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Blanco N, Lavoie MC, Ngeno C, Wangusi R, Jumbe M, Kimonye F, Ndaga A, Ndichu G, Makokha V, Awuor P, Momanyi E, Oyuga R, Nzyoka S, Mutisya I, Joseph R, Miruka F, Musingila P, Stafford KA, Lascko T, Ngunu C, Owino E, Kiplangat A, Abuya K, Koech E. Effects of Multi-Month Dispensing on Clinical Outcomes: Retrospective Cohort Analysis Conducted in Kenya. AIDS Behav 2024; 28:583-590. [PMID: 38127168 DOI: 10.1007/s10461-023-04247-1] [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] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
Multi-month dispensing (MMD) has been widely adopted by national HIV programs as a key strategy for improving the quality of HIV care and treatment services while meeting the unique needs of diverse client populations. We assessed the clinical outcomes of clients receiving MMD in Kenya by conducting a retrospective cohort study using routine programmatic data in 32 government health facilities in Kenya. We included clients who were eligible for multi-month antiretroviral therapy (ART) dispensing for ≥ 3 months (≥ 3MMD) according to national guidelines. The primary exposure was enrollment into ≥ 3MMD. The outcomes were lost to follow-up (LTFU) and viral rebound. Multilevel modified-Poisson regression models with robust standard errors were used to compare clinical outcomes between clients enrolled in ≥ 3MMD and those receiving ART dispensing for less than 3 months (< 3MMD). A total of 3,501 clients eligible for ≥ 3MMD were included in the analysis, of whom 65% were enrolled in ≥ 3MMD at entry into the cohort. There was no difference in LTFU of ≥ 180 days between the two types of care (aRR 1.1, 95% CI 0.7-1.6), while ≥ 3MMD was protective for viral rebound (aRR 0.1 95% CI 0.0-0.2). As more diverse client-focused service delivery models are being implemented, robust evaluations are essential to guide the implementation, monitor progress, and assess acceptability and effectiveness to deliver optimal people-centered care.
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Affiliation(s)
- Natalia Blanco
- Centre for International Health, Education, and Biosecurity (Ciheb), University of Maryland School of Medicine, Baltimore, USA.
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - M C Lavoie
- Centre for International Health, Education, and Biosecurity (Ciheb), University of Maryland School of Medicine, Baltimore, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Global Health Sciences, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - C Ngeno
- Center for International Health Education and Biosecurity (Ciheb), MGIC-an affiliate of the University of Maryland Baltimore, Nairobi, Kenya
| | - R Wangusi
- Center for International Health Education and Biosecurity (Ciheb), MGIC-an affiliate of the University of Maryland Baltimore, Nairobi, Kenya
| | - M Jumbe
- Center for International Health Education and Biosecurity (Ciheb), MGIC-an affiliate of the University of Maryland Baltimore, Nairobi, Kenya
| | - F Kimonye
- Center for International Health Education and Biosecurity (Ciheb), MGIC-an affiliate of the University of Maryland Baltimore, Nairobi, Kenya
| | - A Ndaga
- Center for International Health Education and Biosecurity (Ciheb), MGIC-an affiliate of the University of Maryland Baltimore, Nairobi, Kenya
| | - G Ndichu
- Center for International Health Education and Biosecurity (Ciheb), MGIC-an affiliate of the University of Maryland Baltimore, Nairobi, Kenya
| | - V Makokha
- Center for International Health Education and Biosecurity (Ciheb), MGIC-an affiliate of the University of Maryland Baltimore, Nairobi, Kenya
| | - P Awuor
- Center for International Health Education and Biosecurity (Ciheb), MGIC-an affiliate of the University of Maryland Baltimore, Nairobi, Kenya
| | - E Momanyi
- Center for International Health Education and Biosecurity (Ciheb), MGIC-an affiliate of the University of Maryland Baltimore, Nairobi, Kenya
| | - R Oyuga
- Center for International Health Education and Biosecurity (Ciheb), MGIC-an affiliate of the University of Maryland Baltimore, Nairobi, Kenya
| | - S Nzyoka
- Center for International Health Education and Biosecurity (Ciheb), MGIC-an affiliate of the University of Maryland Baltimore, Nairobi, Kenya
| | - I Mutisya
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - R Joseph
- Center for International Health Education and Biosecurity (Ciheb), MGIC-an affiliate of the University of Maryland Baltimore, Nairobi, Kenya
| | - F Miruka
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - P Musingila
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - K A Stafford
- Centre for International Health, Education, and Biosecurity (Ciheb), University of Maryland School of Medicine, Baltimore, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Global Health Sciences, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - T Lascko
- Centre for International Health, Education, and Biosecurity (Ciheb), University of Maryland School of Medicine, Baltimore, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - C Ngunu
- Nairobi Metropolitan Services Health Management Team, Nairobi, Kenya
| | - E Owino
- Migori County Health Management Team, Western, Kenya
| | - A Kiplangat
- Nairobi Metropolitan Services Health Management Team, Nairobi, Kenya
| | - K Abuya
- Kisii County Health Management Team, Western, Kenya
| | - E Koech
- Center for International Health Education and Biosecurity (Ciheb), MGIC-an affiliate of the University of Maryland Baltimore, Nairobi, Kenya
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Lavoie MCC, Koech E, Blanco N, Wangusi R, Jumbe M, Kimonye F, Ndaga A, Ndichu G, Makokha V, Awuor P, Momanyi E, Oyuga R, Nzyoka S, Mutisya I, Joseph R, Miruka F, Musingila P, Stafford KA, Lascko T, Ngunu C, Owino E, Kiplangat A, Kepha A, Ng'eno C. Factors associated with enrollment into differentiated service delivery model among adults with HIV in Kenya. AIDS 2023; 37:2409-2417. [PMID: 37707787 DOI: 10.1097/qad.0000000000003725] [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] [Indexed: 09/15/2023]
Abstract
INTRODUCTION Differentiated service delivery (DSD) such as multimonth dispensing (MMD) aims to provide client-centered HIV services, while reducing the workload within health facilities. We assessed individual and facility factors associated with receiving more than three MMD and switching from ≥3MMD back to <3MMD in Kenya. METHODS We conducted a retrospective cohort study of clients eligible for DSD between July 2017 and December 2019. A random sample of clients eligible for DSD was selected from 32 randomly selected facilities located in Nairobi, Kisii, and Migori counties. We used a multilevel Poisson regression model to assess the factors associated with receiving ≥3MMD, and with switching from ≥3MMD back to <3MMD. RESULTS A total of 3501 clients eligible for ≥3MMD were included in our analysis: 1808 (51.6%) were receiving care in Nairobi County and the remaining 1693 (48.4%) in Kisii and Migori counties. Overall, 65% of clients were enrolled in ≥3MMD at the time of entry into the cohort. In the multivariable model, younger age (20-24; 25-29; 30-34 vs. 50 or more years) and switching ART regimen was significantly associated with a lower likelihood of ≥3MMD uptake. Factors associated with a higher likelihood of enrollment in ≥3MMD included receiving DTG vs. EFV-based ART regimen (aRR: 1.10; 95% confidence interval: 1.05-1.15). CONCLUSION Client-level characteristics are associated with being on ≥3MMD and the likelihood of switching from ≥3MMD to <3MMD. Monitoring DSD enrollment across different populations is critical to successfully implementing these models continually.
