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Mugo C, Adedokun O, Alo OD, Ezeokafor N, Adeyemi S, Kpamor Z, Madueke L, James E, Adebajo SB, Semo BW. Effects of the COVID-19 pandemic on HIV service delivery and viral suppression: Findings from the SHARP program in Northern Nigeria. PLoS One 2024; 19:e0300335. [PMID: 38564514 PMCID: PMC10986928 DOI: 10.1371/journal.pone.0300335] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 02/26/2024] [Indexed: 04/04/2024] Open
Abstract
During the COVID-19 pandemic, HIV programs scaled up differentiated service delivery (DSD) models for people living with HIV (PLHIV). We evaluated the effects of COVID-19 on HIV service delivery and viral suppression in facilities in Northern Nigeria, and determined factors associated with viral suppression among adolescents and adults. We analysed a cross-sectional survey data from facility heads, and retrospective, routinely collected patient data from 63 facilities for PLHIV ≥10 years old in care between April 2019-March 2021, defining study periods as "pre-COVID-19" (before April 2020) and "during COVID-19" (after April 2020). For the pre-COVID and the COVID-19 periods we compared uptake of antiretroviral therapy (ART) refills of ≥3 months (MMD3), and ≥6 months (MM6), missed appointments, viral load (VL) testing, VL testing turnaround time (TAT) and viral suppression among those on ART for ≥6 months using two proportions Z-test and t-tests. We fit a multivariable logistic regression model to determine factors associated with maintaining or achieving viral suppression. Of 84,776 patients, 58% were <40 years, 67% were female, 55% on ART for >5 years, 93% from facilities with community-based ART refill, a higher proportion were on MMD3 (95% versus 74%, p<0.001) and MMD6 (56% versus 22%, p<0.001) during COVID-19 than pre-COVID-19, and a higher proportion had VL testing during COVID-19 (55,271/69,630, [84%]) than pre-COVID-19 (47,747/68,934, [73%], p<0.001). Viral suppression was higher during COVID-19 pandemic compared to the pre-COVID era (93% [51,196/55,216] versus 91% [43,336/47,728], p<0.001), and there was a higher proportion of missed visits (40% [28,923/72,359] versus 39% [26,304/67,365], p<0.001) and increased VL TAT (mean number of days: 38 versus 36, p<0.001) during COVID-19 pandemic and pre-COVID period respectively. Factors associated with maintaining or achieving suppression during COVID-19 were receiving MMD3 and MMD6 refills (OR: 2.8 [95% CI: 2.30-3.47] and OR: 6.3 [95% CI: 5.11-7.69], respectively) and attending clinics with community-based ART refill (OR: 1.6 [95% CI: 1.39-1.87]). The program in Northern Nigeria demonstrated resilience during the COVID-19 pandemic and adoption of MMD had a positive impact on HIV care. Though VL TAT and missed clinic visits slightly increased during the pandemic, VL testing improved and viral suppression moved closer to 95%. Adoption of MMD and community-based models of care at scale are recommended for future pandemic preparedness.
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Affiliation(s)
- Cyrus Mugo
- Kenyatta National Hospital, Nairobi, Kenya
| | - Oluwasanmi Adedokun
- Center for International Health, Education, and Biosecurity (CIHEB), Maryland Global Initiatives Corporation (MGIC) – University of Maryland, Abuja, Nigeria
| | - Oluwafemi David Alo
- Center for International Health, Education, and Biosecurity (CIHEB), Maryland Global Initiatives Corporation (MGIC) – University of Maryland, Abuja, Nigeria
| | - Nnenna Ezeokafor
- Center for International Health, Education, and Biosecurity (CIHEB), Maryland Global Initiatives Corporation (MGIC) – University of Maryland, Abuja, Nigeria
| | | | | | | | - Ezekiel James
- United States Agency for International Development, Abuja, Nigeria
| | - Sylvia Bolanle Adebajo
- Center for International Health, Education, and Biosecurity (CIHEB), Maryland Global Initiatives Corporation (MGIC) – University of Maryland, Abuja, Nigeria
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Cherkos AS, Cranmer LM, Njuguna I, LaCourse SM, Mugo C, Moraa H, Maleche-Obimbo E, Enquobahrie DA, Richardson BA, Wamalwa D, John-Stewart G. Effect of tuberculosis-HIV co-treatment on clinical and growth outcomes among hospitalized children newly initiating antiretroviral therapy. AIDS 2024; 38:579-588. [PMID: 38016160 PMCID: PMC10922257 DOI: 10.1097/qad.0000000000003797] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
OBJECTIVE Evaluate effects of tuberculosis (TB)-HIV co-treatment on clinical and growth outcomes in children with HIV (CHIV). DESIGN Longitudinal study among Kenyan hospitalized ART-naive CHIV in the PUSH trial (NCT02063880). METHODS CHIV started ART within 2 weeks of enrollment; Anti-TB therapy was initiated based on clinical and TB diagnostics. Children were followed for 6 months with serial viral load, CD4%, and growth assessments [weight-for-age z -score (WAZ), height-for-age z -score (HAZ), and weight-for-height z -score (WHZ)]. TB-ART treated and ART-only groups were compared at 6 months post-ART for undetectable viral load (<40 c/ml), CD4% change, and growth using generalized linear models, linear regression, and linear mixed-effects models, respectively. RESULT Among 152 CHIV, 40.8% (62) were TB-ART treated. Pre-ART, median age was 2.0 years and growth was significantly lower, and viral load significantly higher in the TB-ART versus ART-only group. After 6 months on ART, 37.2% of CHIV had undetectable viral load and median CD4% increased by 7.2% (IQR 2.0-11.6%) with no difference between groups. The TB-ART group had lower WAZ and HAZ over 6 month follow-up [WAZ -0.81 (95% CI: -1.23 to -0.38], P < 0.001; HAZ -0.15 (95% CI: -0.29 to -0.01), P = 0.030] and greater rate of WAZ increase in analyses unadjusted and adjusted for baseline WAZ [unadjusted 0.62 (95% CI: 0.18-1.07, P = 0.006) or adjusted 0.58 (95% CI: 0.12-1.03, P = 0.013)]. CONCLUSION TB-HIV co-treatment did not adversely affect early viral suppression and CD4 + recovery post-ART. TB-ART-treated CHIV had more rapid growth reconstitution, but growth deficits persisted, suggesting need for continued growth monitoring.
