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Chupradit S, Wamalwa DC, Maleche-Obimbo E, Kekitiinwa AR, Mwanga-Amumpaire J, Bukusi EA, Nyandiko WM, Mbuthia JK, Swanson A, Cressey TR, Punyawudho B, Musiime V. Population Pharmacokinetics of Pediatric Lopinavir/Ritonavir Oral Pellets in Children Living with HIV in Africa. Clin Pharmacol Ther 2024; 115:1105-1113. [PMID: 38247190 DOI: 10.1002/cpt.3174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/23/2023] [Indexed: 01/23/2024]
Abstract
Antiretroviral therapy for children living with HIV (CLHIV) under 3 years of age commonly includes lopinavir/ritonavir (LPV/r). However, the original liquid LPV/r formulation has taste and cold storage difficulties. To address these challenges, LPV/r oral pellets have been developed. These pellets can be mixed with milk or food for administration and do not require refrigeration. We developed the population pharmacokinetic (PK) model and assessed drug exposure of LPV/r oral pellets administered twice daily to CLHIV per World Health Organization (WHO) weight bands. The PK analysis included Kenyan and Ugandan children participating in the LIVING studies (NCT02346487) receiving LPV/r pellets (40/10 mg) and ABC/3TC (60/30 mg) dispersible tablets. Population PK models were developed for lopinavir (LPV) and ritonavir (RTV) to evaluate the impact of RTV on the oral clearance (CL/F) of LPV. The data obtained from the study were analyzed using nonlinear mixed-effects modeling approach. Data from 514 children, comprising a total of 2,998 plasma concentrations of LPV/r were included in the analysis. The LPV and RTV concentrations were accurately represented by a one-compartment model with first-order absorption (incorporating a lag-time) and elimination. Body weight influenced LPV and RTV PK parameters. The impact of RTV concentrations on the CL/F of LPV was characterized using a maximum effect model. Simulation-predicted target LPV exposures were achieved in children with this pellet formulation across the WHO weight bands. The LPV/r pellets dosed in accordance with WHO weight bands provide adequate LPV exposures in Kenyan and Ugandan children weighing 3.0 to 24.9 kg.
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Affiliation(s)
- Suthunya Chupradit
- PhD's Degree Program in Pharmacy, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Dalton C Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | | | | | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Winstone M Nyandiko
- Department of Child Health and Paediatrics - Moi University, AMPATH and Moi Teaching and Referral Hospital, Eldoret, Kenya
| | | | - Alistair Swanson
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
- Drugs for Neglected Diseases Initiative, Nairobi, Kenya
- Drugs for Neglected Diseases Initiative, Bethesda, Maryland, USA
| | - Tim R Cressey
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Baralee Punyawudho
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Victor Musiime
- Joint Clinical Research Centre, Kampala, Uganda
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
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Mulinge MM, Abisi HK, Kabahweza HM, Okutoyi L, Wamalwa DC, Nduati RW. The Role of Maternal Secretor Status and Human Milk Oligosaccharides on Early Childhood Development: A Systematic Review and Meta-Analysis. Breastfeed Med 2024. [PMID: 38577928 DOI: 10.1089/bfm.2023.0274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Background: Breast milk is the gold standard of infant nutrition, delivering nutrients and bioactive molecules as needed to support optimal infant growth and cognitive development. Increasing evidence links human milk oligosaccharides (HMOs) to these early childhood development milestones. Aims: To summarize and synthesize the evidence relating to HMOs and infant brain development, physical growth, and cognitive development. In addition, HMO concentrations in secretor and nonsecretor mothers were compared via a meta-analysis. Study Design: A systematic review and meta-analysis were carried out in accordance with the PRISMA statement. This review used three databases (PubMed, Scopus, and Web of Science) and was limited to English-language articles published between 2000 and June 30, 2023. Results: The initial searches yielded 245 articles, 27 of which were included in the systematic review and 12 in the meta-analysis. The meta-analysis revealed a substantial between-study heterogeneity, I2 = 97.3%. The pooled effect was 0.21 (95% CI: -0.41 to 0.83; p = 0.484), indicating that secretors had higher HMO concentrations, although this difference was not statistically significant. At one month of age, 2'FL, 3FL, and 3'SL play an important role in brain maturation and thus play a critical role in cognitive development. Secretors produce higher concentrations of 2'FL and 3'SL, explaining the benefits to infants of secretor mothers. Growth velocity was correlated to fucosylated and sialylated HMO concentrations, with lower concentrations linked to stunting. Conclusions: According to evidence from the systematically reviewed articles, HMOs are essential for a child's early development, but the extent to which they have an impact depends on maternal secretor status.
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Affiliation(s)
- Martin M Mulinge
- Department of Biochemistry, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Hellen K Abisi
- Department of Biochemistry, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Hellen M Kabahweza
- Department of Pediatric Hematology & Oncology, Joint Clinical Research Centre, Kampala, Uganda
| | - Lydia Okutoyi
- Department of Health Care Quality, Kenyatta National Hospital, Nairobi, Kenya
| | - Dalton C Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Ruth W Nduati
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Mulinge MM, Kibui NK, Kimani H, Wainaina J, Bwana P, Omondi M, Wafula K, Wamalwa DC, Omondi EO, Nduati RW, Mwau M. Factors associated with viral load non-suppression among treatment-experienced pre-teenage children living with HIV in Kenya: a nationwide population-based cohort study, 2015-2021. EClinicalMedicine 2024; 68:102454. [PMID: 38333535 PMCID: PMC10850406 DOI: 10.1016/j.eclinm.2024.102454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 01/13/2024] [Accepted: 01/15/2024] [Indexed: 02/10/2024] Open
Abstract
Background Viral load non-suppression (VLNS) in children is a major public health concern because of attendant HIV disease progression and risk of morbidity and mortality. Based on a nationally representative database we present estimates of the prevalence, trends and factors associated with VLNS in Kenyan pre-teenage children between 2015 and 2021. Methods Kenya National AIDS & STI Control Program's (NASCOP) maintains an early infant diagnosis and viral load (EID/VL) database for all persons living with HIV who are enrolled in the country's primary care clinics for purposes of monitoring progress towards achievement of the 95% viral suppression goals. Participants were eligible if they were children living with HIV (CLHIV), on combination ART (cART) treatment, and ≤12 years old. The modified Mann-Kendall trend test for serially correlated data was used to identify VLNS trends. Generalized estimating equations (GEE) with a logit link was used to assess the effects of covariates on the odds of VLNS (VL ≥1,000 copies/mL) over repeated points in time, allowing for the correlation among the repeated measures. Findings Between January 2015 and December 2021, 508,743 viral load tests were performed on samples collected from 109,682 pre-teenage children. The prevalence of VLNS decreased from 22.9% (95% CI 22.4-23.3) to 12.5% (95% CI 12.1-12.9), p < 0.0001, and mean age increased from 3.1 (4.2) to 8.0 (3.2) years in 2015 and 2021 respectively. A modified Mann-Kendall trend test for serially correlated data denotes a statistically significant decreasing trend (τ = -0.300, p < 0.0001) over the study period. In the multivariable GEE analysis adjusted for covariates, the odds of VLNS decreased by 11% per year during the study period, (GEE-aOR 0.89, 95% CI 0.88-0.90; p < 0.0001). Factors positively associated with VLNS were EFV/NVP-based first-line cART regimen (GEE-aOR 1.74, 95% CI 1.65-1.84, p < 0.0001), PI-based cART regimen (GEE-aOR 1.82, 95% CI 1.72-1.92, p < 0.0001), and children aged 1-3 years (toddlers) (GEE-aOR: 1.84, 95% CI 1.79-1.90, p < 0.0001). On the contrary, DTG-based cART regimen, were negatively associated with VLNS (GEE-aOR 0.70, 95% CI 0.65-0.75, p < 0.0001). Interpretation There is a strong evidence of decreasing viremia between 2015 and 2021. To sustain the decreasing trend, accelerating the switch from the suboptimal EVP/NVP first-line regimen to optimised DTG regimen is warranted. Funding U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and Clinton Health Access Initiative (CHAI).
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Affiliation(s)
| | - Nancy K. Kibui
- Department of Biochemistry, University of Nairobi, Nairobi, Kenya
- Centre for Infectious and Parasitic Diseases Control Research, Kenya Medical Research Institute, Busia, Kenya
| | - Humphrey Kimani
- Centre for Infectious and Parasitic Diseases Control Research, Kenya Medical Research Institute, Busia, Kenya
| | - Joseph Wainaina
- Centre for Infectious and Parasitic Diseases Control Research, Kenya Medical Research Institute, Busia, Kenya
| | - Priska Bwana
- Centre for Infectious and Parasitic Diseases Control Research, Kenya Medical Research Institute, Busia, Kenya
| | - Martin Omondi
- Centre for Infectious and Parasitic Diseases Control Research, Kenya Medical Research Institute, Busia, Kenya
| | - Kevin Wafula
- Centre for Infectious and Parasitic Diseases Control Research, Kenya Medical Research Institute, Busia, Kenya
| | - Dalton C. Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Evans O. Omondi
- African Population and Health Research Center, Nairobi, Kenya
- Institute of Mathematical Sciences, Strathmore University, Nairobi, Kenya
| | - Ruth W. Nduati
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Matilu Mwau
- Centre for Infectious and Parasitic Diseases Control Research, Kenya Medical Research Institute, Busia, Kenya
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Mugo C, Njuguna IN, Beima-Sofie K, Mburu CW, Onyango A, Itindi J, Richardson BA, Oyiengo L, John-Stewart G, Wamalwa DC. Adolescent experiences, perceptions, and preferences for the process of HIV status disclosure in Kenya. Front Public Health 2023; 11:1165557. [PMID: 38106888 PMCID: PMC10725248 DOI: 10.3389/fpubh.2023.1165557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 10/30/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction Disclosure of HIV status to adolescents living with HIV has been associated with improved treatment outcomes. However, there are limited data regarding the experiences of, perceptions of, and preferences for the process of disclosure of HIV status among adolescents and young adults living with HIV (AYLH), especially in sub-Saharan Africa. Methods Young adults living with HIV from 20 HIV clinics in Kenya who participated in a clinical trial evaluating the effectiveness of a disclosure and transition package completed an anonymous survey in 2019. We described their experiences and preferences using counts and proportions and assessed factors associated with satisfaction with the disclosure process using linear regression, reporting age-adjusted mean differences (aMD), and 95% confidence intervals (95%CIs). Results Of the 375 enrolled AYLH, 265 (71%) had perinatally acquired HIV, of whom 162 (61%) were female. The median age of the enrolled AYLH was 16 years (IQR: 14-19 years), and all of them were on antiretroviral therapy (ART). For over half (55%) of the participants, caregivers disclosed their HIV status, and 57% preferred that their caregivers disclose the status to them. Most (78%) of the participants preferred full disclosure by 12 years of age. The majority (69%) believed the disclosure was planned, and 11% suspected being HIV positive before the disclosure. Overall, 198 (75%) AYLH reported that they were ready for disclosure when it happened, and 86% were satisfied with the process. During both pre-disclosure (67 and 70%, respectively) and post-disclosure (>75% for each), AYLH felt supported by the clinic and caregivers. Factors associated with higher satisfaction with the disclosure process were pre-disclosure clinic support (aMD: 0.19 [95%CI: 0.05-0.33]) and pre-disclosure (aMD: 0.19 [0.06-0.31]) and post-disclosure (aMD: 0.17 [0.03-0.31]) caregiver support. AYLH who suspected they were HIV positive before they were disclosed to tended to have lower satisfaction when compared to those who never suspected (aMD: -0.37 [-0.74-(-0.01)]). Overall, they reported that disclosure positively influenced their ART adherence (78%), clinic attendance (45%), and communication with caregivers (20%), and 40% reported being happier after disclosure. Conclusion Young adults living with HIV advocated for an appropriately timed disclosure process with the involvement of caregivers and healthcare workers (HCWs). Support from caregivers and HCWs before and during disclosure is key to improving their disclosure experience.
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Affiliation(s)
- Cyrus Mugo
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Irene N. Njuguna
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Kristin Beima-Sofie
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Caren W. Mburu
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Alvin Onyango
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | - Barbra A. Richardson
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Laura Oyiengo
- National AIDS and STI Control Program, Ministry of Health, Kenya, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Dalton C. Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Chupradit S, Wamalwa DC, Maleche-Obimbo E, Kekitiinwa AR, Mwanga-Amumpaire J, Bukusi EA, Nyandiko WM, Mbuthia JK, Swanson A, Cressey TR, Punyawudho B, Musiime V. Abacavir Drug Exposures in African Children Under 14 kg Using Pediatric Solid Fixed Dose Combinations According to World Health Organization Weight Bands. J Pediatric Infect Dis Soc 2023; 12:574-580. [PMID: 37798141 PMCID: PMC10756690 DOI: 10.1093/jpids/piad082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/04/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND The pharmacokinetics of abacavir (ABC) in African children living with HIV (CLHIV) weighing <14 kg and receiving pediatric fixed dose combinations (FDC) according to WHO weight bands dosing are limited. An ABC population pharmacokinetic model was developed to evaluate ABC exposure across different World Health Organization (WHO) weight bands. METHODS Children enrolled in the LIVING study in Kenya and Uganda receiving ABC/lamivudine (3TC) dispersible tablets (60/30 mg) according to WHO weight bands. A population approach was used to determine the pharmacokinetic parameters. Monte Carlo simulations were conducted using an in silico population with demographic characteristics associated with African CLHIV. ABC exposures (AUC0-24) of 6.4-50.4 mg h/L were used as targets. RESULTS Plasma samples were obtained from 387 children. A 1-compartment model with allometric scaling of clearance (CL/F) and volume of distribution (V/F) according to body weight best characterized the pharmacokinetic data of ABC. The maturation of ABC CL/F was characterized using a sigmoidal Emax model dependent on postnatal age (50% of adult CL/F reached by 0.48 years of age). Exposures to ABC were within the target range for children weighing 6.0-24.9 kg, but children weighing 3-5.9 kg were predicted to be overexposed. CONCLUSIONS Lowering the ABC dosage to 30 mg twice daily or 60 mg once daily for children weighing 3-5.9 kg increased the proportion of children within the target and provided comparable exposures. Further clinical study is required to investigate clinical implications and safety of the proposed alternative ABC doses.