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Affiliation(s)
- Marie-Claude C Lavoie
- Division of Global Health Sciences, Department of Epidemiology and Public Health
- Institute of Human Virology
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Emily Koech
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Natalia Blanco
- Institute of Human Virology
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rebecca Wangusi
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Marline Jumbe
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Francis Kimonye
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Angela Ndaga
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Geofrey Ndichu
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Violet Makokha
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Patrick Awuor
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Emmah Momanyi
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Roseline Oyuga
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Sarah Nzyoka
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
| | - Immaculate Mutisya
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu
| | - Rachel Joseph
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu
| | - Fredrick Miruka
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu
| | - Paul Musingila
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu
| | - Kristen A Stafford
- Division of Global Health Sciences, Department of Epidemiology and Public Health
- Institute of Human Virology
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Taylor Lascko
- Institute of Human Virology
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Carol Ngunu
- Nairobi Metropolitan Services Health Management Team, Nairobi
| | | | | | - Abuya Kepha
- Kisii County Health Management Team, Western, Kenya
| | - Caroline Ng'eno
- Center for International Health, Education, and Biosecurity, MGIC-an affiliate of the University of Maryland Baltimore, Nairobi
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Aoko A, Pals S, Ngugi T, Katiku E, Joseph R, Basiye F, Kimanga D, Kimani M, Masamaro K, Ngugi E, Musingila P, Nganga L, Ondondo R, Makory V, Ayugi R, Momanyi L, Mambo B, Bowen N, Okutoyi S, Chun HM. Retrospective longitudinal analysis of low-level viremia among HIV-1 infected adults on antiretroviral therapy in Kenya. EClinicalMedicine 2023; 63:102166. [PMID: 37649807 PMCID: PMC10462863 DOI: 10.1016/j.eclinm.2023.102166] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 09/01/2023] Open
Abstract
Background HIV low-level viremia (LLV) (51-999 copies/mL) can progress to treatment failure and increase potential for drug resistance. We analyzed retrospective longitudinal data from people living with HIV (PLHIV) on antiretroviral therapy (ART) in Kenya to understand LLV prevalence and virologic outcomes. Methods We calculated rates of virologic suppression (≤50 copies/mL), LLV (51-999 copies/mL), virologic non-suppression (≥1000 copies/mL), and virologic failure (≥2 consecutive virologic non-suppression results) among PLHIV aged 15 years and older who received at least 24 weeks of ART during 2015-2021. We analyzed risk for virologic non-suppression and virologic failure using time-dependent models (each viral load (VL) <1000 copies/mL used to predict the next VL). Findings Of 793,902 patients with at least one VL, 18.5% had LLV (51-199 cp/mL 11.1%; 200-399 cp/mL 4.0%; and 400-999 cp/mL 3.4%) and 9.2% had virologic non-suppression at initial result. Among all VLs performed, 26.4% were LLV. Among patients with initial LLV, 13.3% and 2.4% progressed to virologic non-suppression and virologic failure, respectively. Compared to virologic suppression (≤50 copies/mL), LLV was associated with increased risk of virologic non-suppression (adjusted relative risk [aRR] 2.43) and virologic failure (aRR 3.86). Risk of virologic failure increased with LLV range (aRR 2.17 with 51-199 copies/mL, aRR 3.98 with 200-399 copies/mL and aRR 7.99 with 400-999 copies/mL). Compared to patients who never received dolutegravir (DTG), patients who initiated DTG had lower risk of virologic non-suppression (aRR 0.60) and virologic failure (aRR 0.51); similarly, patients who transitioned to DTG had lower risk of virologic non-suppression (aRR 0.58) and virologic failure (aRR 0.35) for the same LLV range. Interpretation Approximately a quarter of patients experienced LLV and had increased risk of virologic non-suppression and failure. Lowering the threshold to define virologic suppression from <1000 to <50 copies/mL to allow for earlier interventions along with universal uptake of DTG may improve individual and program outcomes and progress towards achieving HIV epidemic control. Funding No specific funding was received for the analysis. HIV program support was provided by the President's Emergency Plan for AIDS Relief (PEPFAR) through the United States Centers for Disease Control and Prevention (CDC).
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Affiliation(s)
- Appolonia Aoko
- U.S. Centers for Disease Control and Prevention (CDC), Division of Global HIV&TB, Center for Global Health, Nairobi, Kenya
| | - Sherri Pals
- U.S. Centers for Disease Control and Prevention (CDC), Division of Global HIV/TB, Center for Global Health, Atlanta, Georgia, USA
| | | | - Elizabeth Katiku
- U.S. Centers for Disease Control and Prevention (CDC), Division of Global HIV&TB, Center for Global Health, Nairobi, Kenya
| | - Rachael Joseph
- U.S. Centers for Disease Control and Prevention (CDC), Division of Global HIV&TB, Center for Global Health, Nairobi, Kenya
| | - Frank Basiye
- U.S. Centers for Disease Control and Prevention (CDC), Division of Global HIV&TB, Center for Global Health, Nairobi, Kenya
| | - Davies Kimanga
- U.S. Centers for Disease Control and Prevention (CDC), Division of Global HIV&TB, Center for Global Health, Nairobi, Kenya
| | - Maureen Kimani
- Ministry of Health Kenya, Division of Community Health, Nairobi, Kenya
| | - Kenneth Masamaro
- U.S. Centers for Disease Control and Prevention (CDC), Division of Global HIV&TB, Center for Global Health, Nairobi, Kenya
| | - Evelyn Ngugi
- U.S. Centers for Disease Control and Prevention (CDC), Division of Global HIV&TB, Center for Global Health, Nairobi, Kenya
| | - Paul Musingila
- U.S. Centers for Disease Control and Prevention (CDC), Division of Global HIV&TB, Center for Global Health, Nairobi, Kenya
| | - Lucy Nganga
- U.S. Centers for Disease Control and Prevention (CDC), Division of Global HIV&TB, Center for Global Health, Nairobi, Kenya
| | - Raphael Ondondo
- U.S. Centers for Disease Control and Prevention (CDC), Division of Global HIV&TB, Center for Global Health, Nairobi, Kenya
| | - Valeria Makory
- Ministry of Health Kenya, National AIDS & STI Control Program, Nairobi, Kenya
| | - Rose Ayugi
- Ministry of Health Kenya, National AIDS & STI Control Program, Nairobi, Kenya
| | - Lazarus Momanyi
- Ministry of Health Kenya, National AIDS & STI Control Program, Nairobi, Kenya
| | - Barbara Mambo
- Ministry of Health Kenya, National AIDS & STI Control Program, Nairobi, Kenya
| | - Nancy Bowen
- Ministry of Health Kenya, National Public Health Laboratory, Nairobi, Kenya
| | | | - Helen M. Chun
- U.S. Centers for Disease Control and Prevention (CDC), Division of Global HIV/TB, Center for Global Health, Atlanta, Georgia, USA
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Ogolla M, Nyabiage OL, Musingila P, Gachau S, Odero TMA, Odoyo-June E, Ochanda B, Appolonia A, Katiku E, Joseph R, Ogolla C, Otieno L, Odhiambo F, Truong HHM. Uptake and continuation of HIV pre-exposure prophylaxis among women of reproductive age in two health facilities in Kisumu County, Kenya. J Int AIDS Soc 2023; 26:e26069. [PMID: 36912204 PMCID: PMC10009800 DOI: 10.1002/jia2.26069] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 02/08/2023] [Indexed: 03/14/2023] Open
Abstract
INTRODUCTION In 2020, Kenya had 19,000 new HIV infections among women aged 15+ years. Studies have shown sub-optimal oral pre-exposure prophylaxis (PrEP) use among sub-populations of women. We assessed the uptake and continuation of oral PrEP among women 15-49 years in two health facilities in Kisumu County, Kenya. METHODS A retrospective cohort of 262 women aged 15-49 years, initiated into oral PrEP between 12 November 2019 and 31 March 2021, was identified from two health facilities in the urban setting of Kisumu County, Kenya. Data on baseline characteristics and oral PrEP continuation at months 1, 3 and 6 were abstracted from patient records and summarized using descriptive statistics. Missing data in the predictor variables were imputed within the joint modelling multiple imputation framework. Using logistic regression, we evaluated factors associated with the discontinuation of oral PrEP at month 1. RESULTS Of the 66,054 women screened, 320 (0.5%) were eligible and 262 (82%) were initiated on oral PrEP. Uptake was higher among women 25-29 years as compared to those 15-24 years (77% vs. 33%). Oral PrEP continuation declined significantly with increasing duration of follow-up; 37% at month 1, 21% at month 3 and 12% at month 6 (p<0.05). In the adjusted analysis, women 15-24 years had lower adjusted odds of continuing at month 1 than women ≥25 years (adjusted odds ratio [aOR]: 0.41, 95% CI: 0.21-0.82). There was no association between being sero-discordant and continuation of oral PrEP at month 1 (aOR; 1.21, 95% CI 0.59-2.50). Women from the sub-county hospital were more likely to continue at month 1 of follow-up compared to women enrolled in the county referral hospital (aOR 5.11; 95% CI 2.24-11.70). CONCLUSIONS The low eligibility for oral PrEP observed among women 15-49 years in an urban setting with high HIV prevalence calls for a review of the screening process to validate the sensitivity of the screening tool and its proper application. The low uptake and continuation among adolescent girls and young women underscores the need to identify and address specific patient- and facility-level barriers affecting different sub-populations at risk for HIV acquisition.