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Affiliation(s)
- Ashenafi S Cherkos
- Department of Population and Community Health, School of Public Health, University of North Texas Health Science Center, Fort Worth, TX
| | - Lisa M Cranmer
- Department of Pediatrics, Emory School of Medicine
- Department of Epidemiology, Emory Rollins School of Public Health
- Children's Healthcare of Atlanta, Atlanta, GA
| | - Irene Njuguna
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
| | - Sylvia M LaCourse
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Cyrus Mugo
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
| | - Hellen Moraa
- Department of Pediatrics and Child Health, University of Nairobi, Kenya
| | | | - Daniel A Enquobahrie
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
| | - Barbra A Richardson
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Biostatistics, School of Public Health
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Kenya
| | - Grace John-Stewart
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
- Department of Pediatrics, University of Washington, Seattle, WA, USA
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Mirieri H, Nduati R, Dawa J, Okutoyi L, Osoro E, Mugo C, Wamalwa D, Jin H, Mwaengo D, Otieno N, Marwanga D, Shabibi M, Munyua P, Kinuthia J, Clancey E, Widdowson MA, Njenga MK, Verani JR, Inwani I. Risk factors of adverse birth outcomes among a cohort of pregnant women in Coastal Kenya, 2017-2019. BMC Pregnancy Childbirth 2024; 24:127. [PMID: 38347445 PMCID: PMC10860222 DOI: 10.1186/s12884-024-06320-6] [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: 04/05/2023] [Accepted: 02/05/2024] [Indexed: 02/15/2024] Open
Abstract
INTRODUCTION Adverse birth outcomes particularly preterm births and congenital anomalies, are the leading causes of infant mortality globally, and the burden is highest in developing countries. We set out to determine the frequency of adverse birth outcomes and the risk factors associated with such outcomes in a cohort of pregnant women in Kenya. METHODS From October 2017 to July 2019, pregnant women < 28 weeks gestation were enrolled and followed up until delivery in three hospitals in coastal Kenya. Newborns were examined at delivery. Among women with birth outcome data, we assessed the frequency of congenital anomalies defined as gastroschisis, umbilical hernia, limb abnormalities and Trisomy 21, and adverse birth outcomes, defined as either stillbirth, miscarriage, preterm birth, small for gestational age, or microcephaly. We used log-binomial regression to identify maternal characteristics associated with the presence of at least one adverse outcome. RESULTS Among the 2312 women enrolled, 1916 (82.9%) had birth outcome data. Overall, 402/1916 (20.9%; 95% confidence interval (CI): 19.1-22.8) pregnancies had adverse birth outcomes. Specifically, 66/1916 (3.4%; 95% CI: 2.7-4.4) were stillbirths, 34/1916 (1.8%; 95% CI: 1.2-2.4) were miscarriages and 23/1816 (1.2%; 95% CI: 0.8-1.9) had congenital anomalies. Among the participants with anthropometric measurements data, 142/1200 (11.8%; 95% CI: 10.1 - 13.8) were small for gestational age and among the participants with ultrasound records, 143/1711 (8.4%; 95% CI: 7.1-9.8) were preterm. Febrile illnesses in current pregnancy (adjusted risk ratio (aRR): 1.7; 95% CI: 1.1-2.8), a history of poor birth outcomes in prior pregnancy (aRR: 1.8; 95% CI: 1.3-2.4) and high blood pressure in pregnancy (aRR: 3.9, 95% CI: (1.7-9.2) were independently associated with adverse birth outcomes in a model that included age, education, human immunodeficiency virus status and high blood pressure at enrolment. CONCLUSION We found similar rates of overall adverse birth outcomes, congenital anomalies, and small for gestational age but higher rates of stillbirths and lower rates of prematurity compared to the rates that have been reported in the sub-Saharan Africa region. However, the rates of adverse birth outcomes in this study were comparable to other studies conducted in Kenya. Febrile illnesses during the current pregnancy, previous history of poor birth outcomes and high blood pressure in pregnancy are predictive of an increased risk of adverse birth outcomes.
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Affiliation(s)
- Harriet Mirieri
- Washington State University (WSU) Global Health Kenya, Nairobi, Kenya.