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Affiliation(s)
- Suthunya Chupradit
- PhD’s Degree Program in Pharmacy, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Dalton C Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | | | | | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Winstone M Nyandiko
- Department of Child Health and Paediatrics—Moi University, AMPATH and Moi Teaching and Referral Hospital, Eldoret, Kenya
| | | | - Alistair Swanson
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
- Drugs for Neglected Diseases Initiative, Nairobi, Kenya
- Drugs for Neglected Diseases Initiative, New York, USA
| | - DNDi Clinical Team
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
- Drugs for Neglected Diseases Initiative, Nairobi, Kenya
- Drugs for Neglected Diseases Initiative, New York, USA
| | - Tim R Cressey
- AMS/IRD Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Baralee Punyawudho
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Victor Musiime
- Joint Clinical Research Centre, Kampala, Uganda
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
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Mulinge MM, Oluoch JO, Abisi HK, Otieno LE, Anzala O, Wamalwa DC, Nduati RW, Kimani J, Herbeck J, McKinnon L. Age and CD4+ T cell counts are inversely associated with HIV drug resistance mutations in treatment naive female sex workers. Medicine (Baltimore) 2023; 102:e34060. [PMID: 37327289 PMCID: PMC10270489 DOI: 10.1097/md.0000000000034060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/31/2023] [Indexed: 06/18/2023] Open
Abstract
The increasing prevalence of human immunodeficiency virus (HIV) drug resistance mutations (HIVDRM) in untreated seropositive persons has consequences for future treatment options. This is extremely important in key populations such as female sex workers (FSWs), where the prevalence of pretreatment drug resistance (PDR) and associated risk factors are unknown. In this study, we analyzed PDR and associated risk factors in recently diagnosed and treatment-naive FSWs in Nairobi, Kenya. In this cross-sectional study, we used 64 HIV-seropositive plasma samples collected from FSWs between November 2020 and April 2021. To identify HIVDRM, the pol gene was amplified and genotyped using sanger sequencing. The effects of age, tropism, CD4+ T cell count, subtype, and location on HIVDRM counts were examined using Poisson regression. Overall, the prevalence of PDR was 35.9% (95% CI: 24.3-48.9), which was strongly influenced by K103N and M184V mutations, which confer resistance to non-nucleoside reverse transcriptase inhibitors (NNRTIs) and nucleoside reverse transcriptase inhibitors (NRTI), respectively. Subtype A1 was predominant followed by subtype D with a notable increase in inter-subtype recombinants. We found statistically significant evidence that age was inversely related to HIVDRM. A FSW who is 1 year older had 12% less HIVDRM (incidence rate ratios [IRR]: 0.88; 95% CI: 0.82-0.95; P < .001), after adjusting for CD4+ T cell count, subtype, location, and tropism. Similarly, an increase in CD4+ T cell count by 1 unit, was associated with 0.4% fewer HIVDRM (IRR: 0.996; 95% CI: 0.994-0.998; P = .001), while controlling for the other variables. HIV-1 tropism was not associated with HIVDRM counts. In conclusion, our findings show a high prevalence of NNRTIs. Lower CD4+ T cell counts and younger age were significant risk factors that influenced HIVDRM loads. This finding underscores the relevance of targeted interventions and the importance of continuing to focus on FSWs as a way of addressing the HIV epidemic.
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Affiliation(s)
- Martin M. Mulinge
- Department of Biochemistry, University of Nairobi, Nairobi, Kenya
- Kenya AIDS Vaccine Initiative - Institute of Clinical Research (KAVI-ICR), University of Nairobi, Nairobi, Kenya
| | - Jeff O. Oluoch
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Hellen K. Abisi
- Department of Biochemistry, University of Nairobi, Nairobi, Kenya
| | - Leon E. Otieno
- Molecular Medicine and Infectious Diseases Laboratory, University of Nairobi, Kenya
| | - Omu Anzala
- Kenya AIDS Vaccine Initiative - Institute of Clinical Research (KAVI-ICR), University of Nairobi, Nairobi, Kenya
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Dalton C. Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Ruth W. Nduati
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Joshua Kimani
- Partners for Health and Development in Africa (PHDA), Nairobi, Kenya
| | - Joshua Herbeck
- Department of Global Health, University of Washington, Seattle, WA
| | - Lyle McKinnon
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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Mugo C, Kohler P, Kumar M, Badia J, Kibugi J, Wamalwa DC, Kapogiannis B, Agot K, John-Stewart GC. Effect of HIV stigma on depressive symptoms, treatment adherence, and viral suppression among youth with HIV. AIDS 2023; 37:813-821. [PMID: 36728652 PMCID: PMC10023427 DOI: 10.1097/qad.0000000000003473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We estimated the effects of HIV stigma on mental health and treatment outcomes for youth with HIV (YWH). DESIGN Secondary analysis of data for YWH ages 15-24 years in Western Kenya. METHODS Participants completed a longitudinal survey (baseline, months 6 and 12) assessing socio-demographics, antiretroviral therapy (ART) adherence, depressive symptoms (PHQ-9), and HIV stigma (10-item Wright scale). First viral load (VL) after enrollment was abstracted from records. We estimated risk of depressive symptoms (score > 4), nonadherence (missing ≥2 days of ART in a month), and detectable VL (≥50 copies/ml) for each standard deviation (SD) increase in HIV stigma score, adjusted for age and sex (and regimen in VL model). The generalizing estimating equation models included measures for the three visits. RESULTS Median age for the 1011 YWH was 18 years. At baseline, frequency of nonadherence, depressive symptoms and detectable VL was 21%, 21%, and 46%, respectively. Mean stigma score was 25 (SD = 7.0). Each SD stigma score increment was associated with higher risk of depressive symptoms {adjusted relative risk [aRR] 1.31 [95% confidence interval (CI): 1.20-1.44]}, nonadherence [aRR 1.16 (CI: 1.05-1.27)] and detectable VL [aRR 1.20 (CI: 1.08-1.32)]. Experienced and anticipated stigma were associated with detectable VL [aRR 1.16 (CI: 1.10-1.22) and aRR 1.23 (CI: 1.12-1.35), respectively]. Internalized and perceived community stigma were associated with depressive symptoms [aRR 1.31 (CI: 1.21-1.40) and aRR 1.24 (CI: 1.13-1.36), respectively]. CONCLUSIONS Stigma was associated with depressive symptoms, nonadherence and detectable VL. Interventions to decrease stigma may improve virologic and mental health outcomes in YWH.
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Affiliation(s)
- Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Epidemiology
| | - Pamela Kohler
- Department of Child, Family, and Population Health Nursing
- Department of Global Health
| | - Manasi Kumar
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
- Department of Psychiatry
| | - Jacinta Badia
- Impact Research and Development Organization, Kisumu, Kenya
| | - James Kibugi
- Impact Research and Development Organization, Kisumu, Kenya
| | - Dalton C Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Grace C John-Stewart
- Department of Epidemiology
- Department of Global Health
- Department of Pediatrics and
- Department of Medicine, University of Washington, Seattle, Washington, USA
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Mugo C, Firdawsi O, Wang J, Njuguna IN, Wamalwa DC, Slyker JA, John-Stewart GC, O'Malley G, Wagner AD. "When they are all grown, I will tell them": Experience and perceptions of parental self-disclosure of HIV status to children in Nairobi, Kenya. BMC Public Health 2023; 23:519. [PMID: 36932351 PMCID: PMC10024367 DOI: 10.1186/s12889-023-15387-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 03/07/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND There is mixed evidence on the influence of self-disclosure of one's HIV status on mental health, health behaviours and clinical outcomes. We studied the patterns of self-disclosure among parents living with HIV, and factors that influence parental disclosure. METHODS This mixed-methods study was among adults in HIV care participating in a study assessing the uptake of pediatric index-case testing. They completed a survey to provide demographic and HIV-related health information, and assess self-disclosure to partners, children and others. We ran generalized linear models to determine factors associated with disclosure and reported prevalence ratios (PR). Eighteen participants also participated in in-depth interviews to explore perceived barriers and facilitators of self-disclosure to one's child. A content analysis approach was used to analyze interview transcripts. RESULTS Of 493 caregivers, 238 (48%) had a child ≥ 6 years old who could potentially be disclosed to about their parent's HIV status. Of 238 participants, 205 (86%) were female, median age was 35 years, and 132 (55%) were in a stable relationship. Among those in a stable relationship, 96 (73%) knew their partner's HIV status, with 79 (60%) reporting that their partner was living with HIV. Caregivers had known their HIV status for a median 2 years, and the median age of their oldest child was 11 years old. Older caregiver age and older first born child's age were each associated with 10% higher likelihood of having disclosed to a child (PR: 1.10 [1.06-1.13] and PR: 1.10 [1.06-1.15], per year of age, respectively). The child's age or perceived maturity and fear of causing anxiety to the child inhibited disclosure. Child's sexual activity was a motivator for disclosure, as well as the belief that disclosing was the "right thing to do". Caregivers advocated for peer and counseling support to gain insight on appropriate ways to disclose their status. CONCLUSIONS Child's age is a key consideration for parents to disclose their own HIV status to their children. While parents were open to disclosing their HIV status to their children, there is a need to address barriers including anticipated stigma, and fear that disclosure will cause distress to their children.
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Affiliation(s)
- Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, 00202, Kenya.
- Department of Epidemiology, University of Washington, Box 359909, 3980 15th Ave. NE, Seattle, WA, 98195, USA.
| | - Olivia Firdawsi
- Department of Global Health, University of Washington, Box 359909, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Jiayu Wang
- Department of Global Health, University of Washington, Box 359909, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Irene N Njuguna
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, 00202, Kenya
- Department of Global Health, University of Washington, Box 359909, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Dalton C Wamalwa
- Department of Medicine, University of Washington, Box 359909, WA, 98104, Seattle, USA
| | - Jennifer A Slyker
- Department of Global Health, University of Washington, Box 359909, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Grace C John-Stewart
- Department of Epidemiology, University of Washington, Box 359909, 3980 15th Ave. NE, Seattle, WA, 98195, USA
- Department of Global Health, University of Washington, Box 359909, 3980 15th Ave. NE, Seattle, WA, 98195, USA
- Department of Medicine, University of Washington, Box 359909, 3980 15th Ave. NE, Seattle, WA, 98195, USA
- Department of Pediatrics, University of Nairobi, Nairobi, KE, 00202, USA
| | - Gabrielle O'Malley
- Department of Global Health, University of Washington, Box 359909, 3980 15th Ave. NE, Seattle, WA, 98195, USA
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, Box 359909, 3980 15th Ave. NE, Seattle, WA, 98195, USA
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9
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Black DA, LaCourse SM, Njuguna IN, Beima-Sofie KM, Mburu CW, Mugo C, Itindi J, Onyango A, Richardson BA, Wamalwa DC, John-Stewart GC. Tuberculosis Preventative Therapy Initiation and Completion Among Adolescents and Young Adults Living With HIV in Kenya. J Acquir Immune Defic Syndr 2023; 92:250-259. [PMID: 36724437 PMCID: PMC9928888 DOI: 10.1097/qai.0000000000003131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/24/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Tuberculosis is the leading cause of death among adolescents and young adults living with HIV (YWHIV) and their heightened risk warrants deeper understanding of utilization of tuberculosis-prevention measures within HIV care. SETTING Retrospective study using clinic surveys and medical record data from 86 Kenyan HIV clinics. METHODS Clinic surveys obtained information on tuberculosis preventive therapy (TPT) services. Medical records of YWHIV were abstracted. Bivariate and multivariate analyses used generalized linear models to determine individual-level and clinic-level cofactors of TPT initiation and completion. RESULTS Among 10,328 eligible YWHIV, 4337 (42.0%) initiated TPT. Of 3295 with ≥6 months follow-up, 1774 (53.8%) completed TPT. A lower patient-to-staff ratio was a clinic-level cofactor of TPT initiation ( P = 0.044) and completion ( P = 0.004); designated adolescent areas were associated with TPT initiation {prevalence ratio 2.05 [95% confidence interval (CI): 1.46 to -2.88]}. Individual cofactors of TPT initiation included younger age at HIV-care enrollment [relative risk (RR) 0.85 (95% CI: 0.80 to 0.90)] and antiretroviral therapy (ART) duration [1-2 vs. <1 year RR 1.31 (95% CI: 1.18 to 1.45)]. TPT completion was associated with younger age [RR 0.91 (95% CI: 0.85 to 0.98)] and ART duration [2-5 vs. <1 year RR 1.27 (95% CI: 1.03 to 1.57)]. In multivariate models, TPT initiation was associated with younger age and ART duration [1-2 vs. 1 year; adjusted RR 1.30 (95% CI: 1.16 to 1.46)] and TPT completion with ART duration [2-5 vs. 1 year adjusted RR 1.23 (95% CI: 0.99 to 1.52)]. CONCLUSION Over half of YWHIV did not initiate and >40% did not complete TPT, with distinct clinic-level and individual-level cofactors. Approaches to enhance adolescent-friendly infrastructure and support older YWHIV are necessary to improve TPT use.