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Affiliation(s)
- Mercelline Ogolla
- Afya Bora Consortium, Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Omoto Lennah Nyabiage
- Division of Global HIV & TB (DGHT), Center for Global Health (CGH), US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Paul Musingila
- Division of Global HIV & TB (DGHT), Center for Global Health (CGH), US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Susan Gachau
- Division of Global HIV & TB (DGHT), Center for Global Health (CGH), US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Theresa M A Odero
- Afya Bora Consortium, Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Elijah Odoyo-June
- Division of Global HIV & TB (DGHT), Center for Global Health (CGH), US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Boniface Ochanda
- Division of Global HIV & TB (DGHT), Center for Global Health (CGH), US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Aoko Appolonia
- Division of Global HIV & TB (DGHT), Center for Global Health (CGH), US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Elizabeth Katiku
- Division of Global HIV & TB (DGHT), Center for Global Health (CGH), US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Rachael Joseph
- Division of Global HIV & TB (DGHT), Center for Global Health (CGH), US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Cirrilus Ogolla
- Center for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Linda Otieno
- Center for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Francesca Odhiambo
- Center for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Hong-Ha M Truong
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
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Grund JM, Onchiri F, Mboya E, Ussery F, Musingila P, Ohaga S, Odoyo-June E, Bock N, Ayieko B, Agot K. Strategies to increase uptake of voluntary medical male circumcision among men aged 25-39 years in Nyanza Region, Kenya: Results from a cluster randomized controlled trial (the TASCO study). PLoS One 2023; 18:e0276593. [PMID: 36735665 PMCID: PMC9897540 DOI: 10.1371/journal.pone.0276593] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 10/04/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Voluntary medical male circumcision (VMMC) for HIV prevention began in Nyanza Region, Kenya in 2008. By 2014, approximately 800,000 VMMCs had been conducted, and 84.9% were among males aged 15-24 years. We evaluated the impact of interpersonal communication (IPC) and dedicated service outlets (DSO) on VMMC uptake among men aged 25-39 years in Nyanza Region. MATERIALS AND METHODS We conducted a cluster randomized controlled trial in 45 administrative Locations (clusters) in Nyanza Region between May 2014 and June 2016 among uncircumcised men aged 25-34 years. In arm one, an IPC toolkit was used to address barriers to VMMC. In the second arm, men were referred to DSO that were modified to address their preferences. Arm three combined the IPC and DSO arms, and arm four was standard of care (SOC). Randomization was done at Location level (11-12 per arm). The primary outcome was the proportion of enrolled men who received VMMC within three months. Generalized estimating equations were used to evaluate the effect of interventions on the outcome. RESULTS At baseline, 9,238 households with men aged 25-39 years were enumerated, 9,679 men were assessed, and 2,792 (28.8%) were eligible. For enrollment, 577 enrolled in the IPC arm, 825 in DSO, 723 in combined IPC + DSO, and 667 in SOC. VMMC uptake among men in the SOC arm was 3.2%. In IPC, DSO, and combined IPC + DSO arms, uptake was 3.3%, 4.5%, and 4.4%, respectively. The adjusted odds ratio (aOR) of VMMC uptake in the study arms compared to SOC were IPC aOR = 1.03; 95% CI: 0.50-2.13, DSO aOR = 1.31; 95% CI: 0.67-2.57, and IPC + DSO combined aOR = 1.31, 95% CI: 0.65-2.67. DISCUSSION Using these interventions among men aged 25-39 years did not significantly impact VMMC uptake. These findings suggest that alternative demand creation strategies for VMMC services are needed to reach men aged 25-39 years. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT02497989.
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Affiliation(s)
- Jonathan M. Grund
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
| | - Frankline Onchiri
- Core for Biomedical Statistics, Seattle Children’s Research Institute, Seattle, Washington, United States of America
| | - Edward Mboya
- Impact Research and Development Organization, Kisumu, Kenya
| | - Faith Ussery
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Paul Musingila
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Spala Ohaga
- Impact Research and Development Organization, Kisumu, Kenya
| | - Elijah Odoyo-June
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Naomi Bock
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Benard Ayieko
- Impact Research and Development Organization, Kisumu, Kenya
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
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Young PW, Musingila P, Kingwara L, Voetsch AC, Zielinski-Gutierrez E, Bulterys M, Kim AA, Bronson MA, Parekh BS, Dobbs T, Patel H, Reid G, Achia T, Keter A, Mwalili S, Ogollah FM, Ondondo R, Longwe H, Chege D, Bowen N, Umuro M, Ngugi C, Justman J, Cherutich P, De Cock KM. HIV Incidence, Recent HIV Infection, and Associated Factors, Kenya, 2007-2018. AIDS Res Hum Retroviruses 2023; 39:57-67. [PMID: 36401361 PMCID: PMC9942172 DOI: 10.1089/aid.2022.0054] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Nationally representative surveys provide an opportunity to assess trends in recent human immunodeficiency virus (HIV) infection based on assays for recent HIV infection. We assessed HIV incidence in Kenya in 2018 and trends in recent HIV infection among adolescents and adults in Kenya using nationally representative household surveys conducted in 2007, 2012, and 2018. To assess trends, we defined a recent HIV infection testing algorithm (RITA) that classified as recently infected (<12 months) those HIV-positive participants that were recent on the HIV-1 limiting antigen (LAg)-avidity assay without evidence of antiretroviral use. We assessed factors associated with recent and long-term (≥12 months) HIV infection versus no infection using a multinomial logit model while accounting for complex survey design. Of 1,523 HIV-positive participants in 2018, 11 were classified as recent. Annual HIV incidence was 0.14% in 2018 [95% confidence interval (CI) 0.057-0.23], representing 35,900 (95% CI 16,300-55,600) new infections per year in Kenya among persons aged 15-64 years. The percentage of HIV infections that were determined to be recent was similar in 2007 and 2012 but fell significantly from 2012 to 2018 [adjusted odds ratio (aOR) = 0.31, p < .001]. Compared to no HIV infection, being aged 25-34 versus 35-64 years (aOR = 4.2, 95% CI 1.4-13), having more lifetime sex partners (aOR = 5.2, 95% CI 1.6-17 for 2-3 partners and aOR = 8.6, 95% CI 2.8-26 for ≥4 partners vs. 0-1 partners), and never having tested for HIV (aOR = 4.1, 95% CI 1.5-11) were independently associated with recent HIV infection. Although HIV remains a public health priority in Kenya, HIV incidence estimates and trends in recent HIV infection support a significant decrease in new HIV infections from 2012 to 2018, a period of rapid expansion in HIV diagnosis, prevention, and treatment.