| | - Ruth Nduati
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Jeanette Dawa
- Washington State University (WSU) Global Health Kenya, Nairobi, Kenya
| | - Lydia Okutoyi
- Department of Health Care Quality, Kenyatta National Hospital, Nairobi, Kenya
| | - Eric Osoro
- Washington State University (WSU) Global Health Kenya, Nairobi, Kenya
- Paul G. Allen School of Global Health, Washington State University (WSU), Pullman, USA
| | - Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Dalton Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Hafsa Jin
- Coast General Teaching and Referral Hospital, Mombasa, Kenya
| | - Dufton Mwaengo
- University of Nairobi Institute of Tropical and Infectious Diseases, Nairobi, Kenya
| | - Nancy Otieno
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Doris Marwanga
- Washington State University (WSU) Global Health Kenya, Nairobi, Kenya
| | | | - Peninah Munyua
- Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya
| | - John Kinuthia
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Erin Clancey
- Paul G. Allen School of Global Health, Washington State University (WSU), Pullman, USA
| | - Marc-Alain Widdowson
- Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya
- Institute of Tropical Medicine, Antwerp, Belgium
| | - M Kariuki Njenga
- Washington State University (WSU) Global Health Kenya, Nairobi, Kenya
- Paul G. Allen School of Global Health, Washington State University (WSU), Pullman, USA
| | - Jennifer R Verani
- Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Irene Inwani
- Department of Paediatrics, Kenyatta National Hospital, Nairobi, Kenya
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Saldarriaga EM, Beima-Sofie K, Wamalwa D, Mugo C, Njuguna I, Onyango A, John-Stewart G, Sharma M. Estimating the costs of adolescent HIV care visits and an intervention to facilitate transition to adult care in Kenya. PLoS One 2024; 19:e0296734. [PMID: 38330069 PMCID: PMC10852328 DOI: 10.1371/journal.pone.0296734] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/18/2023] [Indexed: 02/10/2024] Open
Abstract
INTRODUCTION Adolescents with HIV in sub-Saharan Africa face challenges transitioning to adult HIV care, which can affect long-term HIV care adherence and retention. An adolescent transition package (ATP) focused on transition tools can improve post-transition clinical outcomes, but its implementation costs are unknown. METHODS We estimated the average cost per patient of an HIV care visit and ATP provision to adolescents. Data was collected from 13 HIV clinics involved in a randomized clinical trial evaluating ATP in western Kenya. We conducted a micro-costing and activity-driven time estimation to assess costs from the provider perspective. We developed a flow-map, conducted staff interviews, and completed time and motion observation. ATP costs were estimated as the difference in average cost for an HIV care transition visit in the intervention compared to control facilities. We assessed uncertainty in costing estimates via Monte Carlo simulations. RESULTS The average cost of an adolescent HIV care visit was 29.8USD (95%CI 27.5, 33.4) in the standard of care arm and 32.9USD (95%CI 30.5, 36.8) in the ATP intervention arm, yielding an incremental cost of 3.1USD (95%CI 3.0, 3.4) for the ATP intervention. The majority of the intervention cost (2.8USD) was due ATP booklet discussion with the adolescent. CONCLUSION The ATP can be feasibly implemented in HIV care clinics at a modest increase in overall clinic visit cost. Our cost estimates can be used to inform economic evaluations or budgetary planning of adolescent HIV care interventions in Kenya.
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Affiliation(s)
- Enrique M. Saldarriaga
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Kristin Beima-Sofie
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Dalton Wamalwa
- Department of Pediatrics & Child Health, University of Nairobi, Nairobi, Kenya
- Department of Pediatrics, Kenyatta National Hospital, Nairobi, Kenya
| | - Cyrus Mugo
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Irene Njuguna
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, United States of America
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
| | - Alvin Onyango
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Departments of Pediatrics and Medicine, University of Washington, Seattle, Washington, United States of America
| | - Monisha Sharma
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, United States of America
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Hunsperger E, Osoro E, Munyua P, Njenga MK, Mirieri H, Kikwai G, Odhiambo D, Dayan M, Omballa V, Agogo GO, Mugo C, Widdowson MA, Inwani I. Seroconversion and seroprevalence of TORCH infections in a pregnant women cohort study, Mombasa, Kenya, 2017-2019. Epidemiol Infect 2024; 152:e68. [PMID: 38305089 PMCID: PMC11077605 DOI: 10.1017/s0950268824000165] [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: 01/03/2023] [Revised: 01/02/2024] [Accepted: 01/08/2024] [Indexed: 02/03/2024] Open
Abstract
Women infected during pregnancy with TORCH (Toxoplasmosis, Other, Rubella, Cytomegalovirus, and Herpes simplex viruses) pathogens have a higher risk of adverse birth outcomes including stillbirth / miscarriage because of mother-to-child transmission. To investigate these risks in pregnant women in Kenya, we analyzed serum specimens from a pregnancy cohort study at three healthcare facilities. A sample of 481 participants was selected for TORCH pathogen antibody testing to determine seroprevalence. A random selection of 285 from the 481 participants was selected to measure seroconversion. These sera were tested using an IgG enzyme-linked immunosorbent assay against 10 TORCH pathogens. We found that the seroprevalence of all but three of the 10 TORCH pathogens at enrollment was >30%, except for Bordetella pertussis (3.8%), Treponema pallidum (11.4%), and varicella zoster virus (0.5%). Conversely, very few participants seroconverted during their pregnancy and were herpes simplex virus type 2 (n = 24, 11.2%), parvovirus B19 (n = 14, 6.2%), and rubella (n = 12, 5.1%). For birth outcomes, 88% of the participant had live births and 12% had stillbirths or miscarriage. Cytomegalovirus positivity at enrolment had a statistically significant positive association with a live birth outcome (p = 0.0394). Of the 10 TORCH pathogens tested, none had an association with adverse pregnancy outcome.