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Affiliation(s)
- Danae A Black
- Departments of Epidemiology; Medicine; Global Health, University of Washington, Seattle, WA
| | - Sylvia M LaCourse
- Departments of Epidemiology; Medicine; Global Health, University of Washington, Seattle, WA
| | - Irene N Njuguna
- Departments of Epidemiology; Medicine; Global Health, University of Washington, Seattle, WA
- Kenyatta National Hospital, Nairobi, Kenya
| | - Kristin M Beima-Sofie
- Departments of Epidemiology; Medicine; Global Health, University of Washington, Seattle, WA
| | - Caren W Mburu
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Cyrus Mugo
- Departments of Epidemiology; Medicine; Global Health, University of Washington, Seattle, WA
- Kenyatta National Hospital, Nairobi, Kenya
| | - Janet Itindi
- Kenya Medical Research Institute, Nairobi, Kenya; and
| | - Alvin Onyango
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Barbra A Richardson
- Departments of Epidemiology; Medicine; Global Health, University of Washington, Seattle, WA
- Departments of Biostatistics; Pediatrics, University of Washington, Seattle, WA
| | - Dalton C Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace C John-Stewart
- Departments of Epidemiology; Medicine; Global Health, University of Washington, Seattle, WA
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10
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Mugo C, Kohler P, Kumar M, Badia J, Kibugi J, Wamalwa DC, Agot K, John-Stewart GC. Individual-, Interpersonal- and Institutional-Level Factors Associated with HIV Stigma Among Youth in Kenya. AIDS Behav 2023:10.1007/s10461-023-03982-9. [PMID: 36646929 PMCID: PMC9843110 DOI: 10.1007/s10461-023-03982-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 01/18/2023]
Abstract
HIV stigma remains a barrier in achieving optimal HIV treatment. We studied the prevalence and predictors of HIV stigma among adolescents and youth with HIV (AYWHIV) ages 15-24 years in Western Kenya. Of 1011 AYWHIV, 69% were female with a median age of 18 years. Most (59%) attended adolescent clinic days, and 40% attended support groups. One-quarter (27%) had experienced physical, 18% emotional, and 7% sexual violence. The majority of AYWHIV (88%) reported disclosure concerns, 48% reported perceived community stigma, 36% experienced, and 24% internalized stigma. Compared to AYWHIV attending adolescent clinics, those in general/adult clinics had higher internalized stigma. Similarly, having dropped out of school was associated with higher internalized stigma. AYWHIV in sexual relationships had higher experienced stigma and disclosure concerns. Lastly, exposure to violence was associated with higher experienced, internalized, perceived community stigma and disclosure concerns. These risk factors can be targeted when developing stigma-prevention interventions.
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Affiliation(s)
- Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, Hospital Road, P.O. Box 00202, Nairobi, Kenya.
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | - Pamela Kohler
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Manasi Kumar
- Department of Research and Programs, Kenyatta National Hospital, Hospital Road, P.O. Box 00202, Nairobi, Kenya
- Department of Psychiatry, University of Nairobi, Nairobi, Kenya
- Brain and Mind Institute, Aga Khan University, Nairobi, Kenya
| | - Jacinta Badia
- Impact Research and Development Organization, Kisumu, Kenya
| | - James Kibugi
- Impact Research and Development Organization, Kisumu, Kenya
| | - Dalton C Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Grace C John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
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11
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Abisi HK, Otieno LE, Irungu E, Onyambu FG, Chepchirchir A, Anzala O, Wamalwa DC, Nduati RW, McKinnon L, Kimani J, Mulinge MM. Net charge and position 22 of the V3 loop are associated with HIV-1 tropism in recently infected female sex workers in Nairobi, Kenya. Medicine (Baltimore) 2022; 101:e32024. [PMID: 36626483 PMCID: PMC9750520 DOI: 10.1097/md.0000000000032024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Human immunodeficiency virus (HIV) infection affects around 37 million people worldwide, and in Kenya, key populations especially female sex workers (FSW), are thought to play a substantial role in the wider, mostly heterosexual HIV-1 transmission structure. Notably, HIV tropism has been found to correlate with HIV-1 transmission and disease progression in HIV-infected patients. In this study, recently infected FSWs from Nairobi, Kenya, were assessed for HIV tropism and the factors related to it. We used a cross-sectional study design to analyze 76 HIV-1 positive plasma samples obtained from FSWs enrolled in sex worker outreach program clinics in Nairobi between November 2020 and April 2021. The effects of clinical, demographic, and viral genetic characteristics were determined using multivariable logistic regression. HIV-1 subtype A1 accounted for 89.5% of all cases, with a prevalence of CXCR4-tropic viruses of 26.3%. WebPSSMR5X4 and Geno2Pheno [G2P:10-15% false positive rate] showed high concordance of 88%. Subjects infected with CXCR4-tropic viruses had statistically significant lower baseline CD4+T-cell counts than those infected with CCR5-tropic viruses (P = .044). Using multivariable logistic regression and adjusting for potential confounders, we found that net charge, the amino acid at position 22 of the V3 loop, and the geographic location of the subject were associated with tropism. A unit increase in V3 loop's net-charge increased the odds of a virus being CXCR4-tropic by 2.4 times (OR = 2.40, 95%CI = 1.35-5.00, P = .007). Second, amino acid threonine at position 22 of V3 loop increased the odds of a strain being X4 by 55.7 times compared to the alanine which occurred in CCR5-tropic strains (OR = 55.7, 95%CI = 4.04-84.1, P < .003). The Kawangware sex worker outreach program clinic was associated with CXCR4-tropic strains (P = .034), but there was there was no evidence of a distinct CXCR4-tropic transmission cluster. In conclusion, this study revealed a high concordance of WebPSSMR5X4 and Geno2Pheno in predicting HIV tropism. The most striking finding was that amino acid position 22 of the V3 loop is linked to tropism in HIV-1 subtype A1. Additional studies with a large dataset are warranted to confirm our findings.
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Affiliation(s)
- Hellen K Abisi
- Department of Biochemistry, University of Nairobi, Nairobi, Kenya
| | - Leon E Otieno
- Molecular Medicine and Infectious Diseases Laboratory, University of Nairobi, Nairobi, Kenya
| | - Erastus Irungu
- Partners for Health and Development in Africa (PHDA), Nairobi, Kenya
| | - Frank G Onyambu
- School of Health Sciences, Meru University of Science and Technology, Meru, Kenya
| | | | - Omu Anzala
- Kenya AIDS Vaccine Initiative - Institute of Clinical Research, University of Nairobi, Nairobi, Kenya
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Dalton C Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Ruth W Nduati
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Lyle McKinnon
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Manitoba, MB, Canada
| | - Joshua Kimani
- Partners for Health and Development in Africa (PHDA), Nairobi, Kenya
| | - Martin M Mulinge
- Department of Biochemistry, University of Nairobi, Nairobi, Kenya
- Kenya AIDS Vaccine Initiative - Institute of Clinical Research, University of Nairobi, Nairobi, Kenya
- * Correspondence: Martin M Mulinge, University of Nairobi, Chiromo Campus - Nairobi 30197-00100, Kenya (e-mail: )
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12
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Cranmer LM, Njuguna IN, LaCourse SM, Figueroa J, Gillespie S, Maleche-Obimbo E, Otieno V, Mugo C, Okinyi H, Benki-Nugent S, Pavlinac PB, Malik AA, Gandhi NR, Richardson BA, Stern J, Wamalwa DC, John-Stewart GC. Brief Report: Performance of Tuberculosis Symptom Screening Among Hospitalized ART-Naive Children With HIV in Kenya. J Acquir Immune Defic Syndr 2022; 91:280-284. [PMID: 36166517 PMCID: PMC9588620 DOI: 10.1097/qai.0000000000003060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The World Health Organization (WHO) recommends tuberculosis (TB) diagnostic evaluation for children with HIV (CHIV) who have history of TB contact, poor weight gain, cough, or fever. These screening criteria were developed based on studies of symptomatic CHIV with incomplete microbiologic confirmation. We performed routine TB microbiologic evaluation of hospitalized CHIV with and without symptoms to develop a data-driven TB symptom screen. METHODS Among hospitalized antiretroviral therapy-naive Kenyan CHIV enrolled in the Pediatric Urgent Start of Highly Active Antiretroviral Therapy (PUSH) trial, we performed Xpert MTB/RIF and mycobacterial culture of respiratory and stool specimens independent of TB symptoms. We evaluated performance of WHO and other published pediatric TB screening criteria and derived optimized criteria using a combination of symptoms. RESULTS Of 168 CHIV who underwent TB microbiologic evaluation, 13 (8%) had confirmed TB. WHO TB symptom screening had 100% sensitivity and 4% specificity to detect confirmed TB. Published TB screening criteria that relied on prolonged symptoms missed cases of confirmed TB (sensitivity 85%-92%). An optimized symptom screen including weight loss, cough, anorexia, or TB contact had 100% sensitivity and improved specificity (31%) compared with the WHO pediatric TB symptom screen. CONCLUSIONS The WHO TB symptom screen was highly sensitive but resulted in a high proportion of hospitalized CHIV who would require TB diagnostic evaluation. Other published TB screening criteria missed CHIV with confirmed TB. Our optimized screening tool increased specificity while preserving sensitivity. Future multicenter studies are needed to improve TB screening tools for CHIV in both inpatient and outpatient settings.
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Affiliation(s)
- Lisa M. Cranmer
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Children’s Healthcare of Atlanta, Atlanta, GA, USA
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Irene N. Njuguna
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Sylvia M. LaCourse
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | | | | | | | - Vincent Otieno
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Helen Okinyi
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | | | - Amyn A. Malik
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale Institute for Global Health, New Haven, CT, USA
| | - Neel R. Gandhi
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Barbara A. Richardson
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Joshua Stern
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Dalton C. Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace C. John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
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13
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Neary J, Bulterys MA, Ogutu EA, O’Malley G, Otieno AA, Omondi VO, Wang Y, Zhai X, Katz DA, Oyiengo L, Wamalwa DC, Slyker JA, John-Stewart GC, Njuguna IN, Wagner AD. Brief Report: Pediatric Saliva-Based HIV Testing: Health care Worker and Caregiver Acceptability. J Acquir Immune Defic Syndr 2022; 90:517-523. [PMID: 35499505 PMCID: PMC9283261 DOI: 10.1097/qai.0000000000003004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/07/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric HIV testing remains suboptimal. The OraQuick test [saliva-based test (SBT)] is validated in pediatric populations ≥18 months. Understanding caregiver and health care worker (HCW) acceptability of pediatric SBT is critical for implementation. METHODS A trained qualitative interviewer conducted 8 focus group discussions (FGDs): 4 with HCWs and 4 with caregivers of children seeking health services in western Kenya. FGDs explored acceptability of pediatric SBT and home- and facility-based SBT use. Two reviewers conducted consensus coding and thematic analyses of transcripts using Dedoose. RESULTS Most HCWs but few caregivers had heard of SBT. Before seeing SBT instructions, both had concerns about potential HIV transmission through saliva, which were mostly alleviated after kit demonstration. Noted benefits of SBT included usability and avoiding finger pricks. Benefits of facility-based pediatric SBT included shorter client waiting and service time, higher testing coverage, and access to HCWs, while noted challenges included ensuring confidentiality. Benefits of caregivers using home-based SBT included convenience, privacy, decreased travel costs, increased testing, easier administration, and child comfort. Perceived challenges included not receiving counseling, disagreements with partners, child neglect, and negative emotional response to a positive test result. Overall, HCWs felt that SBT could be used for pediatric HIV testing but saw limited utility for caregivers performing SBT without an HCW present. Caregivers saw utility in home-based SBT but wanted easy access to counseling in case of a positive test result. CONCLUSIONS SBT was generally acceptable to HCWs and caregivers and is a promising strategy to expand testing coverage.
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Affiliation(s)
- Jillian Neary
- Department of Epidemiology, University of Washington, Seattle, WA
| | | | - Emily A. Ogutu
- Gangarosa Department of Environmental Health, Emory University, Atlanta, GA
| | - Gabrielle O’Malley
- Department of Global Health, University of Washington, Seattle, WA
- International Training and Education Center for Health, University of Washington, Seattle, WA
| | | | | | - Yu Wang
- Department of Global Health, University of Washington, Seattle, WA
| | - Xinyi Zhai
- Department of Global Health, University of Washington, Seattle, WA
| | - David A. Katz
- Department of Global Health, University of Washington, Seattle, WA
| | - Laura Oyiengo
- National AIDS and STI Control Programme, Ministry of Health, Nairobi, Kenya
| | - Dalton C. Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Jennifer A. Slyker
- Department of Epidemiology, University of Washington, Seattle, WA
- Department of Global Health, University of Washington, Seattle, WA
| | - Grace C. John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA
- Department of Global Health, University of Washington, Seattle, WA
- Department of Medicine, University of Washington, Seattle, WA
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Irene N. Njuguna
- Department of Global Health, University of Washington, Seattle, WA
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, WA
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14
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Zheng W, LaCourse SM, Song B, Singh DK, Khanna M, Olivo J, Stern J, Escudero JN, Vergara C, Zhang F, Li S, Wang S, Cranmer LM, Huang Z, Bojanowski CM, Bao D, Njuguna I, Xiao Y, Wamalwa DC, Nguyen DT, Yang L, Maleche-Obimbo E, Nguyen N, Zhang L, Phan H, Fan J, Ning B, Li C, Lyon CJ, Graviss EA, John-Stewart G, Mitchell CD, Ramsay AJ, Kaushal D, Liang R, Pérez-Then E, Hu TY. Diagnosis of paediatric tuberculosis by optically detecting two virulence factors on extracellular vesicles in blood samples. Nat Biomed Eng 2022; 6:979-991. [PMID: 35986185 PMCID: PMC9391224 DOI: 10.1038/s41551-022-00922-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/01/2022] [Indexed: 11/09/2022]
Abstract
Sensitive and specific blood-based assays for the detection of pulmonary and extrapulmonary tuberculosis would reduce mortality associated with missed diagnoses, particularly in children. Here we report a nanoparticle-enhanced immunoassay read by dark-field microscopy that detects two Mycobacterium tuberculosis virulence factors (the glycolipid lipoarabinomannan and its carrier protein) on the surface of circulating extracellular vesicles. In a cohort study of 147 hospitalized and severely immunosuppressed children living with HIV, the assay detected 58 of the 78 (74%) cases of paediatric tuberculosis, 48 of the 66 (73%) cases that were missed by microbiological assays, and 8 out of 10 (80%) cases undiagnosed during the study. It also distinguished tuberculosis from latent-tuberculosis infections in non-human primates. We adapted the assay to make it portable and operable by a smartphone. With further development, the assay may facilitate the detection of tuberculosis at the point of care, particularly in resource-limited settings.