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Affiliation(s)
- Peter Wesley Young
- Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention, Maputo, Mozambique.,Address correspondence to: Peter Wesley Young, U.S. Embassy Maputo, Avenida Marginal nr 5467, Sommerschield, Distrito Municipal de KaMpfumo, Caixa Postal 783, CEP 0101-11 Maputo, Mozambique
| | - Paul Musingila
- Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Leonard Kingwara
- National AIDS & STI Control Programme, Ministry of Health, Nairobi, Kenya
| | - Andrew C. Voetsch
- Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Emily Zielinski-Gutierrez
- Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya.,Central America Regional Office, U.S. Centers for Disease Control and Prevention, Guatemala City, Guatemala
| | - Marc Bulterys
- Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Andrea A. Kim
- Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Megan A. Bronson
- Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Bharat S. Parekh
- Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Trudy Dobbs
- Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Hetal Patel
- Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Giles Reid
- Survey Unit, ICAP at Columbia University, New York, New York, USA
| | - Thomas Achia
- Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Alfred Keter
- National AIDS & STI Control Programme, Ministry of Health, Nairobi, Kenya
| | - Samuel Mwalili
- Department of Statistics and Actuarial Sciences, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | | | - Raphael Ondondo
- Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Herbert Longwe
- Survey Unit, ICAP at Columbia University, New York, New York, USA
| | - Duncan Chege
- Survey Unit, ICAP at Columbia University, New York, New York, USA
| | - Nancy Bowen
- National Public Health Laboratory, Ministry of Health, Nairobi, Kenya
| | - Mamo Umuro
- National Public Health Laboratory, Ministry of Health, Nairobi, Kenya
| | | | - Jessica Justman
- Survey Unit, ICAP at Columbia University, New York, New York, USA
| | | | - Kevin M. De Cock
- Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
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Achia T, Cervantes IF, Stupp P, Musingila P, Muthusi J, Waruru A, Schmitz M, Bronson M, Chang G, Bore J, Kingwara L, Mwalili S, Muttunga J, Gitonga J, De Cock KM, Young P. Methods for conducting trends analysis: roadmap for comparing outcomes from three national HIV Population-based household surveys in Kenya (2007, 2012, and 2018). BMC Public Health 2022; 22:1337. [PMID: 35831818 PMCID: PMC9281165 DOI: 10.1186/s12889-022-13633-8] [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] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 06/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND For assessing the HIV epidemic in Kenya, a series of independent HIV indicator household-based surveys of similar design can be used to investigate the trends in key indicators relevant to HIV prevention and control and to describe geographic and sociodemographic disparities, assess the impact of interventions, and develop strategies. We developed methods and tools to facilitate a robust analysis of trends across three national household-based surveys conducted in Kenya in 2007, 2012, and 2018. METHODS We used data from the 2007 and 2012 Kenya AIDS Indicator surveys (KAIS 2007 and KAIS 2012) and the 2018 Kenya Population-based HIV Impact Assessment (KENPHIA 2018). To assess the design and other variables of interest from each study, variables were recoded to ensure that they had equivalent meanings across the three surveys. After assessing weighting procedures for comparability, we used the KAIS 2012 nonresponse weighting procedure to revise normalized KENPHIA weights. Analyses were restricted to geographic areas covered by all three surveys. The revised analysis files were then merged into a single file for pooled analysis. We assessed distributions of age, sex, household wealth, and urban/rural status to identify unexpected changes between surveys. To demonstrate how a trend analysis can be carried out, we used continuous, binary, and time-to-event variables as examples. Specifically, temporal trends in age at first sex and having received an HIV test in the last 12 months were used to demonstrate the proposed analytical approach. These were assessed with respondent-specific variables (age, sex, level of education, and marital status) and household variables (place of residence and wealth index). All analyses were conducted in SAS 9.4, but analysis files were created in Stata and R format to support additional analyses. RESULTS This study demonstrates trends in selected indicators to illustrate the approach that can be used in similar settings. The incidence of early sexual debut decreased from 11.63 (95% CI: 10.95-12.34) per 1,000 person-years at risk in 2007 to 10.45 (95% CI: 9.75-11.2) per 1,000 person-years at risk in 2012 and to 9.58 (95% CI: 9.08-10.1) per 1,000 person-years at risk in 2018. HIV-testing rates increased from 12.6% (95% CI: 11.6%-13.6%) in 2007 to 56.1% (95% CI: 54.6%-57.6%) in 2012 but decreased slightly to 55.6% [95% CI: 54.6%-56.6%) in 2018. The decrease in incidence of early sexual debut could be convincingly demonstrated between 2007 and 2012 but not between 2012 and 2018. Similarly, there was virtually no difference between HIV Testing rates in 2012 and 2018. CONCLUSIONS Our approach can be used to support trend comparisons for variables in HIV surveys in low-income settings. Independent national household surveys can be assessed for comparability, adjusted as appropriate, and used to estimate trends in key indicators. Analyzing trends over time can not only provide insights into Kenya's progress toward HIV epidemic control but also identify gaps.
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Affiliation(s)
- Thomas Achia
- Division of Global HIV & TB, Center for Global Health, US Centers for Disease Control and Prevention, Nairobi, Kenya.
| | | | - Paul Stupp
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Paul Musingila
- Division of Global HIV and TB, Center for Global Health, US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Jacques Muthusi
- Division of Global HIV & TB, Center for Global Health, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Anthony Waruru
- Division of Global HIV & TB, Center for Global Health, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Mary Schmitz
- Division of Global HIV & TB, Center for Global Health, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Megan Bronson
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Gregory Chang
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - John Bore
- Kenya National Bureau of Statistics, Nairobi, Kenya
| | | | - Samuel Mwalili
- Department of Statistics and Actuarial Science, Jomo Kenyatta University, Juja, Kenya
| | | | | | - Kevin M De Cock
- Division of Global HIV & TB, Center for Global Health, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Peter Young
- Division of Global HIV & TB, Center for Global Health, US Centers for Disease Control and Prevention, Nairobi, Kenya
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8
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Opollo V, Nyakeriga E, Kingwara L, Sila A, Oguta M, Oyaro B, Onyango D, Mboya FO, Waruru A, Musingila P, Mwangome M, Nyagah LM, Ngugi C, Sava S, Waruiru W, Young PW, Junghae M. Evaluation of the Performance of OraQuick Rapid HIV-1/2 Test Among Decedents in Kisumu, Kenya. J Acquir Immune Defic Syndr 2022; 89:282-287. [PMID: 34732683 PMCID: PMC8826608 DOI: 10.1097/qai.0000000000002857] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 09/20/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Estimating cause-related mortality among the dead is not common, yet for clinical and public health purposes, a lot can be learnt from the dead. HIV/AIDS accounted for the third most frequent cause of deaths in Kenya; 39.7 deaths per 100,000 population in 2019. OraQuick Rapid HIV-1/2 has previously been validated on oral fluid and implemented as a screening assay for HIV self-testing in Kenya among living subjects. We assessed the feasibility and diagnostic accuracy of OraQuick Rapid HIV-1/2 for HIV screening among decedents. METHODS Trained morticians collected oral fluid from 132 preembalmed and postembalmed decedents aged >18 months at Jaramogi Oginga Odinga Teaching and Referral Hospital mortuary in western Kenya and tested for HIV using OraQuick Rapid HIV-1/2. Test results were compared with those obtained using the national HIV Testing Services algorithm on matched preembalming whole blood specimens as a gold standard (Determine HIV and First Response HIV 1-2-O). We calculated positive predictive values, negative predictive values, area under the curve, and sensitivity and specificity of OraQuick Rapid HIV-1/2 compared with the national HTS algorithm. RESULTS OraQuick Rapid HIV-1/2 had similar sensitivity of 92.6% [95% confidence interval (CI): 75.7 to 99.1] on preembalmed and postembalmed samples compared with the gold standard. Specificity was 97.1% (95% CI: 91.9 to 99.4) and 95.2% (95% CI: 89.2 to 98.4) preembalming and postembalming, respectively. Preembalming and postembalming positive predictive value was 89.3% (95% CI: 71.8 to 97.7) and 83.3% (95% CI: 65.3 to 94.4), respectively. The area under the curve preembalming and postembalming was 94.9% (95% CI: 89.6 to 100) and 93.9% (95% CI: 88.5 to 99.4), respectively. CONCLUSIONS The study showed a relatively high-performance sensitivity and specificity of OraQuick Rapid HIV-1/2 test among decedents, similar to those observed among living subjects. OraQuick Rapid HIV-1/2 presents a convenient and less invasive screening test for surveillance of HIV among decedents within a mortuary setting.