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Affiliation(s)
- Elizabeth Hunsperger
- Division of Global Health Protection, US Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Eric Osoro
- Washington State University (WSU) Global Health Kenya, Nairobi, Kenya
- Paul G. Allen School for Global Health, Washington State University (WSU), Pullman, WA, USA
| | - Peninah Munyua
- Division of Global Health Protection, US Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - M. Kariuki Njenga
- Washington State University (WSU) Global Health Kenya, Nairobi, Kenya
- Paul G. Allen School for Global Health, Washington State University (WSU), Pullman, WA, USA
| | - Harriet Mirieri
- Washington State University (WSU) Global Health Kenya, Nairobi, Kenya
| | - Gilbert Kikwai
- Kenya Medical Research Institute (KEMRI), Center for Global Health Research, Nairobi, Kenya
| | - Dennis Odhiambo
- Kenya Medical Research Institute (KEMRI), Center for Global Health Research, Nairobi, Kenya
| | - Moshe Dayan
- Kenya Medical Research Institute (KEMRI), Center for Global Health Research, Nairobi, Kenya
| | - Victor Omballa
- Kenya Medical Research Institute (KEMRI), Center for Global Health Research, Nairobi, Kenya
| | - George O. Agogo
- Division of Global Health Protection, US Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - Cyrus Mugo
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Marc-Alain Widdowson
- Division of Global Health Protection, US Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Irene Inwani
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
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Njuguna I, Mugo C, Mbwayo A, Augusto O, Wamalwa D, Inwani I. Gaps and Opportunities for Strengthening In-School Support for Youth Living With HIV. J Sch Health 2024; 94:178-183. [PMID: 37919544 PMCID: PMC10790302 DOI: 10.1111/josh.13403] [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] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 09/21/2023] [Accepted: 09/23/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVES With optimized antiretroviral treatment youth living with HIV (YLH) now spend most of their time in schools, making schools an important venue to optimize outcomes. We evaluated school support for YLH. METHODS We conducted surveys with public secondary/high schools in 3 Kenyan counties (Nairobi, Homa Bay, and Kajiado) to determine policies and training related to HIV. Chi-squared tests and Poisson regression were used to compare policy availability and staff training by county HIV prevalence and school type. RESULTS Of 512 schools in the 3 counties, we surveyed 100. The majority (60%) of schools surveyed had boarding facilities. The median student population was 406 (IQR: 200, 775). Only half (49%) of schools had medication use policies; more in boarding than day schools (65% vs 30%, p = .003). While most schools (82%) had clinic attendance policies; policy availability was higher in higher HIV prevalence counties (Homa Bay [100%], Nairobi [82%], Kajiado [56%], p < .05). Overall, 64% had confidentiality policies with higher policy availability in higher HIV prevalence regions (p < .05). Few schools had staff trained in HIV-related topics: HIV prevention (37%), HIV treatment (18%), HIV stigma reduction (36%). Few were trained in confidentiality (41%), psychosocial support (40%), or mental health (26%). Compared to day schools, boarding school were more likely to have staff trained in HIV prevention (prevalence ratio: 2.1 [95% confidence interval 1.0, 4.0], p = .037). CONCLUSION In this survey of Kenyan schools, there were notable gaps in HIV care policy availability and training, despite high HIV burden. Development and implementation of national school HIV policies and staff training as well as strengthening clinic and family support may improve outcomes for YLH.
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Affiliation(s)
- Irene Njuguna
- Kenyatta National Hospital, Research and Programs, P.O. Box 20723-00202, Nairobi, Kenya
- Department of Global Health, University of Washington, Box 359931, Seattle, WA 98104, USA
| | - Cyrus Mugo
- Kenyatta National Hospital, Research and Programs, P.O. Box 20723-00202, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Box 359931, Seattle, WA 98104, USA
| | - Anne Mbwayo
- Department of Psychiatry, University of Nairobi P.O. Box 19676-00202, Nairobi, Kenya
| | | | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi P.O. Box 19676-00202, Nairobi, Kenya
| | - Irene Inwani
- Kenyatta National Hospital, Research and Programs, P.O. Box 20723-00202, Nairobi, 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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Semo BW, Ezeokafor NA, Oyawola B, Mugo C. Effect of Multi-Month Dispensing on Viral Suppression for Newly Enrolled Adolescents and Adults in Northern Nigeria. HIV AIDS (Auckl) 2023; 15:697-704. [PMID: 38028192 PMCID: PMC10658956 DOI: 10.2147/hiv.s432976] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 10/15/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose We evaluated the effect of multi-month dispensing (MMD) on viral suppression among newly enrolled adolescents and adults with HIV in 11 northern Nigerian states. Patients and Methods We conducted a retrospective analysis of longitudinal data from 75 health facilities. We abstracted electronic medical records for patients ≥10 years, initiated on ART April 1, 2019 - June 30, 2021, and with a 6- or 12-month viral load (VL) result. We categorized participants in the MMD group to see if they received antiretroviral treatment (ART) for ≥84 days at any visit within 6 months of ART initiation. We consider cut-offs for viral suppression at 50 copies/mL. The period when the VL was performed was classified as pre-COVID-19 (before April 1, 2020) or during the COVID-19 pandemic. We estimated relative risks (RR) by comparing the unsuppressed proportion of those on MMD to those not on MMD, adjusted for age, gender, and COVID-19 period. Results Overall, 19,859 participant records were abstracted. Median age was 33 years, 64% were female, 91% were started on a dolutegravir (DTG)-based regimen, and 65% were on MMD. Overall, 15,259 (77%) participants were followed for ≥6 months, 4136 (27%) had a VL at 6 months and 3640 (24%) had a VL at 12 months after ART initiation. A slightly higher proportion of patients on MMD had undetectable VL levels at 6 months (65% vs 58%) and 12 months (66% vs 62%). In the adjusted analysis, we found no significant differences in undetectable VL at 6 months and 12 months between newly enrolled patients on MMD and those not on MMD. Those on Protease inhibitor-based regimen had 54% lower likelihood of undetectable VL compared to those on DTG-based regimen. Conclusion MMD does not result in poorer viral suppression among newly enrolled patients.