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Affiliation(s)
- Wenshu Zheng
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Sylvia M LaCourse
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Bofan Song
- James C. Wyant College of Optical Sciences, The University of Arizona, Tucson, AZ, USA
| | - Dhiraj Kumar Singh
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX, USA
| | - Mayank Khanna
- Department of Microbiology, Immunology and Parasitology, LSU Health Sciences Center, New Orleans, LA, USA
| | - Juan Olivo
- O&M Medical School (O&Med), Santo Domingo, Dominican Republic
| | - Joshua Stern
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jaclyn N Escudero
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Carlos Vergara
- O&M Medical School (O&Med), Santo Domingo, Dominican Republic
| | - Fangfang Zhang
- Virginia G. Piper Biodesign Center for Personalized Diagnostics, The Biodesign Institute, Arizona State University, Tempe, AZ, USA
| | - Shaobai Li
- James C. Wyant College of Optical Sciences, The University of Arizona, Tucson, AZ, USA
| | - Shu Wang
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Lisa M Cranmer
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Emory School of Medicine, Atlanta, GA, USA
- Children's Healthcare of Atlanta, Atlanta, GA, USA
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Zhen Huang
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Christine M Bojanowski
- Section of Pulmonary Diseases, Tulane University School of Medicine, New Orleans, LA, USA
| | - Duran Bao
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Irene Njuguna
- Department of Global Health, University of Washington, Seattle, WA, USA
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
| | - Yating Xiao
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Dalton C Wamalwa
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist, Houston, TX, USA
| | - Li Yang
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Elizabeth Maleche-Obimbo
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | - Lili Zhang
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Ha Phan
- Center for Promotion of Advancement of Society (CPAS), Ha Noi, Vietnam
- Vietnam National Tuberculosis Program/University of California San Francisco Research Collaboration, Ha Noi, Vietnam
| | - Jia Fan
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Bo Ning
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Chenzhong Li
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Christopher J Lyon
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist, Houston, TX, USA
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, TX, USA
| | - Grace John-Stewart
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Charles D Mitchell
- Department of Pediatrics, Division of Infectious Diseases and Immunology, University of Miami Miller School of Medicine, Batchelor Children's Research Institute, Miami, FL, USA
| | - Alistair J Ramsay
- Department of Microbiology, Immunology and Parasitology, LSU Health Sciences Center, New Orleans, LA, USA
| | - Deepak Kaushal
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX, USA
| | - Rongguang Liang
- James C. Wyant College of Optical Sciences, The University of Arizona, Tucson, AZ, USA
| | - Eddy Pérez-Then
- O&M Medical School (O&Med), Santo Domingo, Dominican Republic
| | - Tony Y Hu
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA.
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA.
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15
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Huang Z, LaCourse SM, Kay AW, Stern J, Escudero JN, Youngquist BM, Zheng W, Vambe D, Dlamini M, Mtetwa G, Cranmer LM, Njuguna I, Wamalwa DC, Maleche-Obimbo E, Catanzaro DG, Lyon CJ, John-Stewart G, DiNardo A, Mandalakas AM, Ning B, Hu TY. CRISPR detection of circulating cell-free Mycobacterium tuberculosis DNA in adults and children, including children with HIV: a molecular diagnostics study. Lancet Microbe 2022; 3:e482-e492. [PMID: 35659882 PMCID: PMC9300929 DOI: 10.1016/s2666-5247(22)00087-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/17/2022] [Accepted: 03/23/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Tuberculosis remains a leading cause of global mortality, especially for adults and children living with HIV (CLHIV) underdiagnosed by sputum-based assays. Non-sputum-based assays are needed to improve tuberculosis diagnosis and tuberculosis treatment monitoring. Our aim in this study was to determine whether ultrasensitive detection of Mycobacterium tuberculosis cell-free DNA (Mtb-cfDNA) in blood can diagnose tuberculosis and evaluate tuberculosis treatment responses. METHODS In this molecular diagnostics study we analysed archived serum from two patient populations evaluated for tuberculosis in Eswatini and Kenya to detect Mtb-cfDNA, analysing serum from all individuals who had both sufficient serum volumes and clear diagnostic results. An optimised CRISPR-mediated tuberculosis (CRISPR-TB) assay was used to detect Mtb-cfDNA in serum at enrolment from adults and children with presumptive tuberculosis and their asymptomatic household contacts, and at enrolment and during tuberculosis treatment from a cohort of symptomatic CLHIV at high risk for tuberculosis, who provided longitudinal serum at enrolment and during tuberculosis treatment. FINDINGS CRISPR-TB identified microbiologically and clinically confirmed tuberculosis cases in the predominantly HIV-negative Eswatini adult cohort with 96% sensitivity (27 [96%] of 28, 95% CI 80-100) and 94% specificity (16 [94%] of 17, 71-100), and with 83% sensitivity (5 [83%] of 6, 36-100) and 95% specificity (21 [95%] of 22, 77-100) in the paediatric cohort, including all six cases of extrapulmonary tuberculosis. In the Kenyan CLHIV cohort, CRISPR-TB detected all (13 [100%] of 13, 75-100) confirmed tuberculosis cases and 85% (39 [85%] of 46, 71-94) of unconfirmed tuberculosis cases diagnosed by non-microbiological clinical findings. CLHIV who were CRISPR-TB positive at enrolment had a 2·4-times higher risk of mortality by 6 months after enrolment. Mtb-cfDNA signal decreased after tuberculosis treatment initiation, with near or complete Mtb-cfDNA clearance by 6 months after tuberculosis treatment initiation. INTERPRETATION CRISPR-mediated detection of circulating Mtb-cfDNA shows promise to increase the identification of paediatric tuberculosis and HIV-associated tuberculosis, and potential for early diagnosis and rapid monitoring of tuberculosis treatment responses. FUNDING US Department of Defense, National Institute of Child Health and Human Development, National Institute of Allergy and Infectious Diseases, University of Washington Center for AIDS Research, and the Weatherhead Presidential Endowment fund.
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Affiliation(s)
- Zhen Huang
- Center for Cellular and Molecular Diagnostics,Department of Biochemistry and Molecular Biology,Tulane University School of Medicine, New Orleans, LA, USA; State Key Laboratory of Food Science and Technology, Nanchang University, Nanchang, Jiangxi, China
| | - Sylvia M LaCourse
- Department of Medicine, Division of Allergy and Infectious Diseases,Department of Global Health
| | - Alexander W Kay
- University of Washington, Seattle, WA, USA; Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Baylor Children’s Foundation-Eswatini, Mbabane, Eswatini
| | | | | | - Brady M Youngquist
- Center for Cellular and Molecular Diagnostics,Department of Biochemistry and Molecular Biology
| | - Wenshu Zheng
- Center for Cellular and Molecular Diagnostics,Department of Biochemistry and Molecular Biology
| | - Debrah Vambe
- Eswatini National Tuberculosis Control Programme, Ministry of Health, Manzini, Eswatini
| | - Muyalo Dlamini
- National TB Reference Laboratory, Eswatini Health Laboratory Services, Ministry of Health, Mbabane, Eswatini
| | - Godwin Mtetwa
- University of Washington, Seattle, WA, USA; Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Baylor Children’s Foundation-Eswatini, Mbabane, Eswatini
| | - Lisa M Cranmer
- Department of Pediatrics, Division of Infectious Diseases, Emory University, Atlanta, GA, USA,Children’s Healthcare of Atlanta, Atlanta, GA, USA,Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Irene Njuguna
- Research and Programmes, Kenyatta National Hospital, Nairobi, Kenya
| | - Dalton C Wamalwa
- Department of Global Health,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Elizabeth Maleche-Obimbo
- Department of Global Health,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Donald G Catanzaro
- Department of Biological Sciences, University of Arkansas, Fayetteville, AR, USA
| | - Christopher J Lyon
- Center for Cellular and Molecular Diagnostics,Department of Biochemistry and Molecular Biology
| | - Grace John-Stewart
- Department of Medicine, Division of Allergy and Infectious Diseases,Department of Global Health,Department of Epidemiology,Department of Pediatrics
| | - Andrew DiNardo
- University of Washington, Seattle, WA, USA; Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Anna M Mandalakas
- University of Washington, Seattle, WA, USA; Global TB Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Bo Ning
- Center for Cellular and Molecular Diagnostics,Department of Biochemistry and Molecular Biology
| | - Tony Y Hu
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, USA; Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, USA.
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16
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Benki-Nugent SF, Yunusa R, Mueni A, Laboso T, Tamasha N, Njuguna I, Gómez L, Wamalwa DC, Tapia K, Maleche-Obimbo E, Bangirana P, Boivin MJ, John-Stewart GC. Lower Neurocognitive Functioning in HIV-Exposed Uninfected Children Compared With That in HIV-Unexposed Children. J Acquir Immune Defic Syndr 2022; 89:441-447. [PMID: 35202050 PMCID: PMC8873990 DOI: 10.1097/qai.0000000000002881] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 11/29/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Perinatal HIV and antiretroviral therapy exposure may influence neurocognitive outcomes, although evidence is mixed and most studies are limited to outcomes in the first 24 months. We compared neurocognitive outcomes in school-aged children who were HIV exposed uninfected (CHEU) with those in children who were HIV unexposed uninfected (CHUU). SETTING Children were recruited from a health center in Nairobi, Kenya. METHODS Key inclusion criteria were children aged 5-12 years and confirmed child and maternal HIV status; for CHEU, mothers reported knowing HIV-positive status before or at delivery of the index child. Children underwent a detailed battery of neuropsychological tests and behavioral assessment, and comparisons of scores between CHEU and CHUU were conducted using linear regression. RESULTS Among 56 CHEU and 65 CHUU, the median age and sex distributions were 6.8 and 7.0 years (P = 0.8) and 48% and 60% girls (P = 0.2), respectively. In analyses adjusted for child's age and sex and caregiver's age, education, and household rent, CHEU had significantly lower mean z scores for global cognitive ability than CHUU [-0.35, 95% confidence interval (CI): -0.64 to -0.05; P = 0.02], short-term memory (-0.44, 95% CI: -0.76 to -0.12; P = 0.008), delayed memory (-0.43, 95% CI: -0.79 to -0.08; P = 0.02), attention (-0.41, 95% CI: -0.78 to -0.05; P = 0.03), and processing speed (-0.76, 95% CI: -1.37 to -0.16; P = 0.01). Models adjusted for child nutritional status, household food security, and orphanhood yielded similar results. CONCLUSIONS Children exposed to HIV had poorer long-term neurocognitive outcomes than CHUU. These data suggest that long-term studies of neurocognitive and educational attainment in CHEU are warranted.
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Affiliation(s)
| | - Rabi Yunusa
- Department of Global Health, University of Washington, Seattle, WA
| | - Alice Mueni
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Tony Laboso
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Nancy Tamasha
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Irene Njuguna
- Department of Global Health, University of Washington, Seattle, WA
| | - Laurén Gómez
- Department of Global Health, University of Washington, Seattle, WA
| | - Dalton C Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Kenneth Tapia
- Department of Global Health, University of Washington, Seattle, WA
| | | | - Paul Bangirana
- Department of Psychiatry, Makerere University, Kampala, Uganda
| | - Michael J Boivin
- Departments of Psychiatry and of Neurology & Ophthalmology, Michigan State University, East Lansing
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Grace C John-Stewart
- Department of Global Health, University of Washington, Seattle, WA
- Departments of Pediatrics
- Epidemiology; and
- Medicine, University of Washington, Seattle, WA
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17
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Okinyi HM, Wachira CM, Wilson KS, Nduati MN, Onyango AD, Mburu CW, Inwani IW, Owens TL, Bukusi DE, John-. Stewart GC, Wamalwa DC, Kohler PK. “I Have Actually not Lost any Adolescent Since I Started Engaging Them one on one:” Training Satisfaction and Subsequent Practice among Health Providers Participating in a Standardized Patient Actor Training to Improve Adolescent Engagement in HIV Care. J Int Assoc Provid AIDS Care 2022; 21:23259582221075133. [PMID: 35068204 PMCID: PMC8793424 DOI: 10.1177/23259582221075133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Poor health care worker (HCW) interactions with adolescents negatively influence engagement in HIV care. We assessed the impact of standardized patient actor training on HCW competence in providing adolescent HIV care in Kenya. Methods: We conducted pre-post cross-sectional surveys and qualitative exit interviews during a stepped wedge randomized trial. Cross-sectional surveys assessed self-rated competence in providing adolescent services before and after the intervention, and training satisfaction. In-depth interviews with a subset of HCW participants one year after training. Results: Over 90% of HCWs reported satisfaction with the training and there was significant improvement in self-rated competence scores (mean = 4.63 [highest possible score of 5] post-training vs 3.86 pre-training, p < 0.001). One-year following training, HCWs reported using skills in patient-centered communication and structuring an adolescent clinical encounter. Conclusions: This SP training intervention improved self-rated competence and showed sustained perceived impact on HCW skills in adolescent HIV service provision one year later.