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Affiliation(s)
- Valarie Opollo
- HIV Research Branch, Kenya Medical Research Institute, Kisumu, Kenya
| | - Emmanuel Nyakeriga
- Institute for Global Health Sciences, University of California, San-Franscisco
| | | | - Alex Sila
- Institute for Global Health Sciences, University of California, San-Franscisco
| | - Macxine Oguta
- HIV Research Branch, Kenya Medical Research Institute, Kisumu, Kenya
| | - Boaz Oyaro
- HIV Research Branch, Kenya Medical Research Institute, Kisumu, Kenya
| | - Dickens Onyango
- Kisumu County Department of Health, Kisumu, Kenya
- Julius Centre for Health Sciences and Primary Care, University Medical Centre, Utrecht, Netherlands
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium; and
| | - Frankline O. Mboya
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Kenya
| | - Anthony Waruru
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Kenya
| | - Paul Musingila
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Kenya
| | - Mary Mwangome
- Institute for Global Health Sciences, University of California, San-Franscisco
| | | | | | | | - Wanjiru Waruiru
- Institute for Global Health Sciences, University of California, San-Franscisco
| | - Peter W. Young
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Kenya
| | - Muthoni Junghae
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Kenya
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Muttai H, Guyah B, Achia T, Musingila P, Nakhumwa J, Oyoo R, Olweny W, Odeny R, Ohaga S, Agot K, Oruenjo K, Awino B, Joseph RH, Miruka F, Zielinski-Gutierrez E. Mapping geographic clusters of new HIV diagnoses to inform granular-level interventions for HIV epidemic control in western Kenya. BMC Public Health 2021; 21:1926. [PMID: 34688267 PMCID: PMC8542332 DOI: 10.1186/s12889-021-11890-7] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/30/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND As countries make progress towards HIV epidemic control, there is increasing need to identify finer geographic areas to target HIV interventions. We mapped geographic clusters of new HIV diagnoses, and described factors associated with HIV-positive diagnosis, in order to inform targeting of HIV interventions to finer geographic areas and sub-populations. METHODS We analyzed data for clients aged > 15 years who received home-based HIV testing as part of a routine public health program between May 2016 and July 2017 in Siaya County, western Kenya. Geospatial analysis using Kulldorff's spatial scan statistic was used to detect geographic clusters (radius < 5 kilometers) of new HIV diagnoses. Factors associated with new HIV diagnosis were assessed in a spatially-integrated Bayesian hierarchical model. RESULTS Of 268,153 clients with HIV test results, 2906 (1.1%) were diagnosed HIV-positive. We found spatial variation in the distribution of new HIV diagnoses, and identified nine clusters in which the number of new HIV diagnoses was significantly (1.56 to 2.64 times) higher than expected. Sub-populations with significantly higher HIV-positive yield identified in the multivariable spatially-integrated Bayesian model included: clients aged 20-24 years [adjusted relative risk (aRR) 3.45, 95% Bayesian Credible Intervals (CI) 2.85-4.20], 25-35 years (aRR 4.76, 95% CI 3.92-5.81) and > 35 years (aRR 2.44, 95% CI 1.99-3.00); those in polygamous marriage (aRR 1.84, 95% CI 1.55-2.16), or separated/divorced (aRR 3.36, 95% CI 2.72-4.08); and clients who reported having never been tested for HIV (aRR 2.35, 95% CI 2.02-2.72), or having been tested > 12 months ago (aRR 1.53, 95% CI 1.41-1.66). CONCLUSION Our study used routine public health program data to identify granular geographic clusters of higher new HIV diagnoses, and sub-populations with higher HIV-positive yield in the setting of a generalized HIV epidemic. In order to target HIV testing and prevention interventions to finer granular geographic areas for maximal epidemiologic impact, integrating geospatial analysis into routine public health programs can be useful.
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Affiliation(s)
- Hellen Muttai
- Division of Global HIV & TB, United States Centers for Disease Control and Prevention, 00621, Nairobi, Kenya.
| | - Bernard Guyah
- School of Public Health, Maseno University, Kisumu, Kenya
| | - Thomas Achia
- Division of Global HIV & TB, United States Centers for Disease Control and Prevention, 00621, Nairobi, Kenya
| | - Paul Musingila
- Division of Global HIV & TB, United States Centers for Disease Control and Prevention, 00621, Nairobi, Kenya
| | - Jesse Nakhumwa
- Impact Research and Development Organization, Kisumu, Kenya
| | - Rose Oyoo
- Impact Research and Development Organization, Kisumu, Kenya
| | | | | | - Spala Ohaga
- Impact Research and Development Organization, Kisumu, Kenya
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | | | - Bob Awino
- Siaya County Department of Health, Siaya, Kenya
| | - Rachael H Joseph
- Division of Global HIV & TB, United States Centers for Disease Control and Prevention, 00621, Nairobi, Kenya
| | - Fredrick Miruka
- Division of Global HIV & TB, United States Centers for Disease Control and Prevention, 00621, Nairobi, Kenya
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Odoyo-June E, Davis S, Owuor N, Laube C, Wambua J, Musingila P, Young PW, Aoko A, Agot K, Joseph R, Mwandi Z, Ojiambo V, Lucas T, Toledo C, Wanyonyi A. Prevalence of male circumcision in four culturally non-circumcising counties in western Kenya after 10 years of program implementation from 2008 to 2019. PLoS One 2021; 16:e0254140. [PMID: 34264971 PMCID: PMC8281999 DOI: 10.1371/journal.pone.0254140] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 06/20/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Kenya started implementing voluntary medical male circumcision (VMMC) for HIV prevention in 2008 and adopted the use of decision makers program planning tool version 2 (DMPPT2) in 2016, to model the impact of circumcisions performed annually on the population prevalence of male circumcision (MC) in the subsequent years. Results of initial DMPPT2 modeling included implausible MC prevalence estimates, of up to 100%, for age bands whose sustained high uptake of VMMC pointed to unmet needs. Therefore, we conducted a cross-sectional survey among adolescents and men aged 10–29 years to determine the population level MC prevalence, guide target setting for achieving the goal of 80% MC prevalence and for validating DMPPT2 modelled estimates. Methods Beginning July to September 2019, a total of 3,569 adolescents and men aged 10–29 years from households in Siaya, Kisumu, Homa Bay and Migori Counties were interviewed and examined to establish the proportion already circumcised medically or non-medically. We measured agreement between self-reported and physically verified circumcision status and computed circumcision prevalence by age band and County. All statistical were test done at 5% level of significance. Results The observed MC prevalence for 15-29-year-old men was above 75% in all four counties; Homa Bay 75.6% (95% CI [69.0–81.2]), Kisumu 77.9% (95% CI [73.1–82.1]), Siaya 80.3% (95% CI [73.7–85.5]), and Migori 85.3% (95% CI [75.3–91.7]) but were 0.9–12.4% lower than DMPPT2-modelled estimates. For young adolescents 10–14 years, the observed prevalence ranged from 55.3% (95% CI [40.2–69.5]) in Migori to 74.9% (95% CI [68.8–80.2]) in Siaya and were 25.1–32.9% lower than DMMPT 2 estimates. Nearly all respondents (95.5%) consented to physical verification of their circumcision status with an agreement rate of 99.2% between self-reported and physically verified MC status (kappa agreement p-value<0.0001). Conclusion This survey revealed overestimation of MC prevalence from DMPPT2-model compared to the observed population MC prevalence and provided new reference data for setting realistic program targets and re-calibrating inputs into DMPPT2. Periodic population-based MC prevalence surveys, especially for established programs, can help reconcile inconsistencies between VMMC program uptake data and modeled MC prevalence estimates which are based on the number of procedures reported in the program annually.