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Affiliation(s)
| | - Nnenna A Ezeokafor
- Maryland Global Initiative Cooperation, University of Maryland, Abuja, Nigeria
- Global Health Division, Chemonics International, Abuja, Nigeria
| | | | - Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
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Ronen K, Mugo C, Kaggiah A, Seeh D, Kumar M, Guthrie BL, Moreno MA, John-Stewart G, Inwani I. Facilitated WhatsApp Support Groups for Youth Living With HIV in Nairobi, Kenya: Single-Arm Pilot Intervention Study. JMIR Form Res 2023; 7:e49174. [PMID: 37955957 PMCID: PMC10682925 DOI: 10.2196/49174] [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] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/28/2023] [Accepted: 10/03/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Mobile technology can support HIV care, but studies in youth are limited. In 2014, youth receiving HIV care at several health care facilities in Nairobi, Kenya spontaneously formed peer support groups using the social media platform WhatsApp. OBJECTIVE Inspired by youth-initiated groups, we aimed to evaluate the use of WhatsApp to deliver a social support intervention to improve HIV treatment and psychosocial outcomes in youth. We developed a facilitated WhatsApp group intervention (named Vijana-SMART), which was grounded in social support theory and guided by the design recommendations of youth living with HIV. This paper evaluates the intervention's acceptability and pre-post changes in health outcomes. METHODS The intervention involved interactive WhatsApp groups facilitated by study staff for 6 months, with each group having approximately 25 members. Study staff sent weekly structured messages, and the message content was based on social support theory and encouraged unstructured peer-to-peer messaging and support. We conducted a single-arm pilot among 55 youth living with HIV aged 14-24 years recruited from a government health care facility serving a mixed-income area of Nairobi. At enrollment and follow-up, self-report questionnaires assessed acceptability; antiretroviral therapy (ART) information, motivation, and behavioral skills (IMB); depression; social support; stigma; resilience; and ART adherence. All participants received the intervention. We used generalized estimating equations (GEEs) clustered by participant to evaluate changes in scores from baseline to follow-up, and correlates of participant WhatsApp messaging. RESULTS The median participant age was 18 years, and 67% (37/55) were female. Intervention acceptability was high. All participants reported that it was helpful, and 73% (38/52) sent ≥1 WhatsApp message. Messaging levels varied considerably between participants and were higher during school holidays, earlier in the intervention period, and among youth aged ≥18 years. IMB scores increased from enrollment to follow-up (66.9% to 71.3%; P<.001). Stigma scores also increased (8.3% to 16.7%; P=.001), and resilience scores decreased (75.0% to 70.0%; P<.001). We found no significant change in ART adherence, social support, or depression. We detected a positive association between the level of messaging during the study and the resilience score, but no significant association between messaging and other outcomes. Once enrolled, it was common for participants to change their phone numbers or leave the groups and request to be added back, which may present implementation challenges at a larger scale. CONCLUSIONS Increased IMB scores following WhatsApp group participation may improve HIV outcomes. Increased stigma and decreased resilience were unintended consequences and may reflect transient effects of group sharing of challenging experiences, which should be addressed in larger randomized evaluations. WhatsApp groups present a promising and acceptable modality to deliver supportive interventions to youth living with HIV beyond the clinic, and further evaluation is warranted. TRIAL REGISTRATION ClinicalTrials.gov (NCT05634265); https://clinicaltrials.gov/study/NCT05634265.
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Affiliation(s)
- Keshet Ronen
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Cyrus Mugo
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Anne Kaggiah
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - David Seeh
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Manasi Kumar
- Department of Psychiatry, University of Nairobi, Nairobi, Kenya
- New York University Langone Health, New York, NY, United States
| | - Brandon L Guthrie
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Megan A Moreno
- Department of Pediatrics, University of Wisconsin - Madison, Madison, WI, United States
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, 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
| | - Irene Inwani
- Department of Pediatrics, Kenyatta National Hospital, Nairobi, Kenya
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Mangale DI, Onyango A, Mugo C, Mburu C, Chhun N, Wamalwa D, Njuguna I, Means AR, John-Stewart G, Weiner BJ, Beima-Sofie K. Characterizing provider-led adaptations to mobile phone delivery of the Adolescent Transition Package (ATP) in Kenya using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS): a mixed methods approach. Implement Sci Commun 2023; 4:95. [PMID: 37580836 PMCID: PMC10424422 DOI: 10.1186/s43058-023-00446-y] [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] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/30/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic resulted in disruptions to routine HIV services for youth living with HIV (YLH), provoking rapid adaptation to mitigate interruptions in care. The Adolescent Transition to Adult Care for HIV-infected adolescents (ATTACH) study (NCT03574129) was a hybrid I cluster randomized trial testing the effectiveness of a healthcare worker (HCW)-delivered disclosure and transition intervention - the Adolescent Transition Package (ATP). During the pandemic, HCWs leveraged phone delivery of the ATP and were supported to make adaptations. We characterized real-time, provider-driven adaptations made to support phone delivery of the ATP. METHODS We conducted continuous quality improvement (CQI) meetings with HCWs involved in phone delivery of the ATP at 10 intervention sites. CQI meetings used plan-do-study-act (PDSA) cycles and were audio-recorded. Adaptations were coded by two-independent coders using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS). Adaptation testing outcomes (adopt, retest, or abandon) and provider experience implementing the adaptations were also recorded. We summarized adaptation characteristics, provider experience, and outcomes. RESULTS We identified 72 adaptations, 32 were unique. Overall, adaptations included modification to context (53%, n = 38), content (49%, n = 35), and evaluation processes (13%, n = 9). Context adaptations primarily featured changes to personnel, format, and setting, while content and evaluation adaptations were frequently achieved by simple additions, repetition, and tailoring/refining of the phone delivery strategy. Nine adaptations involved abandoning, then returning to phone delivery. HCWs sought to increase reach, improve fidelity, and intervention fit within their context. Most adaptations (96%, n = 69) were perceived to increase the feasibility of phone delivery when compared to before the changes were introduced, and HCWs felt 83% (n = 60) of adaptations made phone delivery easier. Most adaptations were either incorporated into routine workflows (47%) or tested again (47%). CONCLUSION Adaptation of phone delivery was a feasible and effective way of addressing challenges with continuity of care for YLH during the COVID-19 pandemic. Adaptations were primarily context adaptions. While FRAME-IS was apt for characterizing adaptations, more use cases are needed to explore the range of its utility. TRIAL REGISTRATION Trial registered on ClinicalTrial.gov as NCT03574129.