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18
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Ronen K, Choo EM, Wandika B, Udren JI, Osborn L, Kithao P, Hedstrom AB, Masinde M, Kumar M, Wamalwa DC, Richardson BA, Kinuthia J, Unger JA. Evaluation of a two-way SMS messaging strategy to reduce neonatal mortality: rationale, design and methods of the Mobile WACh NEO randomised controlled trial in Kenya. BMJ Open 2021; 11:e056062. [PMID: 34949631 PMCID: PMC9066367 DOI: 10.1136/bmjopen-2021-056062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Globally, approximately half of the estimated 6.3 million under-5 deaths occur in the neonatal period (within the first 28 days of life). Kenya ranks among countries with the highest number of neonatal deaths, at 20 per 1000 live births. Improved identification and management of neonates with potentially life-threatening illness is critical to meet the WHO's target of ≤12 neonatal deaths per 1000 live births by 2035. We developed an interactive (two-way) short messaging service (SMS) communication intervention, Mobile Solutions for Neonatal Health (Mobile women's and children's health (WACh) NEO), focused on the perinatal period. Mobile WACh NEO sends automated tailored SMS messages to mothers during pregnancy and up to 6 weeks post partum. Messages employ the Information-Motivation-Behaviour Skills framework to promote (1) maternal implementation of essential newborn care (ENC, including early, exclusive breast feeding, cord care and thermal care), (2) maternal identification of neonatal danger signs and care-seeking, and (3) maternal social support and self-efficacy. Participants can also send SMS to the study nurse, enabling on-demand remote support. METHODS AND ANALYSIS We describe a two-arm unblinded randomised controlled trial of the Mobile WACh NEO intervention. We will enrol 5000 pregnant women in the third trimester of pregnancy at 4 facilities in Kenya and randomise them 1:1 to receive interactive SMS or no SMS (control), and conduct follow-up visits at 2 and 6 weeks post partum. Neonatal mortality will be compared between arms as the primary outcome. Secondary outcomes include care-seeking, practice of ENC and psychosocial health. Exploratory analysis will investigate associations between maternal mental health, practice of ENC, care-seeking and SMS engagement. ETHICS AND DISSEMINATION This study received ethical approval from the University of Washington (STUDY00006395), Women and Infants Hospital (1755292-1) and Kenyatta National Hospital/University of Nairobi (P310/04/2019). All participants will provide written informed consent. Findings will be published in peer-reviewed journals and international conferences. TRIAL REGISTRATION NUMBER NCT04598165.
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Affiliation(s)
- Keshet Ronen
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Esther M Choo
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Brenda Wandika
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Jenna I Udren
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Lusi Osborn
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Peninah Kithao
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Anna B Hedstrom
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Millicent Masinde
- Department of Obstetrics and Gynecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Manasi Kumar
- Department of Psychiatry, University of Nairobi, Nairobi, Kenya
| | - Dalton C Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Barbra A Richardson
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - John Kinuthia
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Jennifer A Unger
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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19
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Zhang J, Atkins DL, Wagner AD, Njuguna IN, Neary J, Omondi VO, Otieno VA, Atieno WO, Odhiambo M, Wamalwa DC, John-Stewart G, Slyker JA, Weiner BJ, Beima-Sofie K. Financial Incentives for Pediatric HIV Testing (FIT): Caregiver Insights on Incentive Mechanisms, Focus Populations, and Acceptability for Programmatic Scale Up. AIDS Behav 2021; 25:2661-2668. [PMID: 34170433 DOI: 10.1007/s10461-021-03356-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 11/30/2022]
Abstract
Children living with HIV experience gaps in HIV testing globally; scaling up evidence-based testing strategies is critical for preventing HIV-related mortality. Financial incentives (FI) were recently demonstrated to increase uptake of pediatric HIV testing. As part of this qualitative follow-up study to the FIT trial (NCT03049917) conducted in Kenya, 54 caregivers participated in individual interviews. Interview transcripts were analyzed to identify considerations for scaling up FI for pediatric testing. Caregivers reported that FI function by directly offsetting costs or nudging caregivers to take action sooner. Caregivers found FI to be feasible and acceptable for broader programmatic implementation, and supported use for a variety of populations. Some concerns were raised about unintended consequences of FI, including caregivers bringing ineligible children to collect incentives and fears about the impact on linkage to care and retention if caregivers become dependent on FI.
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Affiliation(s)
- Junyi Zhang
- Department of Health Services, University of Washington, Seattle, WA, 98195, USA.
| | - Dana L Atkins
- Department of Global Health, University of Washington, UW Box #351620, Seattle, WA, 98195, USA
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, UW Box #351620, Seattle, WA, 98195, USA
| | - Irene N Njuguna
- Department of Global Health, University of Washington, UW Box #351620, Seattle, WA, 98195, USA
- Research and Programs, Kenyatta National Hospital, Ngong Road, Nairobi, 00202, Kenya
| | - Jillian Neary
- Department of Epidemiology, University of Washington, Seattle, WA, 98104, USA
| | - Vincent O Omondi
- Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Verlinda A Otieno
- Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Winnie O Atieno
- Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Merceline Odhiambo
- Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Dalton C Wamalwa
- Department of Pediatrics, University of Nairobi, Nairobi, 00202, Kenya
| | - Grace John-Stewart
- Department of Global Health, University of Washington, UW Box #351620, Seattle, WA, 98195, USA
- Department of Epidemiology, University of Washington, Seattle, WA, 98104, USA
- Department of Medicine, University of Washington, Seattle, WA, 98104, USA
- Department of Pediatrics, University of Washington, Seattle, WA, 98104, USA
| | - Jennifer A Slyker
- Department of Global Health, University of Washington, UW Box #351620, Seattle, WA, 98195, USA
- Department of Epidemiology, University of Washington, Seattle, WA, 98104, USA
| | - Bryan J Weiner
- Department of Health Services, University of Washington, Seattle, WA, 98195, USA
- Department of Global Health, University of Washington, UW Box #351620, Seattle, WA, 98195, USA
| | - Kristin Beima-Sofie
- Department of Global Health, University of Washington, UW Box #351620, Seattle, WA, 98195, USA
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20
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Neary J, Wagner AD, Omondi V, Otieno V, Mugo C, Wamalwa DC, Maleche-Obimbo E, John-Stewart GC, Slyker JA, Njuguna IN. Male Caregiver Barriers to HIV Index Case Testing of Untested Children. J Acquir Immune Defic Syndr 2021; 87:e229-e231. [PMID: 33633034 PMCID: PMC8500355 DOI: 10.1097/qai.0000000000002669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background: Index case testing (ICT) for children—testing children of HIV-positive index adults—reveals a high prevalence of undiagnosed pediatric HIV; however, uptake of ICT is sub-optimal. Methods: During recruitment for a randomized trial (NCT03049917 ), data were collected from sequential clients attending HIV care regarding whether they had children ages 0–12 years of unknown HIV status. We assessed male caregiver barriers to ICT and identified reasons children could not be tested for HIV through ICT. Results: A higher proportion of males receiving HIV care reported untested children ≤12 years of age (7% [483/7,267]) compared to females (2% [358/15,008]; p<0.001). Among caregivers with untested children ≤12 years, 34% (166/483) of males and 89% (320/358) of females were eligible for ICT (p<0.001). Among caregivers who were ineligible for ICT, 29% (141/483) of male and 9% (31/358) of female caregivers were ineligible for ICT due to inability to physically access their children (p<0.001). A higher proportion of males than females did not have access to their children due to separation or divorce (82% [116/141] vs. 52% [16/31]). Overall, a higher proportion of male caregivers declined participation in the trial compared to females (11% [19/166] vs. 5% [15/320]; p=0.006), with 47% (9/19) of those males declining participation because they wanted to consult with their partner compared to 7% (1/15) of female caregivers (p=0.010). Conclusion: As programs scale up ICT, male caregiver barriers to ICT must be addressed to effectively reach untested children.
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Affiliation(s)
| | | | - Vincent Omondi
- Kenya Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Verlinda Otieno
- Kenya Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Cyrus Mugo
- Departments of Epidemiology
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Dalton C Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | - Grace C John-Stewart
- Departments of Epidemiology
- Global Health, University of Washington, Seattle, WA
- Departments of Pediatrics and Medicine, University of Washington, Seattle, WA
| | - Jennifer A Slyker
- Departments of Epidemiology
- Global Health, University of Washington, Seattle, WA
| | - Irene N Njuguna
- Global Health, University of Washington, Seattle, WA
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
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21
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Mugo C, Wang J, Begnel ER, Njuguna IN, Maleche-Obimbo E, Inwani I, Slyker JA, John-Stewart G, Wamalwa DC, Wagner AD. Home- and Clinic-Based Pediatric HIV Index Case Testing in Kenya: Uptake, HIV Prevalence, Linkage to Care, and Missed Opportunities. J Acquir Immune Defic Syndr 2021; 85:535-542. [PMID: 32932411 DOI: 10.1097/qai.0000000000002500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Gaps in HIV testing of children persist, particularly among older children born before the expansion of the prevention of mother-to-child transmission of HIV programs. METHODS The Counseling and Testing for Children at Home study evaluated an index-case pediatric HIV testing approach. Caregivers receiving HIV care at 7 health facilities in Kenya (index cases), who had children of unknown HIV status aged 0-12 years, were offered the choice of clinic-based testing (CBT) or home-based testing (HBT). Testing uptake and HIV prevalence were compared between groups choosing HBT and CBT; linkage to care, missed opportunities, and predictors of HIV-positive diagnosis were identified. RESULTS Among 493 caregivers, 70% completed HIV testing for ≥1 child. Most caregivers who tested children chose CBT (266/347, 77%), with 103 (30%) agreeing to same-day testing of an untested accompanying child. Overall HIV prevalence among 521 tested children was 5.8% (CBT 6.8% vs HBT 2.4%; P = 0.07). Within 1 month of diagnosis, 88% of 30 HIV-positive children had linked to care, and 54% had started antiretroviral treatment. For 851 children eligible for testing, the most common reason for having an unknown HIV status was that the child's mother was not tested for HIV or had tested HIV negative during pregnancy (82%). CONCLUSION Testing uptake and HIV prevalence were moderate with nonsignificant differences between HBT and CBT. Standardized offer to test children accompanying caregivers is feasible to scale-up with little additional investment. Linkage to care for HIV-positive children was suboptimal. Lack of peripartum maternal testing contributed to gaps in pediatric testing.
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Affiliation(s)
- Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, WA
| | - Jiayu Wang
- Department of Global Health, University of Washington, Seattle, WA
| | - Emily R Begnel
- Department of Global Health, University of Washington, Seattle, WA
| | - Irene N Njuguna
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, WA
| | | | - Irene Inwani
- Department of Pediatrics, Kenyatta National Hospital, Nairobi, Kenya; and
| | | | - Grace John-Stewart
- Departments of Pediatrics.,Departments of Medicine, University of Washington, Seattle, WA
| | | | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, WA
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22
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Njuguna IN, Wagner AD, Neary J, Omondi VO, Otieno VA, Orimba A, Mugo C, Babigumira JB, Levin C, Richardson BA, Maleche-Obimbo E, Wamalwa DC, John-Stewart G, Slyker J. Financial incentives to increase pediatric HIV testing: a randomized trial. AIDS 2021; 35:125-130. [PMID: 33048877 PMCID: PMC7791594 DOI: 10.1097/qad.0000000000002720] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Financial incentives can motivate desirable health behaviors, including adult HIV testing. Data regarding the effectiveness of financial incentives for HIV testing in children, who require urgent testing to prevent mortality, are lacking. METHODS In a five-arm unblinded randomized controlled trial, adults living with HIV attending 19 HIV clinics in Western Kenya, with children 0-12 years of unknown HIV status, were randomized with equal allocation to $0, $1.25, $2.50, $5 or $10. Payment was conditional on child HIV testing within 2 months. Block randomization with fixed block sizes was used; participants and study staff were unblinded at randomization. Primary analysis was intent-to-treat, with predefined primary outcomes of completing child HIV testing and time to testing. RESULTS Of 452 caregivers, 90, 89, 93, 92 and 88 were randomized to $0, $1.25, $2.50, $5.00, and $10.00, respectively. Of those, 31 (34%), 31 (35%), 44 (47%), 51 (55%), and 54 (61%) in the $0, $1.25, $2.50, $5.00, and $10.00 arms, respectively, completed child testing. Compared with the $0 arm, and adjusted for site, caregivers in the $10.00 arm had significantly higher uptake of testing [relative risk: 1.80 (95% CI 1.15--2.80), P = 0.010]. Compared with the $0 arm, and adjusted for site, time to testing was significantly faster in the $5.00 and $10.00 arms [hazard ratio: 1.95 (95% CI 1.24--3.07) P = 0.004, 2.42 (95% CI 1.55--3.79), P < 0.001, respectively). CONCLUSION Financial incentives are effective in improving pediatric HIV testing among caregivers living with HIV. REGISTRATION NCT03049917.
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Affiliation(s)
- Irene N Njuguna
- Department of Epidemiology
- Department of Global Health
- Research and Programs, Kenyatta National Hospital
| | | | | | - Vincent O Omondi
- Kenya Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Verlinda A Otieno
- Kenya Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Anita Orimba
- Kenya Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Cyrus Mugo
- Department of Global Health
- Research and Programs, Kenyatta National Hospital
| | - Joseph B Babigumira
- Department of Global Health
- Department of Pharmacy, University of Washington, Seattle, Washington, USA
| | | | - Barbra A Richardson
- Department of Global Health
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | | | - Dalton C Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Epidemiology
- Department of Global Health
- Department of Medicine
- Department of Pediatrics
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Neary J, Njuguna IN, Cranmer LM, Otieno VO, Mugo C, Okinyi HM, Benki-Nugent S, Richardson BA, Stern J, Maleche-Obimbo E, Wamalwa DC, John-Stewart GC, Wagner AD. Newly diagnosed HIV positive children: a unique index case to improve HIV diagnosis and linkage to care of parents. AIDS Care 2020; 32:1400-1405. [PMID: 32019333 DOI: 10.1080/09540121.2020.1719027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Newly diagnosed HIV positive children may be unique index cases to identify undiagnosed parents. Data was used from the Pediatric Urgent Start of HAART (NCT02063880) trial, which enrolled hospitalized, ART-naïve, HIV positive children ages 0-12 years in Kenya. Exact McNemar's tests were used to compare proportions of mothers and fathers tested for HIV, linked to care, and on ART at baseline and 6 months. This analysis included 87 newly diagnosed children with HIV who completed 6 months of follow-up. Among 83 children with living mothers, there were improvements in maternal linkage to care and treatment comparing baseline to 6 months (36% vs. 78%; p < 0.0001 and 22% vs. 52%; p < 0.0001). Among 80 children with living fathers, there were increases from baseline to 6 months in the number of fathers who knew the child's HIV status (34% vs. 78%; p < 0.0001), fathers ever tested for HIV (43% vs. 65%; p < 0.0001), fathers ever tested HIV positive (21% vs. 43%; p < 0.0001), fathers ever linked to care (15% vs. 35%; p < 0.0001), and fathers ever initiated on ART (11% vs. 23%; p = 0.0039). Newly diagnosed HIV positive children can be important index cases to identify parents with undiagnosed HIV or poor engagement in care.
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Affiliation(s)
- Jillian Neary
- Departments of Global Health, University of Washington, Seattle, WA, USA
| | - Irene N Njuguna
- Departments of Epidemiology, University of Washington, Seattle, WA, USA.,Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Lisa M Cranmer
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Cyrus Mugo
- Departments of Global Health, University of Washington, Seattle, WA, USA.,Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Hellen M Okinyi
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Sarah Benki-Nugent
- Departments of Global Health, University of Washington, Seattle, WA, USA
| | - Barbra A Richardson
- Departments of Global Health, University of Washington, Seattle, WA, USA.,Departments of Biostatistics, University of Washington, Seattle, WA, USA
| | - Joshua Stern
- Departments of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Dalton C Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace C John-Stewart
- Departments of Global Health, University of Washington, Seattle, WA, USA.,Departments of Epidemiology, University of Washington, Seattle, WA, USA.,Departments of Medicine, University of Washington, Seattle, WA, USA.,Departments of Pediatrics, University of Washington, Seattle, WA, USA
| | - Anjuli D Wagner
- Departments of Global Health, University of Washington, Seattle, WA, USA
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Njuguna IN, Cranmer LM, Wagner AD, LaCourse SM, Mugo C, Benki-Nugent S, Richardson BA, Stern J, Maleche-Obimbo E, Wamalwa DC, John-Stewart G. Brief Report: Cofactors of Mortality Among Hospitalized HIV-Infected Children Initiating Antiretroviral Therapy in Kenya. J Acquir Immune Defic Syndr 2019; 81:138-144. [PMID: 31095004 PMCID: PMC6609091 DOI: 10.1097/qai.0000000000002012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Identifying factors associated with mortality among acutely ill HIV-infected children presenting with advanced HIV disease may help clinicians optimize care for those at highest risk of death. DESIGN Using data from a randomized controlled trial (NCT02063880), we determined baseline sociodemographic, clinical, and laboratory cofactors of mortality among HIV-infected children in Kenya. METHODS We enrolled hospitalized, HIV-infected, antiretroviral therapy-naive children (0-12 years), initiated antiretroviral therapy, and followed up them for 6 months. We used Cox proportional hazards regression to estimate hazard ratios (HRs) for death and 95% confidence intervals (CIs). RESULTS Of 181 enrolled children, 39 (22%) died. Common diagnoses at death were pneumonia or suspected pulmonary tuberculosis [23 (59%)] and gastroenteritis [7 (18%)]. Factors associated with mortality in univariate analysis included age <2 years [HR 3.08 (95% CI: 1.50 to 6.33)], orphaned or vulnerable child (OVC) [HR 2.05 (95% CI: 1.09 to 3.84)], weight-for-age Z score <-2 [HR 2.29 (95% CI: 1.05 to 5.00)], diagnosis of pneumonia with hypoxia [HR 5.25 (95% CI: 2.00 to 13.84)], oral thrush [HR 2.17 (95% CI: 1.15 to 4.09)], persistent diarrhea [HR 3.81 (95% CI: 1.89 to 7.69)], and higher log10 HIV-1 viral load [HR 2.16 (95% CI: 1.35 to 3.46)] (all P < 0.05). In multivariable analysis, age <2 years and OVC status remained significantly associated with mortality. CONCLUSIONS Young age and OVC status independently predicted mortality. Hypoxic pneumonia, oral thrush, and persistent diarrhea are important clinical features that predict mortality. Strategies to enhance early diagnosis in children and improve hospital management of critically ill HIV-infected children are needed.
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Affiliation(s)
- Irene N Njuguna
- Kenyatta National Hospital, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Lisa M Cranmer
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | | | | | - Cyrus Mugo
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | | | | | | | - Dalton C Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA
- Medicine, University of Washington, Seattle, WA
- Pediatrics, University of Washington, Seattle, WA
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Wagner AD, Njuguna IN, Neary J, Omondi VO, Otieno VA, Babigumira J, Maleche-Obimbo E, Wamalwa DC, John-Stewart GC, Slyker JA. Financial Incentives to Increase Uptake of Pediatric HIV Testing (FIT): study protocol for a randomised controlled trial in Kenya. BMJ Open 2018; 8:e024310. [PMID: 30287676 PMCID: PMC6194484 DOI: 10.1136/bmjopen-2018-024310] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Index case testing (ICT) to identify HIV-infected children is efficient but has suboptimal uptake. Financial incentives (FI) have overcome financial barriers in other populations by offsetting direct and indirect costs. A pilot study found FI to be feasible for motivating paediatric ICT among HIV-infected female caregivers. This randomised trial will determine the effectiveness of FI to increase uptake of paediatric ICT. METHODS AND ANALYSIS The Financial Incentives to Increase Uptake of Pediatric HIV Testing trial is a five-arm, unblinded, randomised controlled trial that determines whether FI increases timely uptake of paediatric ICT. The trial will be conducted in multiple public health facilities in western Kenya. Each HIV-infected adult enrolled in HIV care will be screened for eligibility: primary caregiver to one or more children of unknown HIV status aged 0-12 years. Eligible caregivers will be individually randomised at the time of recruitment in equal 1:1:1:1:1 allocation to one of five arms (US$0 (control), US$1.25, US$2.50, US$5.00 and US$10.00). The trial aims to randomise 800 caregivers. Incentives will be disbursed at the time of child HIV testing using mobile money transfer or cash. Arms will be compared in terms of the proportion of adults who complete testing for at least one child within 2 months of randomisation and time to testing. A cost-effectiveness analysis of FI for paediatric ICT will also be conducted. ETHICS AND DISSEMINATION This study was reviewed and approved by the University of Washington Institutional Review Board and the Kenyatta National Hospital Ethics and Research Committee. Trial results will be disseminated to healthcare workers at study sites, regional and national policymakers, and with patient populations at study sites (regardless of enrolment in the trial). Randomised trials of caregiver-child FI interventions pose unique study design, ethical and operational challenges, detailed here as a resource for future investigations. TRIAL REGISTRATION NUMBER NCT03049917; Pre-results.
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Affiliation(s)
- Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Irene N Njuguna
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Jillian Neary
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Vincent O Omondi
- Kenya Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Verlinda A Otieno
- Kenya Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Joseph Babigumira
- Department of Global Health, University of Washington, Seattle, Washington, USA
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | | | - Dalton C Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace C John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- School of Medicine, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Jennifer A Slyker
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
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Neary J, Wagner AD, Mugo C, Mutiti PM, Bukusi D, John-Stewart GC, Wamalwa DC, Kohler PK, Slyker JA. Influence and involvement of support people in adolescent and young adult HIV testing. AIDS Care 2018; 31:105-112. [PMID: 30261747 DOI: 10.1080/09540121.2018.1524563] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
HIV incidence and mortality are high among adolescents and young adults (AYA) in sub-Saharan Africa, but testing rates are low. Understanding how support people (SP), such as peers, partners, or parents, influence AYA may improve HIV testing uptake. AYA aged 14-24 seeking HIV testing at a referral hospital in Nairobi, Kenya completed a post-test survey assessing the role of SP. Among 1062 AYA, median age was 21. Overall, 12% reported their decision to test was influenced by a parent, 20% by a partner, and 22% by a peer. Young adults (20-24 years old) were more likely than adolescents (14-19 years old) to be influenced to test by partners (23% vs. 12%, p < .001), and less likely by parents (6.6% vs. 27%, p < .001), healthcare workers (11% vs. 16%, p < .05), or counselors (9.4% vs. 19%, p < .001). Half of AYA were accompanied for testing (9.9% with parent, 10% partner, 23% peer, 4.3% others, and 2.1% multiple types). Young adults were more likely than adolescents to present alone (58% vs. 32%, p < .001) or with a partner (12% vs. 6.7%, p < .05), and less likely with a parent (1.6% vs. 31%, p < .001). Similar proportions of adolescents and young adults came with a peer or in a group. Correlates of presenting with SP included: younger age (aRR = 1.55 [95%CI = 1.30-1.85]), female sex (aRR = 1.45 [95%CI = 1.21-1.73]), and school enrollment (aRR = 1.41 [95%CI = 1.05-1.88]). SP play an important role in AYAs' HIV testing and varies with age. Leveraging SP may promote uptake of HIV testing and subsequent linkage care for AYA.
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Affiliation(s)
- Jillian Neary
- a Department of Epidemiology , University of Washington , Seattle , WA , USA.,b Department of Global Health , University of Washington , Seattle , WA , USA
| | - Anjuli D Wagner
- b Department of Global Health , University of Washington , Seattle , WA , USA
| | - Cyrus Mugo
- c Department of Paediatrics and Child Health , University of Nairobi , Nairobi , Kenya
| | - Peter M Mutiti
- d VCT and HIV Prevention Unit/Youth Centre , Kenyatta National Hospital , Nairobi , Kenya
| | - David Bukusi
- d VCT and HIV Prevention Unit/Youth Centre , Kenyatta National Hospital , Nairobi , Kenya
| | - Grace C John-Stewart
- a Department of Epidemiology , University of Washington , Seattle , WA , USA.,b Department of Global Health , University of Washington , Seattle , WA , USA.,e School of Medicine , University of Washington , Seattle , WA , USA.,f Department of Pediatrics , University of Washington , Seattle , WA , USA
| | - Dalton C Wamalwa
- c Department of Paediatrics and Child Health , University of Nairobi , Nairobi , Kenya
| | - Pamela K Kohler
- b Department of Global Health , University of Washington , Seattle , WA , USA.,g Department of Psychosocial and Community Health , University of Washington , Seattle , WA , USA.,h International Training and Education Center for Health , University of Washington , Seattle , WA , USA
| | - Jennifer A Slyker
- a Department of Epidemiology , University of Washington , Seattle , WA , USA.,b Department of Global Health , University of Washington , Seattle , WA , USA
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Njuguna IN, Cranmer LM, Otieno VO, Mugo C, Okinyi HM, Benki-Nugent S, Richardson B, Stern J, Maleche-Obimbo E, Wamalwa DC, John-Stewart GC. Urgent versus post-stabilisation antiretroviral treatment in hospitalised HIV-infected children in Kenya (PUSH): a randomised controlled trial. Lancet HIV 2018; 5:e12-e22. [PMID: 29150377 PMCID: PMC5777310 DOI: 10.1016/s2352-3018(17)30167-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/30/2017] [Accepted: 09/04/2017] [Indexed: 12/03/2022]
Abstract
BACKGROUND Urgent antiretroviral therapy (ART) among hospitalised HIV-infected children might accelerate recovery or worsen outcomes associated with immune reconstitution. We aimed to compare urgent versus post-stabilisation ART among hospitalised HIV-infected children in Kenya. METHODS In this unmasked randomised controlled trial, we randomly assigned (1:1) HIV-infected, ART-naive children aged 0-12 years who were eligible for treatment to receive ART within 48 h (urgent group) or in 7-14 days (post-stabilisation group) at four hospitals in Kenya (two in Nairobi and two in western Kenya). We excluded children with suspected or confirmed CNS infection. A statistician not involved in study procedures did block randomisation with variable block sizes generated using STATA version 12. We followed children for 6 months for primary outcomes: mortality, drug toxicity, and immune reconstitution inflammatory syndrome (IRIS). We did all analyses in a modified intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT02063880. FINDINGS We began enrolment on April 24, 2013, and completed follow-up on Nov 17, 2015. We enrolled 191 (76%) of 250 hospitalised HIV-infected children. Of these, 183 children were randomly assigned: 90 to urgent ART and 93 to post-stabilisation ART. 181 (99%) of 183 children were included in the modified intention-to-treat analysis. Median age was 1·9 years (IQR 0·8-4·8). Baseline sociodemographic, clinical, and virological characteristics did not differ between groups except median CD4 cell percentage, which was lower in the urgent group (13% [IQR 9-18] vs 17% [IQR 9-24]; p=0·052). Of 181 admission diagnoses, 118 (65%) were pneumonia, 58 (32%) malnutrition, and 27 (15%) suspected tuberculosis. Median time to ART was 1 day (IQR 1-1) in the urgent group and 8 days (IQR 7-11) in the post-stabilisation group. Overall, mortality risk at 6 months was 61 per 100 person-years. Mortality risk did not differ by group (70 per 100 person-years in the urgent group vs 54 per 100 person-years in the post-stabilisation group; hazard ratio [HR] 1·26, 95% CI 0·67-2·37) p=0.47, even after adjusting for baseline CD4 cell percentage (adjusted HR 1·30, 95% CI 0·69-2·45; p=0·41). The incidence of IRIS, and drug toxicity was not significantly different between trial arms. There were no differences between treatment groups in the proportion of grade 3 or 4 adverse events (34 [38%] of 90 children in the urgent group vs 40 [44%] of 91 children in the post-stabilisation group; p=0·40) or the proportion of any change in ART regimen (five [7%] vs six [8%]; p=0·79). We discontinued randomisation at interim review when the futility boundary was crossed. INTERPRETATION Early mortality risk was extremely high among hospitalised HIV-infected children. Urgent ART did not improve survival. FUNDING National Institute of Child Health and Human Development, National Institutes of Health, USA.
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Affiliation(s)
- Irene N Njuguna
- Kenyatta National Hospital, Nairobi, Kenya; Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | - Lisa M Cranmer
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Cyrus Mugo
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Hellen M Okinyi
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | - Barbra Richardson
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Joshua Stern
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Dalton C Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace C John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
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Wilson KS, Mugo C, Bukusi D, Inwani I, Wagner AD, Moraa H, Owens T, Babigumira JB, Richardson BA, John-Stewart GC, Slyker JA, Wamalwa DC, Kohler PK. Simulated patient encounters to improve adolescent retention in HIV care in Kenya: study protocol of a stepped-wedge randomized controlled trial. Trials 2017; 18:619. [PMID: 29282109 PMCID: PMC5745919 DOI: 10.1186/s13063-017-2266-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 10/20/2017] [Indexed: 11/15/2022] Open
Abstract
Background Adolescent-friendly policies aim to tailor HIV services for adolescents and young adults aged 10–24 years (AYA) to promote health outcomes and improve retention in HIV care and treatment. However, few interventions focus on improving healthcare worker (HCW) competencies and skills for provision of high-quality adolescent care. Standardized patients (SPs) are trained actors who work with HCWs in mock clinical encounters to improve clinical assessment, communication, and empathy skills. This stepped-wedge randomized controlled trial will evaluate a clinical training intervention utilizing SPs to improve HCW skills in caring for HIV-positive AYA, resulting in increased retention in care. Methods/design The trial will utilize a stepped-wedge design to evaluate a training intervention using SPs to train HCWs in assessment, communication, and empathy skills for AYA HIV care. We will recruit 24 clinics in Kenya with an active electronic medical record (EMR) system and at least 40 adolescents enrolled in HIV care per site. Stratified randomization by county will be used to assign clinics to one of four waves – time periods when they receive the intervention – with each wave including six clinics. From each clinic, up to 10 HCWs will participate in the training intervention. SP training includes didactic sessions in adolescent health, current guidelines, communication skills, and motivational interviewing techniques. HCW participants will rotate through seven standardized SP scenarios, followed by SP feedback, group debriefing, and remote expert evaluation. AYA outcomes will be assessed using routine clinic data. The primary outcome is AYA retention in HIV care, defined as returning for first follow-up visit within 6 months of presenting to care, or returning for a first follow-up visit after re-engagement in care in AYA with a previous history of being lost to follow-up. Secondary outcomes include HCW competency scores, AYA satisfaction with care, and AYA clinical outcomes including CD4 and viral load. Additional analyses will determine cost-effectiveness of the intervention. Discussion This trial will contribute valuable information to HIV programs in Kenya and other low-resource settings, providing a potentially scalable strategy to improve quality of care and retention in critical HIV services in this population. Trial registration ClinicalTrials.gov, ID: NCT02928900. Registered 26 August 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2266-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kate S Wilson
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359932, Seattle, WA, 98104, USA.
| | - Cyrus Mugo
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - David Bukusi
- VCT and HIV Prevention Unit/Youth Centre, Kenyatta National Hospital, Nairobi, Kenya
| | - Irene Inwani
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359932, Seattle, WA, 98104, USA
| | - Helen Moraa
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Tamara Owens
- Clinical Skills and Simulation Center, Howard University Health Sciences, Washington DC, USA
| | - Joseph B Babigumira
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359932, Seattle, WA, 98104, USA
| | | | - Grace C John-Stewart
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359932, Seattle, WA, 98104, USA.,Department of Pediatrics, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jennifer A Slyker
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359932, Seattle, WA, 98104, USA
| | - Dalton C Wamalwa
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Pamela K Kohler
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359932, Seattle, WA, 98104, USA.,Department of Psychosocial and Community Health, University of Washington, Seattle, WA, USA
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Wagner AD, Njuguna IN, Andere RA, Cranmer LM, Okinyi HM, Benki-Nugent S, Chohan BH, Maleche-Obimbo E, Wamalwa DC, John-Stewart GC. Infant/child rapid serology tests fail to reliably assess HIV exposure among sick hospitalized infants. AIDS 2017; 31:F1-F7. [PMID: 28609404 PMCID: PMC5540651 DOI: 10.1097/qad.0000000000001562] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The WHO guidelines for infant and child HIV diagnosis recommend the use of maternal serology to determine child exposure status in ages 0-18 months, but suggest that infant serology can reliably be used to determine exposure for those less than 4 months. There is little evidence about the performance of these recommendations among hospitalized sick infants and children. METHODS Within a clinical trial (NCT02063880) in Kenya, among children 18 months or younger, maternal and child rapid serologic HIV tests were performed in tandem. Dried blood spots were tested using HIV DNA PCR for all children whose mothers were seropositive, irrespective of child serostatus. We characterized the performance of infant/child serology results to detect HIV exposure in three age groups: 0-3, 4-8, and 9-18 months. RESULTS Among 65 maternal serology positive infants age 0-3 months, 48 (74%), 1 (2%) and 16 (25%) had positive, indeterminate and negative infant serology results, respectively. Twelve (25%), 0 and 4 (25%) of those with positive, indeterminate and negative infant serology results, respectively, were HIV-infected by DNA PCR. Among 71 maternal serology positive infants age 4-8 months, 31 (44%), 8 (11%) and 32 (45%) had positive, indeterminate and negative infant serology results, respectively. Fourteen (45%), 2 (25%) and 7 (22%) infants with positive, indeterminate and negative infant serology results, respectively, were HIV-infected. Among 67 maternal serology positive infants/children age 9-18 months, 40 (60%), 2 (3%) and 25 (37%) had positive, indeterminate and negative infant serology results, respectively. Thirty-six (90%), 2 (100%) and 2 (8%) infants with positive, indeterminate and negative infant serology results, respectively, were HIV-infected. In the 0-3, 4-8 and 9-18 month age groups, use of maternal serology to define HIV exposure identified 33% [95% confidence interval (CI) 10-65%], 44% (95% CI 20-70%) and 5% (95% CI 0.1-18%) more HIV infections, respectively. CONCLUSION Maternal serology should preferentially be used for screening among hospitalized infants of all ages to improve early diagnosis of children with HIV.
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Affiliation(s)
- Anjuli D Wagner
- aDepartment of Global Health, University of Washington, Seattle, Washington, USA bKenyatta National Hospital, Nairobi, Kenya cDepartment of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA dDepartment of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya eDepartment of Medicine, University of Washington, Seattle, Washington, USA fKenya Medical Research Institute, Nairobi, Nairobi, Kenya gDepartment of Epidemiology hDepartment of Pediatrics, University of Washington, Seattle, Washington, USA. *Anjuli D. Wagner and Irene N. Njuguna are co-first authors
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Wagner AD, Mugo C, Bluemer-Miroite S, Mutiti PM, Wamalwa DC, Bukusi D, Neary J, Njuguna IN, O’Malley G, John-Stewart GC, Slyker JA, Kohler PK. Continuous quality improvement intervention for adolescent and young adult HIV testing services in Kenya improves HIV knowledge. AIDS 2017; 31 Suppl 3:S243-S252. [PMID: 28665882 PMCID: PMC5497779 DOI: 10.1097/qad.0000000000001531] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 04/24/2017] [Accepted: 04/24/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine whether continuous quality improvement (CQI) improves quality of HIV testing services for adolescents and young adults (AYA). DESIGN CQI was introduced at two HIV testing settings: Youth Centre and Voluntary Counseling and Testing (VCT) Center, at a national referral hospital in Nairobi, Kenya. METHODS Primary outcomes were AYA satisfaction with HIV testing services, intent to return, and accurate HIV prevention and transmission knowledge. Healthcare worker (HCW) satisfaction assessed staff morale. T tests and interrupted time series analysis using Prais-Winsten regression and generalized estimating equations accounting for temporal trends and autocorrelation were conducted. RESULTS There were 172 AYA (Youth Centre = 109, VCT = 63) during 6 baseline weeks and 702 (Youth Centre = 454, VCT = 248) during 24 intervention weeks. CQI was associated with an immediate increase in the proportion of AYA with accurate knowledge of HIV transmission at Youth Centre: 18 vs. 63% [adjusted risk difference (aRD) 0.42,95% confidence interval (CI) 0.21 to 0.63], and a trend at VCT: 38 vs. 72% (aRD 0.30, 95% CI -0.04 to 0.63). CQI was associated with an increase in the proportion of AYA with accurate HIV prevention knowledge in VCT: 46 vs. 61% (aRD 0.39, 95% CI 0.02-0.76), but not Youth Centre (P = 0.759). In VCT, CQI showed a trend towards increased intent to retest (4.0 vs. 4.3; aRD 0.78, 95% CI -0.11 to 1.67), but not at Youth Centre (P = 0.19). CQI was not associated with changes in AYA satisfaction, which was high during baseline and intervention at both clinics (P = 0.384, P = 0.755). HCW satisfaction remained high during intervention and baseline (P = 0.746). CONCLUSION CQI improved AYA knowledge and did not negatively impact HCW satisfaction. Quality improvement interventions may be useful to improve adolescent-friendly service delivery.
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Affiliation(s)
- Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Cyrus Mugo
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Shay Bluemer-Miroite
- International Training and Education Center for Health, University of Washington, Seattle, Washington, USA
| | - Peter M. Mutiti
- VCT and HIV Prevention Unit/Youth Centre, Kenyatta National Hospital, Nairobi, Kenya
| | - Dalton C. Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - David Bukusi
- VCT and HIV Prevention Unit/Youth Centre, Kenyatta National Hospital, Nairobi, Kenya
| | - Jillian Neary
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Irene N. Njuguna
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Gabrielle O’Malley
- Department of Global Health, University of Washington, Seattle, Washington, USA
- International Training and Education Center for Health, University of Washington, Seattle, Washington, USA
| | - Grace C. John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington, USA
- School of Medicine
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Jennifer A. Slyker
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Pamela K. Kohler
- Department of Global Health, University of Washington, Seattle, Washington, USA
- International Training and Education Center for Health, University of Washington, Seattle, Washington, USA
- Department of Psychosocial and Community Health
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Njuguna IN, Wagner AD, Cranmer LM, Otieno VO, Onyango JA, Chebet DJ, Okinyi HM, Benki-Nugent S, Maleche-Obimbo E, Slyker JA, John-Stewart GC, Wamalwa DC. Hospitalized Children Reveal Health Systems Gaps in the Mother-Child HIV Care Cascade in Kenya. AIDS Patient Care STDS 2016; 30:119-24. [PMID: 27308805 DOI: 10.1089/apc.2015.0239] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
To identify missed opportunities in HIV prevention, diagnosis, and linkage to care, we enrolled 183 hospitalized, HIV-infected, ART-naïve Kenyan children 0-12 years from four hospitals in Nairobi and Kisumu, and reviewed prevention of mother-to-child transmission of HIV (PMTCT), hospitalization, and HIV testing history. Median age was 1.8 years (IQR = 0.8, 4.5). Most mothers received HIV testing during pregnancy (77%). Among mothers tested, 60% and 40% reported HIV-negative and positive results, respectively; 33% of HIV-diagnosed mothers did not receive PMTCT antiretrovirals. First missed opportunities for pediatric diagnosis and linkage were due to failure to test mothers (23.1%), maternal HIV acquisition following initial negative test (45.7%), no early infant diagnosis (EID) or provider-initiated testing (PITC) (12.7%), late breastfeeding transmission (8.7%), failure to collect child HIV test results (1.2%), and no linkage to care following HIV diagnosis (8.7%). Among previously hospitalized children, 38% never received an HIV test. Strengthening initial and repeat maternal HIV testing and PITC are key interventions to prevent, detect, and treat pediatric HIV infections.
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Affiliation(s)
- Irene N. Njuguna
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Anjuli D. Wagner
- Department of Global Health, University of Washington, Seattle, Washington
| | - Lisa M. Cranmer
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Vincent O. Otieno
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Judith A. Onyango
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Daisy J. Chebet
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Helen M. Okinyi
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | | | - Jennifer A. Slyker
- Department of Global Health, University of Washington, Seattle, Washington
| | - Grace C. John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology and Pediatrics, University of Washington, Seattle, Washington
| | - Dalton C. Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Olang PR, Wamalwa DC. MATERNAL HYPOTENSION AND NEONATAL ACIDAEMIA DURING CAESEREAN DELIVERY UNDER SPINAL ANAESTHESIA. East Afr Med J 2012; 89:317-321. [PMID: 26852440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To determine the incidence of neonatal acidaemia following delivery through caesarean section under spinal anaesthesia and determine the prevalence of maternal hypotension during Caesarean section under spinal anaesthesia and its correlation with neonatal acidaemia. DESIGN Prospective observational study. SETTING Kenyatta National Hospital (KNH), Nairobi, Kenya. SUBJECTS One hundred and seventy-two ASA I and II consecutive term patients undergoing elective Caesarean section under spinal anaesthesia. RESULTS Forty three babies (27.2%) were born with neonatal acidaemia, defined as umbilical arterial blood pH 7.2. There was, however, no significant difference in the five minute Apgar scores between the acidotic and non-acidotic neonates. Twenty eight patients (17.7%) developed maternal hypotension (systolic Blood Pressure less than 100mmHg). The hypotension was readily corrected within two minutes (mean of 1.43 minutes) of onset using vasopressors and boluses of intravenous fluids. CONCLUSIONS A short period (< 2 minutes) mean of 1.43 minutes of maternal hypotension has no significant effect on the neonate as assessed by five minute Apgar Scores. Similarly, neonatal acidaemia following Caesarean delivery under spinal anaesthesia does not seem to have any short-term effects on neonatal well-being.
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Affiliation(s)
- P R Olang
- Department of Surgery, College of Health Sciences, University of Nairobi, Nairobi, Kenya
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Mwendwa AC, Musoke RN, Wamalwa DC. IMPACT OF PARTIAL KANGAROO MOTHER CARE ON GROWTH RATES AND DURATION OF HOSPITAL STAY OF LOW BIRTH WEIGHT INFANTS AT THE KENYATTA NATIONAL HOSPITAL, NAIROBI. East Afr Med J 2012; 89:53-58. [PMID: 26845812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To determine the effect of partial Kangaroo Mother Care (KMC) on growth rates and duration of hospital stay of Low Birth Weight (LBW) infants. DESIGN Unblinded, randomised clinical controlled trial. SETTING Kenyatta National Hospital, Nairobi, Kenya. SUBJECTS Over a nine month period, consecutive recruitment of eligible LBW infants weighing 1000 g to 1750 g was done until a sample of 166 infants was reached. INTERVENTION Kangaroo mother care was practised over an eight hour period per day for the intervention group while the controls remained in incubators or cots. Weight, head circumference, and mid upper arm circumference were monitored for all infants till discharge at 1800 g. RESULTS Of the 166 infants recruited 157 were followed up to discharge. Baseline characteristics were similar for the two groups except for mother's age, with the KMC group mothers having a mean age of 26.5 years while the control group mothers had a mean age of 24 years, (p = 0.04). The KMC group had significantly higher growth rates as shown by the higher mean weight gain of 22.5 g/kg/day compared with 16.7g/kg/day for the control group, (p < 0.001); higher mean head circumference gain of 0.91 cm/week compared with 0.54 cm/week for the control group, (p < 0.001) and higher mean mid upper arm circumference gain of 0.76 cm/week compared with 0.48 cm/week for the control group, (p = 0.002). Although overall duration of stay was similar between study arms, when infants were stratified into those above or below 1500 g KMC infants' duration of stay was significantly shorter than those in regular care. Using logistic regression, KMCwas the strongest predictor formeanweight, meanhead circumference and mean MUAC gain while mother's age (older) was the strongest predictor for mean duration of stay with KMC being an independent predictor of duration of stay. CONCLUSION Low birth weight infants in this cohort achieved rates of growth within the recommended intrauterine growth but babies managed using partial KMC grew faster and were thus discharged earlier than those on standard of care. Since partial KMC was beneficial, it should be fully implemented for all eligible infants.
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Githinji N, Maleche-Obimbo E, Nderitu M, Wamalwa DC, Mbori-Ngacha D. Utility of total lymphocyte count as a surrogate marker for CD4 counts in HIV-1 infected children in Kenya. BMC Infect Dis 2011; 11:259. [PMID: 21961890 PMCID: PMC3207914 DOI: 10.1186/1471-2334-11-259] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 09/30/2011] [Indexed: 11/20/2022] Open
Abstract
Background In resource-limited settings, such as Kenya, access to CD4 testing is limited. Therefore, evaluation of less expensive laboratory diagnostics is urgently needed to diagnose immuno-suppression in children. Objectives To evaluate utility of total lymphocyte count (TLC) as surrogate marker for CD4 count in HIV-infected children. Methods This was a hospital based retrospective study conducted in three HIV clinics in Kisumu and Nairobi in Kenya. TLC, CD4 count and CD4 percent data were abstracted from hospital records of 487 antiretroviral-naïve HIV-infected children aged 1 month - 12 years. Results TLC and CD4 count were positively correlated (r = 0.66, p < 0.001) with highest correlation seen in children with severe immuno-suppression (r = 0.72, p < 0.001) and children >59 months of age (r = 0.68, p < 0.001). Children were considered to have severe immuno-suppression if they met the following WHO set CD4 count thresholds: age below 12 months (CD4 counts < 1500 cells/mm3), age 12-35 months (CD4 count < 750 cells/mm3), age 36-59 months (CD4 count < 350 cells/mm3, and age above 59 months (CD4 count < 200 cells/mm3). WHO recommended TLC threshold values for severe immuno-suppression of 4000, 3000, 2500 and 2000 cells/mm3 for age categories <12, 12-35, 36-59 and >59 months had low sensitivity of 25%, 23%, 33% and 62% respectively in predicting severe immuno-suppression using CD4 count as gold standard. Raising TLC thresholds to 7000, 6000, 4500 and 3000 cells/mm3 for each of the stated age categories increased sensitivity to 71%, 64%, 56% and 86%, with positive predictive values of 85%, 61%, 37%, 68% respectively but reduced specificity to 73%, 62%, 54% and 68% with negative predictive values of 54%, 65%, 71% and 87% respectively. Conclusion TLC is positively correlated with absolute CD4 count in children but current WHO age-specific thresholds had low sensitivity to identify severely immunosuppressed Kenyan children. Sensitivity and therefore utility of TLC to identify immuno-suppressed children may be improved by raising the TLC cut off levels across the various age categories.
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Affiliation(s)
- Nyawira Githinji
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Wamalwa DC, Obimbo EM, Farquhar C, Richardson BA, Mbori-Ngacha DA, Inwani I, Benki-Nugent S, John-Stewart G. Predictors of mortality in HIV-1 infected children on antiretroviral therapy in Kenya: a prospective cohort. BMC Pediatr 2010; 10:33. [PMID: 20482796 PMCID: PMC2887829 DOI: 10.1186/1471-2431-10-33] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Accepted: 05/18/2010] [Indexed: 11/17/2022] Open
Abstract
Background Among children, early mortality following highly active antiretroviral therapy (HAART) remains high. It is important to define correlates of mortality in order to improve outcome. Methods HIV-1-infected children aged 18 months-12 years were followed up at Kenyatta National Hospital, Nairobi after initiating NNRTI-based HAART. Cofactors for mortality were determined using multivariate Cox regression models. Results Between August 2004 and November 2008, 149 children were initiated on HAART of whom 135 were followed for a total of 238 child-years (median 21 months) after HAART initiation. Baseline median CD4% was 6.8% and median HIV-1-RNA was 5.98-log10 copies/ml. Twenty children (13.4%) died at a median of 35 days post-HAART initiation. Mortality during the entire follow-up period was 8.4 deaths per 100 child-years (46 deaths/100 child-years in first 4 months and 1.0 deaths/100 child-years after 4 months post-HAART initiation). On univariate Cox regression, baseline hemoglobin (Hb) <9 g/dl, weight-for-height z-score (WHZ) < -2, and WHO clinical stage 4 were associated with increased risk of death (Hb <9 g/dl HR 3.00 [95% C.I. 1.21-7.39], p = 0.02, WHZ < -2 HR 3.41 [95% C.I. 1.28-9.08], p = 0.01, and WHO clinical stage 4, HR 3.08 [1.17-8.12], p = 0.02). On multivariate analysis Hb < 9 g/dl remained predictive of mortality after controlling for age, baseline CD4%, WHO clinical stage and weight-for-height z-score (HR 2.95 (95% C.I. 1.04-8.35) p = 0.04). Conclusion High early mortality was observed in this cohort of Kenyan children receiving HAART, and low baseline hemoglobin was an independent risk factor for death.
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Affiliation(s)
- Dalton C Wamalwa
- Department of Paediatrics, University of Nairobi, Box 19676, Nairobi 00202, Kenya.
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Wamalwa DC, Farquhar C, Obimbo EM, Selig S, Mbori-Ngacha DA, Richardson BA, Overbaugh J, Egondi T, Inwani I, John-Stewart G. Medication diaries do not improve outcomes with highly active antiretroviral therapy in Kenyan children: a randomized clinical trial. J Int AIDS Soc 2009; 12:8. [PMID: 19549342 PMCID: PMC2708138 DOI: 10.1186/1758-2652-12-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Accepted: 06/24/2009] [Indexed: 12/03/2022] Open
Abstract
Background As highly active antiretroviral therapy (HAART) becomes increasingly available to African children, it is important to evaluate simple and feasible methods of improving adherence in order to maximize benefits of therapy. Methods HIV-1-infected children initiating World Health Organization non-nucleoside reverse transcriptase-inhibitor-containing first-line HAART regimens were randomized to use medication diaries plus counselling, or counselling only (the control arm of the study). The diaries were completed daily by caregivers of children randomized to the diary and counselling arm for nine months. HIV-1 RNA, CD4+ T cell count, and z-scores for weight-for-age, height-for-age and weight-for-height were measured at a baseline and every three to six months. Self-reported adherence was assessed by questionnaires for nine months. Results Ninety HIV-1-infected children initiated HAART, and were followed for a median of 15 months (interquartile range: 2–21). Mean CD4 percentage was 17.2% in the diary arm versus 16.3% in the control arm at six months (p = 0.92), and 17.6% versus 18.9% at 15 months (p = 0.36). Virologic response with HIV-1 RNA of <100 copies/ml at nine months was similar between the two arms (50% for the diary arm and 36% for the control, p = 0.83). The weight-for-age, height-for-age and weight-for-height at three, nine and 15 months after HAART initiation were similar between arms. A trend towards lower self-reported adherence was observed in the diary versus the control arm (85% versus 92%, p = 0.08). Conclusion Medication diaries did not improve clinical and virologic response to HAART over a 15-month period. Children had good adherence and clinical response without additional interventions. This suggests that paediatric HAART with conventional counselling can be a successful approach. Further studies on targeted approaches for non-adherent children will be important.
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Affiliation(s)
- Dalton C Wamalwa
- Department of Paediatrics University of Nairobi, Nairobi, Kenya.
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Wamalwa DC, Farquhar C, Obimbo EM, Selig S, Mbori-Ngacha DA, Richardson BA, Overbaugh J, Emery S, Wariua G, Gichuhi C, Bosire R, John-Stewart G. Early response to highly active antiretroviral therapy in HIV-1-infected Kenyan children. J Acquir Immune Defic Syndr 2007; 45:311-7. [PMID: 17356470 PMCID: PMC3380073 DOI: 10.1097/qai.0b013e318042d613] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES 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. METHODS 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. RESULTS 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. CONCLUSION Good early clinical and virologic response to NNRTI-based HAART was observed in HIV-1-infected Kenyan children with advanced HIV-1 disease.
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Affiliation(s)
- Dalton C Wamalwa
- Department of Pediatrics, University of Nairobi, Nairobi, Kenya.
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Drake AL, John-Stewart GC, Wald A, Mbori-Ngacha DA, Bosire R, Wamalwa DC, Lohman-Payne BL, Ashley-Morrow R, Corey L, Farquhar C. Herpes Simplex Virus Type 2 and Risk of Intrapartum Human Immunodeficiency Virus Transmission. Obstet Gynecol 2007; 109:403-9. [PMID: 17267842 DOI: 10.1097/01.aog.0000251511.27725.5c] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether herpes simplex virus type 2 (HSV-2) infection was associated with risk of intrapartum human immunodeficiency virus type 1 (HIV-1) transmission and to define correlates of HSV-2 infection among HIV-1-seropositive pregnant women. METHODS We performed a nested case control study within a perinatal cohort in Nairobi, Kenya. Herpes simplex virus type 2 serostatus and the presence of genital ulcers were ascertained at 32 weeks of gestation. Maternal cervical and plasma HIV-1 RNA and cervical HSV DNA were measured at delivery. RESULTS One hundred fifty-two (87%) of 175 HIV-1-infected mothers were HSV-2-seropositive. Among the 152 HSV-2-seropositive women, nine (6%) had genital ulcers at 32 weeks of gestation, and 13 (9%) were shedding HSV in cervical secretions. Genital ulcers were associated with increased plasma HIV-1 RNA levels (P=.02) and an increased risk of intrapartum HIV-1 transmission (16% of transmitters versus 3% of nontransmitters had ulcers; P = .003), an association which was maintained in multivariable analysis adjusting for plasma HIV-1 RNA levels (P=.04). We found a borderline association for higher plasma HIV-1 RNA among women shedding HSV (P=.07) and no association between cervical HSV shedding and either cervical HIV-1 RNA levels or intrapartum HIV-1 transmission (P=.4 and P=.5, [corrected] respectively). CONCLUSION Herpes simplex virus type 2 is the leading cause of genital ulcers among women in sub-Saharan Africa and was highly prevalent in this cohort of pregnant women receiving prophylactic zidovudine. After adjusting for plasma HIV-1 RNA levels, genital ulcers were associated with increased risk of intrapartum HIV-1 transmission. These data suggest that management of HSV-2 during pregnancy may enhance mother-to-child HIV-1 prevention efforts. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Alison L Drake
- Departments of Epidemiology and Medicine, University of Washington, Seattle, WA 98195, USA.
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Wamalwa DC, Wafula EM, Munyao TM, Murila FV. Pattern of use of skin care products in children with and without eczematous skin lesions. East Afr Med J 2002; 79:645-50. [PMID: 12678448 DOI: 10.4314/eamj.v79i12.8672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare the pattern of use of skin care products between children with eczematous skin lesions and those without. DESIGN Case control study. SETTING Two well baby clinics at the Kenyatta National Hospital and the Mbagathi District Hospital in Nairobi. SUBJECTS Eighty nine infants with eczematous skin lesions and 89 age and sex matched controls without skin lesions. MAIN OUTCOME MEASURES Presence and severity of skin lesions related to the type of skin care products used by the child. RESULTS Exposure to various products was not significantly different between infants with skin lesions and those without. However, more mothers whose children had a skin rash had made a change in the type of soap and or skin cream used for their child (p<0.0001). The principal reason for changing products was skin rash in the baby and most mothers made changes away from scented baby soap products. CONCLUSION The study found no significant difference between the cases and controls regarding the type of skin care products used.
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Affiliation(s)
- D C Wamalwa
- Department of Paediatrics and Child Health, College of Health Sciences, University of Nairobi, P.O. Box 19676, Nairobi, Kenya
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