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Affiliation(s)
- Elijah Odoyo-June
- U.S. Centers for Disease Control and Prevention (CDC), Division of HIV & TB, Nairobi, Kenya
- * E-mail:
| | - Stephanie Davis
- U.S. Centers for Disease Control and Prevention (CDC), Division of HIV & TB Atlanta, GA, United States of America
| | | | - Catey Laube
- Jhpiego, Baltimore, Maryland, United States of America
| | | | - Paul Musingila
- U.S. Centers for Disease Control and Prevention (CDC), Division of HIV & TB, Nairobi, Kenya
| | - Peter W. Young
- U.S. Centers for Disease Control and Prevention (CDC), Division of HIV & TB, Nairobi, Kenya
| | - Appolonia Aoko
- U.S. Centers for Disease Control and Prevention (CDC), Division of HIV & TB, Nairobi, Kenya
| | - Kawango Agot
- Impact Research and Development Organization (IRDO), Kisumu, Kenya
| | - Rachael Joseph
- U.S. Centers for Disease Control and Prevention (CDC), Division of HIV & TB, Nairobi, Kenya
| | | | | | - Todd Lucas
- U.S. Centers for Disease Control and Prevention (CDC), Division of HIV & TB Atlanta, GA, United States of America
| | - Carlos Toledo
- U.S. Centers for Disease Control and Prevention (CDC), Division of HIV & TB Atlanta, GA, United States of America
| | - Ambrose Wanyonyi
- National AIDS and STI Control Program (NASCOP), Ministry of Health, Nairobi, Kenya
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11
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Onyango DO, van der Sande MAB, Musingila P, Kinywa E, Opollo V, Oyaro B, Nyakeriga E, Waruru A, Waruiru W, Mwangome M, Macharia T, Young PW, Junghae M, Ngugi C, De Cock KM, Rutherford GW. High HIV prevalence among decedents received by two high-volume mortuaries in Kisumu, western Kenya, 2019. PLoS One 2021; 16:e0253516. [PMID: 34197509 PMCID: PMC8248726 DOI: 10.1371/journal.pone.0253516] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 06/07/2021] [Indexed: 11/28/2022] Open
Abstract
Background Accurate data on HIV-related mortality are necessary to evaluate the impact of HIV interventions. In low- and middle-income countries (LMIC), mortality data obtained through civil registration are often of poor quality. Though not commonly conducted, mortuary surveillance is a potential complementary source of data on HIV-associated mortality. Methods During April-July 2019, we assessed HIV prevalence, the attributable fraction among the exposed, and the population attributable fraction among decedents received by two high-volume mortuaries in Kisumu County, Kenya, where HIV prevalence in the adult population was estimated at 18% in 2019 with high ART coverage (76%). Stillbirths were excluded. The two mortuaries receive 70% of deaths notified to the Kisumu East civil death registry; this registry captures 45% of deaths notified in Kisumu County. We conducted hospital chart reviews to determine the HIV status of decedents. Decedents without documented HIV status, including those dead on arrival, were tested using HIV antibody tests or polymerase chain reaction (PCR) consistent with national HIV testing guidelines. Decedents aged less than 15 years were defined as children. We estimated annual county deaths by applying weights that incorporated the study period, coverage of deaths, and mortality rates observed in the study. Results The two mortuaries received a total of 1,004 decedents during the study period, of which 95.1% (955/1004) were available for study; 89.1% (851/955) of available decedents were enrolled of whom 99.4% (846/851) had their HIV status available from medical records and post-mortem testing. The overall population-based, age- and sex-adjusted mortality rate was 12.4 per 1,000 population. The unadjusted HIV prevalence among decedents was 28.5% (95% confidence interval (CI): 25.5–31.6). The age- and sex-adjusted mortality rate in the HIV-infected population (40.7/1000 population) was four times higher than in the HIV-uninfected population (10.2/1000 population). Overall, the attributable fraction among the HIV-exposed was 0.71 (95% CI: 0.66–0.76) while the HIV population attributable fraction was 0.17 (95% CI: 0.14–0.20). In children the attributable fraction among the exposed and population attributable fraction were 0.92 (95% CI: 0.89–0.94) and 0.11 (95% CI: 0.08–0.15), respectively. Conclusions Over one quarter (28.5%) of decedents received by high-volume mortuaries in western Kenya were HIV-positive; overall, HIV was considered the cause of death in 17% of the population (19% of adults and 11% of children). Despite substantial scale-up of HIV services, HIV disease remains a leading cause of death in western Kenya. Despite progress, increased efforts remain necessary to prevent and treat HIV infection and disease.
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Affiliation(s)
- Dickens O. Onyango
- Kisumu County Department of Health, Kisumu, Kenya
- Ministry of Health, Nairobi, Kenya
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre, Utrecht, Netherlands
- * E-mail:
| | - Marianne A. B. van der Sande
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre, Utrecht, Netherlands
| | - Paul Musingila
- Division of Global HIV & TB (DGHT), US Centres for Disease Control and Prevention, Nairobi, Kenya
| | - Eunice Kinywa
- Kisumu County Department of Health, Kisumu, Kenya
- Ministry of Health, Nairobi, Kenya
| | | | - Boaz Oyaro
- Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | | | - Anthony Waruru
- Division of Global HIV & TB (DGHT), US Centres for Disease Control and Prevention, Nairobi, Kenya
| | | | - Mary Mwangome
- Global Programs for Research and Training, Nairobi, Kenya
| | | | - Peter W. Young
- Division of Global HIV & TB (DGHT), US Centres for Disease Control and Prevention, Nairobi, Kenya
| | - Muthoni Junghae
- Division of Global HIV & TB (DGHT), US Centres for Disease Control and Prevention, Nairobi, Kenya
| | - Catherine Ngugi
- Ministry of Health, Nairobi, Kenya
- Ministry of Health, National AIDS and STI Control Program (NASCOP), Nairobi, Kenya
| | - Kevin M. De Cock
- Division of Global HIV & TB (DGHT), US Centres for Disease Control and Prevention, Nairobi, Kenya
| | - George W. Rutherford
- Institute for Global Health Sciences, University of California, San-Francisco, California, United States of America
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12
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Muttai H, Guyah B, Musingila P, Achia T, Miruka F, Wanjohi S, Dande C, Musee P, Lugalia F, Onyango D, Kinywa E, Okomo G, Moth I, Omondi S, Ayieko C, Nganga L, Joseph RH, Zielinski-Gutierrez E. Development and Validation of a Sociodemographic and Behavioral Characteristics-Based Risk-Score Algorithm for Targeting HIV Testing Among Adults in Kenya. AIDS Behav 2021; 25:297-310. [PMID: 32651762 PMCID: PMC7846530 DOI: 10.1007/s10461-020-02962-7] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
To inform targeted HIV testing, we developed and externally validated a risk-score algorithm that incorporated behavioral characteristics. Outpatient data from five health facilities in western Kenya, comprising 19,458 adults ≥ 15 years tested for HIV from September 2017 to May 2018, were included in univariable and multivariable analyses used for algorithm development. Data for 11,330 adults attending one high-volume facility were used for validation. Using the final algorithm, patients were grouped into four risk-score categories: ≤ 9, 10-15, 16-29 and ≥ 30, with increasing HIV prevalence of 0.6% [95% confidence interval (CI) 0.46-0.75], 1.35% (95% CI 0.85-1.84), 2.65% (95% CI 1.8-3.51), and 15.15% (95% CI 9.03-21.27), respectively. The algorithm's discrimination performance was modest, with an area under the receiver-operating-curve of 0.69 (95% CI 0.53-0.84). In settings where universal testing is not feasible, a risk-score algorithm can identify sub-populations with higher HIV-risk to be prioritized for HIV testing.
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Affiliation(s)
- Hellen Muttai
- Division of Global HIV & TB (DGHT), United States Centers for Disease Control and Prevention (CDC), Kenya, KEMRI Campus, P.O. Box 606, Nairobi, 00621, Kenya.
| | - Bernard Guyah
- School of Public Health, Maseno University, Kisumu, Kenya
| | - Paul Musingila
- Division of Global HIV & TB (DGHT), United States Centers for Disease Control and Prevention (CDC), Kenya, KEMRI Campus, P.O. Box 606, Nairobi, 00621, Kenya
| | - Thomas Achia
- Division of Global HIV & TB (DGHT), United States Centers for Disease Control and Prevention (CDC), Kenya, KEMRI Campus, P.O. Box 606, Nairobi, 00621, Kenya
| | - Fredrick Miruka
- Division of Global HIV & TB (DGHT), United States Centers for Disease Control and Prevention (CDC), Kenya, KEMRI Campus, P.O. Box 606, Nairobi, 00621, Kenya
| | | | - Caroline Dande
- University of California at San Francisco, Kisumu, Kenya
| | - Polycarp Musee
- Elizabeth Glaser Pediatric AIDS Foundation, Homa Bay, Kenya
| | | | | | | | - Gordon Okomo
- Homa Bay County Department of Health, Homa Bay, Kenya
| | - Iscah Moth
- Homa Bay County Department of Health, Homa Bay, Kenya
| | | | | | - Lucy Nganga
- Division of Global HIV & TB (DGHT), United States Centers for Disease Control and Prevention (CDC), Kenya, KEMRI Campus, P.O. Box 606, Nairobi, 00621, Kenya
| | - Rachael H Joseph
- Division of Global HIV & TB (DGHT), United States Centers for Disease Control and Prevention (CDC), Kenya, KEMRI Campus, P.O. Box 606, Nairobi, 00621, Kenya
| | - Emily Zielinski-Gutierrez
- Division of Global HIV & TB (DGHT), United States Centers for Disease Control and Prevention (CDC), Kenya, KEMRI Campus, P.O. Box 606, Nairobi, 00621, Kenya
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Joseph RH, Musingila P, Miruka F, Wanjohi S, Dande C, Musee P, Lugalia F, Onyango D, Kinywa E, Okomo G, Moth I, Omondi S, Ayieko C, Nganga L, Zielinski-Gutierrez E, Muttai H, De Cock KM. Expanded eligibility for HIV testing increases HIV diagnoses-A cross-sectional study in seven health facilities in western Kenya. PLoS One 2019; 14:e0225877. [PMID: 31881031 PMCID: PMC6934319 DOI: 10.1371/journal.pone.0225877] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 11/14/2019] [Indexed: 11/18/2022] Open
Abstract
Homa Bay, Siaya, and Kisumu counties in western Kenya have the highest estimated HIV prevalence (16.3-21.0%) in the country, and struggle to meet program targets for HIV testing services (HTS). The Kenya Ministry of Health (MOH) recommends annual HIV testing for the general population. We assessed the degree to which reducing the interval for retesting to less than 12 months increased diagnosis of HIV in outpatient departments (OPD) in western Kenya. We conducted a retrospective analysis of routinely collected program data from seven high-volume (>800 monthlyOPD visits) health facilities in March-December, 2017. Data from persons ≥15 years of age seeking medical care (patients) in the OPD and non-care-seekers (non-patients) accompanying patients to the OPD were included. Outcomes were meeting MOH (routine) criteria versus criteria for a reduced retesting interval (RRI) of <12 months, and HIV test result. STATA version 14.2 was used to calculate frequencies and proportions, and to test for differences using bivariate analysis. During the 9-month period, 119,950 clients were screened for HIV testing eligibility, of whom 79% (94,766) were eligible and 97% (92,153) received a test. Among 92,153 clients tested, the median age was 28 years, 57% were female and 40% (36,728) were non-patients. Overall, 20% (18,120) of clients tested met routine eligibility criteria: 4% (3,972) had never been tested, 10% (9,316) reported a negative HIV test in the past >12 months, and 5% (4,832) met other criteria. The remaining 80% (74,033) met criteria for a RRI of < 12 months. In total 1.3% (1,185) of clients had a positive test. Although the percent yield was over 2-fold higher among those meeting routine criteria (2.4% vs. 1.0%; p<0.001), 63% (750) of all HIV infections were found among clients tested less than 12 months ago, the majority (81%) of whom reported having a negative test in the past 3-12 months. Non-patients accounted for 45% (539) of all HIV-positive persons identified. Percent yield was higher among non-patients as compared to patients (1.5% vs. 1.2%; p-value = <0.001) overall and across eligibility criteria and age categories. The majority of HIV diagnoses in the OPD occurred among clients reporting a negative HIV test in the past 12 months, clients ineligible for testing under the current MOH guidelines. Nearly half of all HIV-positive individuals identified in the OPD were non-patients. Our findings suggest that in the setting of a generalized HIV epidemic, retesting persons reporting an HIV-negative test in the past 3-12 months, and routine testing of non-patients accessing the OPD are key strategies for timely diagnosis of persons living with HIV.