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Affiliation(s)
| | - Alvin Onyango
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Cyrus Mugo
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Caren Mburu
- Department of Global Health, University of Washington, Seattle, USA
| | - Nok Chhun
- Department of Global Health, University of Washington, Seattle, USA
| | - Dalton Wamalwa
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Irene Njuguna
- Department of Global Health, University of Washington, Seattle, USA
- Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Pediatrics, School of Medicine, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Bryan J Weiner
- Department of Global Health, University of Washington, Seattle, USA
- Department of Health Services, University of Washington, Seattle, USA
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Moraa H, Njuguna I, Mugo C, Mbwayo A, Nyapara F, Aballa C, Wagner AD, Wamalwa D, John-Stewart G, Inwani I, O'Malley G. "We can tell a good teacher who cares, understands, and can be confidential about it": youth and caregiver experiences with HIV disclosure to schools in Kenya. Front Public Health 2023; 11:1172431. [PMID: 37559743 PMCID: PMC10407401 DOI: 10.3389/fpubh.2023.1172431] [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: 02/23/2023] [Accepted: 07/04/2023] [Indexed: 08/11/2023] Open
Abstract
Introduction Disclosure of one's HIV status to others is often difficult due to the fear of stigma. However, disclosure may facilitate receiving social support. Many youth living with HIV (YLH) are enrolled in school as better treatments have improved the health and survival of children with HIV. There is no structured process for disclosure at school for YLH and their caregivers. We sought to understand school disclosure experiences among YLH and their caregivers and assess the need for the development of a structured disclosure intervention tailored to school settings. Methods We conducted in-depth qualitative interviews with 28 school-going YLH aged 14-19 years and 24 caregivers of YLH. Interviews were conducted in English and Swahili, transcribed, and translated. The transcripts were uploaded to Atlas.ti 9 for thematic analysis. Results YLH and caregivers clearly articulated the benefits of disclosing to school staff. Disclosure to school staff was seen as the first step to receiving support for medication storage, adherence, and clinic attendance. However, disclosure was also perceived to be a very complicated and stressful process. Fear of stigma drove caregivers and YLH toward careful planning of when and to whom to disclose. Distrust of school staff was a significant barrier to disclosure, even among those who clearly articulated the benefits of disclosure. Disclosure to school staff largely resulted in positive experiences; the immediate reactions were positive or somewhat neutral and confidentiality was upheld. The anticipated benefits of practical and emotional support were demonstrated by the school staff to whom the HIV information was disclosed. Conclusion Disclosure of HIV status to someone at school is necessary to receive support for medication adherence. Stigma and the lack of structured support for the disclosure process at school often hinder YLH and their caregivers from disclosing. YLH would benefit from better support at schools, including policies to facilitate disclosure that address the caregiver and YLH's fear of stigma and loss of confidentiality. School policies could also provide guidance on whom to disclose to and available post-disclosure support.
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Affiliation(s)
- Hellen Moraa
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
| | - Irene Njuguna
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
- Departments of Global Health, University of Washington, Seattle, WA, United States
| | - Cyrus Mugo
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
| | - Anne Mbwayo
- Department of Psychiatry, University of Nairobi, Nairobi, Kenya
| | - Florence Nyapara
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
| | - Calvins Aballa
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
| | - Anjuli Dawn Wagner
- Departments of Global Health, University of Washington, Seattle, WA, United States
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health University of Nairobi, Nairobi, Kenya
| | - Grace John-Stewart
- Departments of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, 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
| | - Irene Inwani
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
| | - Gabrielle O'Malley
- Departments of Global Health, University of Washington, Seattle, WA, United States
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Semo BW, Ezeokafor N, Adeyemi S, Kpamor Z, Mugo C. Differentiated service delivery models for antiretroviral treatment refills in Northern Nigeria: Experiences of people living with HIV and health care providers-A qualitative study. PLoS One 2023; 18:e0287862. [PMID: 37428746 DOI: 10.1371/journal.pone.0287862] [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] [Received: 11/30/2022] [Accepted: 06/14/2023] [Indexed: 07/12/2023] Open
Abstract
Differentiated service delivery (DSD) and multi-month dispensing (MMD) of antiretroviral therapy (ART) have improved treatment adherence and viral suppression among people living with HIV (PLHIV), and service delivery efficiency. We assessed the experiences of PLHIV and providers with DSD and MMD in Northern Nigeria. We conducted in-depth interviews (IDI) with 40 PLHIV and 6 focus group discussions (FGD) with 39 health care providers across 5 states, exploring their experiences with 6 DSD models. Qualitative data were analyzed using NVivo®1.6.1. Most PLHIV and providers found the models acceptable and expressed satisfaction with service delivery. The DSD model preference of PLHIV was influenced by convenience, stigma, trust, and cost of care. Both PLHIV and providers indicated improvements in adherence and viral suppression; they also raised concerns about quality of care within community-based models. PLHIV and provider experiences suggest that DSD and MMD have the potential to improve patient retention rates and service delivery efficiency.
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Affiliation(s)
- Bazghina-Werq Semo
- Global Health Division, Chemonics International, Washington DC, United States of America
| | - Nnenna Ezeokafor
- Maryland Global Initiative Cooperation, University of Maryland, Abuja, Nigeria
- Global Health Division, Chemonics International, Abuja, Nigeria
| | | | - Zipporah Kpamor
- Global Health Division, Chemonics International, Abuja, Nigeria
| | - Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
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Mburu C, Njuguna I, Neary J, Mugo C, Moraa H, Beima-Sofie K, Onyango A, Oyiengo L, Richardson BA, John-Stewart G, Wamalwa D. Mortality and Loss to Follow-Up Among Adolescents and Young Adults Attending HIV Care Programs in Kenya. AIDS Patient Care STDS 2023; 37:323-331. [PMID: 37432311 PMCID: PMC10354300 DOI: 10.1089/apc.2023.0019] [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: 07/12/2023] Open
Abstract
Mortality and loss to follow-up (LTFU) among adolescents and youth living with HIV (AYLHIV) remain high. We evaluated mortality and LTFU during the test and treat era. We abstracted medical records of AYLHIV for 10-24 years between January 2016 and December 2017 in 87 HIV clinics in Kenya. Using competing risk survival analysis, we compared incidence rates and determined correlates of mortality and LTFU among newly enrolled [<2 years since antiretroviral therapy (ART) initiation] and AYLHIV on ART for ≥2 years. Among 4201 AYLHIV, 1452 (35%) and 2749 (65%) were new enrollments and on ART for ≥2 years, respectively. AYLHIV on antiretroviral therapy (ART) for ≥2 years were younger and more likely to have perinatally acquired HIV (p < 0.001). Incidence of mortality and LTFU per 100 person-years were 2.32 [95% confidence interval (CI): 1.64-3.28] and 37.8 (95% CI: 34.7-41.3), respectively, among new enrollments and 1.22 (95% CI: 0.94-1.59) and 10.2 (95% CI: 9.3-11.1), respectively, among those on ART for ≥2 years. New enrollments had almost twice higher risk of mortality [subdistribution hazard ratio (sHR) 1.92 (1.30, 2.84), p = 0.001] and sevenfold higher risk of LTFU [sHR 7.71 (6.76, 8.79), p < 0.001] than those on ART for ≥2 years. Among new enrollments, mortality was higher in males and those with World Health Organization (WHO) stage III/IV disease at enrollment, and LTFU was associated with pregnancy, older age, and nonperinatal acquisition. Female sex and WHO stage (I/II) were associated with LTFU among those on ART for ≥2 years. During the study period from January 1, 2016, to December 31, 2017, the mortality incidence observed did not demonstrate improvement from earlier studies despite universal test and treat and better ART regimens. This trial was registered with ClinicalTrials.gov, NCT03574129.
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Affiliation(s)
- Caren Mburu
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Irene Njuguna
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Jillian Neary
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Hellen Moraa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Kristin Beima-Sofie
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Alvin Onyango
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Laura Oyiengo
- United Nations International Emergency Children's Fund, Department of Maternal and Newborn Health
| | - Barbra A. Richardson
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Njuguna I, Moraa H, Mugo C, Mbwayo A, Nyapara F, Aballa C, Wagner AD, Wamalwa D, John-Stewart G, Inwani I, O’Malley G. 'They should show them love even if their status of being HIV positive is known': Youth and caregiver stigma experience and strategies to end HIV stigma in schools. Trop Med Int Health 2023; 28:466-475. [PMID: 37177902 PMCID: PMC10278085 DOI: 10.1111/tmi.13878] [Citation(s) in RCA: 1] [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: 05/15/2023]
Abstract
OBJECTIVE HIV stigma and discrimination is widespread in sub-Saharan Africa and is associated with poor clinical outcomes. Schools play a critical role in the life of youth and have been identified as a potentially stigmatising environment. We sought to explore school HIV stigma drivers, facilitators, manifestations and outcomes among youth living with HIV (YLH) as well as potential stigma reduction interventions in Kenya. METHODS Semi-structured in-depth qualitative interviews with 28 school-attending YLH aged 14-19 years and 24 caregivers of YLH were analysed using directed content analysis. Results were summarised using the Health and Stigma Framework. RESULTS Drivers and facilitators of HIV stigma in the school environment included misconceptions about HIV transmission, HIV treatment outcomes and long-term overall health of people living with HIV. HIV stigma manifested largely as gossip, isolation and loss of friendships. Fear of HIV stigma or experienced stigma resulted in poor adherence to antiretroviral treatment-particularly among YLH in boarding schools-and poor mental health. Stigma also impacted school choice (boarding vs. day school) and prevented HIV disclosure to schools which was necessary for optimal support for care. Proposed interventions to address HIV stigma in schools included HIV education, psychosocial support for YLH, support for HIV disclosure to schools while ensuring confidentiality and building YLH resilience. CONCLUSION There is an urgent need to develop interventions to address HIV stigma in schools to ensure optimised health and social outcomes for YLH. Future studies to understand the most effective and efficient interventions are needed.
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Affiliation(s)
- Irene Njuguna
- Kenyatta National Hospital, Research and Programs, P.O. Box 20723-00202, Nairobi, Kenya
- Departments of Global Health, University of Washington, Box 359931, Seattle, WA 98104, USA
| | - Hellen Moraa
- Kenyatta National Hospital, Research and Programs, P.O. Box 20723-00202, Nairobi, Kenya
| | - Cyrus Mugo
- Kenyatta National Hospital, Research and Programs, P.O. Box 20723-00202, Nairobi, Kenya
| | - Anne Mbwayo
- Department of Psychiatry, University of Nairobi P.O. Box 19676-00202, Nairobi, Kenya
| | - Florence Nyapara
- Kenyatta National Hospital, Research and Programs, P.O. Box 20723-00202, Nairobi, Kenya
| | - Calvins Aballa
- Kenyatta National Hospital, Research and Programs, P.O. Box 20723-00202, Nairobi, Kenya
| | - Anjuli D. Wagner
- Departments of Global Health, University of Washington, Box 359931, Seattle, WA 98104, USA
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi P.O. Box 19676-00202, Nairobi, Kenya
| | - Grace John-Stewart
- Departments of Global Health, University of Washington, Box 359931, Seattle, WA 98104, USA
- Departments of Epidemiology, University of Washington, Box 359931, Seattle, WA 98104, USA
- Departments of Medicine, University of Washington, Box 359931, Seattle, WA 98104, USA
- Departments of Pediatrics, University of Washington, Box 359931, Seattle, WA 98104, USA
| | - Irene Inwani
- Kenyatta National Hospital, Research and Programs, P.O. Box 20723-00202, Nairobi, Kenya
| | - Gabrielle O’Malley
- Departments of Global Health, University of Washington, Box 359931, Seattle, WA 98104, USA
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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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Mugo C, Zubayr B, Ezeokafor N, Oyawola B, Ekele DO, Madueke L, Kpamor Z, Semo BW. Effect of Dolutegravir and multi-month dispensing on viral suppression among children with HIV. J Acquir Immune Defic Syndr 2023:00126334-990000000-00207. [PMID: 36943698 DOI: 10.1097/qai.0000000000003190] [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: 03/23/2023]
Abstract
BACKGROUND Few studies in sub-Saharan Africa have assessed the impact of multi-month dispensing (MMD) of antiretroviral therapy (ART) and dolutegravir (DTG) beyond clinical trials among children with HIV (CWHIV). We assessed the effect of the two interventions on achieving undetectable viral load (VL) among CWHIV 0-15 years in Nigeria. METHODS We utilized longitudinal routine records, and cross-sectional survey data from caregivers of a sub-sample of children. VLs were considered suppressed at <1000 copies/ml and undetectable at <50 copies/ml. MMD was defined as ART refill for >84 days. The effect of MMD and DTG on VL levels, and associations between social factors and VL was estimated using generalized linear models, reporting adjusted relative risks (aRR)/prevalence ratios (aPR) and 95% confidence intervals (95%CI). RESULTS Of 2,490 CWHIV, 52% were male, with a median age of 10 years (IQR: 6-13) and median duration on ART of 4.6 years (IQR: 2.8-7.1). Overall, 73% were on DTG and 55% received MMD. At baseline, 63% were suppressed, while 79% and 56% were suppressed and undetectable in their last VL respectively.We found no differences in undetectable VL between those on MMD and not on MMD (aRR: 1.05 [95%CI: 0.94-1.18]); and between those on DTG and not on DTG (1.07 [0.92-1.25]). In secondary analyses, poor adherence and being in a support group were associated with lower likelihood of undetectable VL (aPR: 0.85 [95%CI: 0.74-0.96], and 0.81 [0.68-0.96] respectively). CONCLUSION MMD did not compromise treatment outcomes for CWHIV. Poor adherence however remains a barrier to achieving treatment targets.
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Affiliation(s)
- Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
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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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Healy E, O’Malley G, Mugo C, Kaggiah A, Seeh D, Muriithi A, Lopez AR, Kumar M, Guthrie B, Moreno M, John-Stewart G, Inwani I, Ronen K. "Whenever you need support, you first turn to the group": motivations and functions of WhatsApp groups for youth living with HIV. AIDS Care 2023; 35:437-446. [PMID: 35761786 PMCID: PMC9792620 DOI: 10.1080/09540121.2022.2088680] [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: 06/08/2021] [Accepted: 06/07/2022] [Indexed: 12/30/2022]
Abstract
Social support is a critical component of achieving positive health outcomes for youth living with HIV (YLWH). Mobile health (mHealth) has significant potential for providing social support to YLWH. However, little is known about the domains of social support most needed by YLWH which mHealth interventions might address. Drawing on the spontaneous creation of WhatsApp support groups by YLWH in Nairobi, Kenya, we characterized Kenyan YLWH's social support needs and potential roles of social media groups in meeting them. We conducted interviews and focus-groups with 68 YLWH, 24 caregivers and 20 healthcare workers, and observed two YLWH-led WhatsApp groups for 6 weeks. Youth reported that existing support systems, including family and healthcare workers, already provided informational and instrumental support. However, they emphasized unmet companionship and emotional support needs, leading to isolation, hopelessness, and medication adherence challenges. Participants identified connection with other YLWH as a unique source of emotional and companionship support that allowed them to feel more secure and less isolated. Interviews and observed WhatsApp chats demonstrated that WhatsApp groups were a desirable medium for companionship support that overcame barriers to in-person connection.
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Affiliation(s)
- Elise Healy
- University of Washington, Department of Global Health, Seattle, WA, USA
| | | | - Cyrus Mugo
- University of Washington, Department of Global Health, Seattle, WA, USA
- Kenyatta National Hospital, Nairobi, Kenya
| | | | - David Seeh
- Kenyatta National Hospital, Nairobi, Kenya
| | | | - Alana R Lopez
- University of Washington, Department of Global Health, Seattle, WA, USA
| | | | - Brandon Guthrie
- University of Washington, Department of Global Health, Seattle, WA, USA
| | | | | | | | - Keshet Ronen
- University of Washington, Department of Global Health, Seattle, WA, USA
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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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21
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Kohler PK, Mugo C, Wilson KS, Moraa H, Onyango A, Tapia K, Pike K, Mburu C, Nduati M, