sexual partners and yet condom use is low. This should be an area for emphasis in awareness and practice.
Recommendations:

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  Vigilance in our Universities on data collection, analysis and dissemination.
  
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  Address the needs of the non-academic staff from whom the infected cases were highest.
  
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  Find out why married monogamous clients were most affected
  
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  Continue information dissemination as catalyst for VCT attendance.
  
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  Find out modes of enhancing condom use especially where multiple sexual partners are concerned
  

Maternal-infant single-dose nevirapine (SDNVP) reduces perinatal HIV transmission, but induces viral resistance to non-nucleoside reverse transcriptase inhibitor (NNRTI) drugs in some women. Prior SDNVP exposure may compromise future maternal treatment with NNRTI-based antiretroviral therapy (ART).

Between May ’05 and Jan ’07, we enrolled SDNVP-exposed and unexposed women starting NNRTI-based ART in a prospective cohort study in Zambia, Thailand, and Kenya. Women were frequency matched at entry by WHO stage and CD4 cell count (CD4). We compared treatment failure (viral load [VL] >400 copies/ml, not on NNRTI, died) between exposure groups at 6 months after ART initiation.

We studied 878 women (355 SDNVP-exposed, 523 unexposed). SDNVP-exposed women were younger (29 vs 33 yrs, p<0.001), had a higher median CD4 (160 vs 139 cells/mm³ p=0.007), and lower median VL (97,300 vs 142,000 copies/ml, p=0.02), but were of similar weight (51 vs 52 kg, p=0.4). At 6 months after ART initiation, 186 (21%) women had failed (76 had VL >400 copies/ml, 51 discontinued the study, 48 died, and 11 had been changed to a protease inhibitor). Women with exposure to SDNVP <6 months before NNRTI-based ART initiation, with baseline CD4 0-49 cells/mm³, or VL >100,000 copies/ml had poorer treatment responses (Table). Women exposed to SDNVP >12 months before NNRTI-based ART did as well as unexposed women.

In a secondary analysis including only those still on NNRTI-based ART at 6 months, we found similar results.

A high proportion (79%) of women in this cohort responded to 6 months of NNRTI-based ART whether previously exposed to SDNVP or not. These data do suggest an increased risk of treatment failure among women with recent SDNVP exposure, but not with SDNVP exposure >12 months before initiation of NNRTI-based ART.

Treatment with ART or perinatal HIV prevention strategies other than SDNVP should be considered for pregnant women who are likely to initiate ART within 1 year after delivery.

Mother-to-child transmission (MTCT) is the most important source of HIV infection in children. Most PMTCT programs in Kenya have relied on a single dose nevirapine SDNVP) as the main prophylactic regime for (PMTCT), the simplest regimen for settings where resources are constrained. WHO more recently recommended newer and more efficacious regimens based on the available scientific evidence and progmmatic experience. The revised(2008 version) National Guidelines for Prevention of Mother-to-Child Transmission of HIV Infections in Kenya have incorporated these recommendation.

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  Review the magnitude and trends of mother –to-child transmission in Kenya.
  
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  Outline the components of the new national guidelines of PMTCT.
  
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  Identify new issues and strategies in the PMTCT based on current evidence and programmatic experience.
  
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  Discuss service, research and pragmatic implications of the new recommendations.
  
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  Results:
  
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  The new guidelines consist of the following ten chapters:
  
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  Background
  
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  Antenatal care and prevention of MTCT of HIV
  
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  Intrapartum care
  
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  Use of ARVs in pregnancy in treatment and prevention of mother-to-child transmission of HIV infection.
  
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  Immediate post natal and neonatal care.
  
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  Late post natal care and family planning
  
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  HIV diagnosis in children
  
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  Feeding infants and young children born to HIV infected mothers
  
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  Care and follow up of children of HIV infected mothers
  
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  Monitoring and evaluation pf the PMTCT services.
  

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  All HIV pregnant women in the need of treatment should receive ART
  
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  First line regimen for pregnant women in need of treatment is AZT+3TC +NVP
  
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  In women for whom ART is not indicated, AZT should be given from 28 weeks of pregnancy plus SDNVP and 3TC at the onset of labour with a 7 day tail of AZT plus 3TC to reduce the risk of NVP resistance; and the infant SDNVP soon after birth plus AZT for 7 days.
  
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  Alternative prophylactic regimens include AZT from 28 weeks plus SDNVP for women and SDNVP and 7 days AZT for infant.
  
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  Infants born HIV-positive women who had not received any ARVs should be given SDNVP at birth plus AZT for 4 weeks.
  
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  In programs (such as AMPATH) triple drug prophylaxis has been used since 2003. Experience gained shows that this is a feasible and effective option. Interruption in MTCT of less than 5% has been achieved using this regimen AZT+3TC +NLF/RJV (kaletra)
  

Achieving global as well as local targets of PMTCT is feasible if we can increase access to integrated and comprehensive programmes for preventing HIV infection in infants and young children. The 4 pronged PMTCT approach must be adopted with focus on all the four prongs.

Identification and characterization of bacterial species before and after UniPron administration, toxicity effect of UniPron on vaginal mucosa and body organs (liver and kidney).

To characterize the normal vaginal microbial flora during follicular, luteal and menstrual stages in the baboon.

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  To determine the effect of UniPron on normal vaginal microbial flora in the baboon.
  
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  To evaluate the effect of UniPron on the vaginal epithelium.
  
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  Determine the effect of UniPron on liver and kidney functions.
  

Investigation of safety of UniPron using a baboon model.

RESULTS:

Lactobacilli, the predominant bacteria in the normal vagina of humans was not affected by administration of UniPron. There were no visible lesions/irritation on vagina mucosa and liver and kidney function tests were normal.

UniPron did not cause any negative side effects and therefore safe to use in the baboon model.

These studies can be extended to humans.

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

Qualitative one-on-one in-depth interviews and observations of care provision.

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