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Affiliation(s)
- Rachael H Joseph
- Division of Global HIV&TB, U.S. Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Paul Musingila
- Division of Global HIV&TB, U.S. Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Fredrick Miruka
- Division of Global HIV&TB, U.S. Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Stella Wanjohi
- HIV Prevention and Community Services, Center for Health Solutions, Kisumu, Kenya
| | - Caroline Dande
- HIV Testing and Counseling Services, University of California, San Francisco (FACES), Kisumu, Kenya
| | - Polycarp Musee
- HIV Testing and Counseling Services, Elizabeth Glaser Pediatric AIDS Foundation, Homa Bay, Kenya
| | - Fillet Lugalia
- HIV Testing and Counseling Services, Columbia University, ICAP, Kisumu, Kenya
| | - Dickens Onyango
- Kisumu County Department of Health, County Government of Kisumu, Kisumu, Kenya
| | - Eunice Kinywa
- Kisumu County Department of Health, County Government of Kisumu, Kisumu, Kenya
| | - Gordon Okomo
- Homa Bay County Department of Health, County Government of Homa Bay, Homa Bay, Kenya
| | - Iscah Moth
- Homa Bay County Department of Health, County Government of Homa Bay, Homa Bay, Kenya
| | - Samuel Omondi
- Siaya County Department of Health, County Government of Siaya, Siaya, Kenya
| | - Caren Ayieko
- Siaya County Department of Health, County Government of Siaya, Siaya, Kenya
| | - Lucy Nganga
- Division of Global HIV&TB, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | | | - Hellen Muttai
- Division of Global HIV&TB, U.S. Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Kevin M De Cock
- Division of Global HIV&TB, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
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Odoyo-June E, Agot K, Mboya E, Grund J, Musingila P, Emusu D, Soo L, Otieno-Nyunya B. Agreement between self-reported and physically verified male circumcision status in Nyanza region, Kenya: Evidence from the TASCO study. PLoS One 2018; 13:e0192823. [PMID: 29432444 PMCID: PMC5809057 DOI: 10.1371/journal.pone.0192823] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 07/17/2017] [Accepted: 01/31/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Self-reported male circumcision (MC) status is widely used to estimate community prevalence of circumcision, although its accuracy varies in different settings depending on the extent of misreporting. Despite this challenge, self-reported MC status remains essential because it is the most feasible method of collecting MC status data in community surveys. Therefore, its accuracy is an important determinant of the reliability of MC prevalence estimates based on such surveys. We measured the concurrence between self-reported and physically verified MC status among men aged 25-39 years during a baseline household survey for a study to test strategies for enhancing MC uptake by older men in Nyanza region of Kenya. The objective was to determine the accuracy of self-reported MC status in communities where MC for HIV prevention is being rolled out. METHODS Agreement between self-reported and physically verified MC status was measured among 4,232 men. A structured questionnaire was used to collect data on MC status followed by physical examination to verify the actual MC status whose outcome was recorded as fully circumcised (no foreskin), partially circumcised (foreskin is past corona sulcus but covers less than half of the glans) or uncircumcised (foreskin covers half or more of the glans). The sensitivity and specificity of self-reported MC status were calculated using physically verified MC status as the gold standard. RESULTS Out of 4,232 men, 2,197 (51.9%) reported being circumcised, of whom 99.0% were confirmed to be fully circumcised on physical examination. Among 2,035 men who reported being uncircumcised, 93.7% (1,907/2,035) were confirmed uncircumcised on physical examination. Agreement between self-reported and physically verified MC status was almost perfect, kappa (k) = 98.6% (95% CI, 98.1%-99.1%. The sensitivity of self-reporting being circumcised was 99.6% (95% CI, 99.2-99.8) while specificity of self-reporting uncircumcised was 99.0% (95% CI, 98.4-99.4) and did not differ significantly by age group based on chi-square test. Rate of consenting to physical verification of MC status differed by client characteristics; unemployed men were more likely to consent to physical verification (odds ratio [OR] = 1.48, (95% CI, 1.30-1.69) compared to employed men and those with post-secondary education were less likely to consent to physical verification than those with primary education or less (odds ratio [OR] = 0.61, (95% CI, 0.51-0.74). CONCLUSIONS In this Kenyan context, both sensitivity and specificity of self-reported MC status was high; therefore, MC prevalence estimates based on self-reported MC status should be deemed accurate and applicable for planning. However MC programs should assess accuracy of self-reported MC status periodically for any secular changes that may undermine its usefulness for estimating community MC prevalence in their unique settings.
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Affiliation(s)
- Elijah Odoyo-June
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu, Kenya
- * E-mail:
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Edward Mboya
- Impact Research and Development Organization, Kisumu, Kenya
| | - Jonathan Grund
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
| | - Paul Musingila
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu, Kenya
| | - Donath Emusu
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu, Kenya
| | - Leonard Soo
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu, Kenya
| | - Boaz Otieno-Nyunya
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Kisumu, Kenya
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Odoyo-June E, Agot K, Grund JM, Onchiri F, Musingila P, Mboya E, Emusu D, Onyango J, Ohaga S, Soo L, Otieno-Nyunya B. Predictors of voluntary medical male circumcision prevalence among men aged 25-39 years in Nyanza region, Kenya: Results from the baseline survey of the TASCO study. PLoS One 2017; 12:e0185872. [PMID: 28982175 PMCID: PMC5628861 DOI: 10.1371/journal.pone.0185872] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 09/21/2017] [Indexed: 11/18/2022] Open
Abstract
Introduction Uptake of voluntary medical male circumcision (VMMC) as an intervention for prevention of HIV acquisition has been low among men aged ≥25 years in Nyanza region, western Kenya. We conducted a baseline survey of the prevalence and predictors of VMMC among men ages 25–39 years as part of the preparations for a cluster randomized controlled trial (cRCT) called the Target, Speed and Coverage (TASCO) Study. The TASCO Study aimed to assess the impact of two demand creation interventions—interpersonal communication (IPC) and dedicated service outlets (DSO), delivered separately and together (IPC + DSO)—on VMMC uptake. Methods As part of the preparatory work for implementation of the cRCT to evaluate tailored interventions to improve uptake of VMMC, we conducted a survey of men aged 25–39 years from a traditionally non-circumcising Kenyan ethnic community within non-contiguous locations selected as study sites. We determined their circumcision status, estimated the baseline circumcision prevalence and assessed predictors of being circumcised using univariate and multivariate logistic regression. Results A total of 5,639 men were enrolled of which 2,851 (50.6%) reported being circumcised. The odds of being circumcised were greater for men with secondary education (adjusted Odds Ratio (aOR) = 1.65; 95% CI: 1.45–1.86, p<0.001), post-secondary education (aOR = 1.72; 95% CI: 1.44–2.06, p <0.001), and those employed (aOR = 1.32; 95% CI: 1.18–1.47, p <0.001). However, the odds were lower for men with a history of being married (currently married, divorced, separated, or widowed). Conclusion Among adult men in the rural Nyanza region of Kenya, men with post-primary education and employed were more likely to be circumcised. VMMC programs should focus on specific sub-groups of men, including those aged 25–39 years who are married, divorced/separated/ widowed, and of low socio-economic status (low education and unemployed).
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Affiliation(s)
- Elijah Odoyo-June
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
- * E-mail:
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Jonathan M. Grund
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Atlanta, GA, United States of America
| | - Frankline Onchiri
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Paul Musingila
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Edward Mboya
- Impact Research and Development Organization, Kisumu, Kenya
| | - Donath Emusu
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Jacob Onyango
- Impact Research and Development Organization, Kisumu, Kenya
| | - Spala Ohaga
- Impact Research and Development Organization, Kisumu, Kenya
| | - Leonard Soo
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Boaz Otieno-Nyunya
- Division of Global HIV & TB (DGHT), U.S. Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
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Ngure K, Baeten J, Lingappa J, Heffron R, Musingila P, Irungu E, Mwaniki P, Mwaniki L, Wamae R, Mburu S, Mugo N. P1-S6.02 Contraceptive discontinuation by rural Kenyan women in HIV discordant partnerships after exiting an HIV prevention trial. Br J Vener Dis 2011. [DOI: 10.1136/sextrans-2011-050108.226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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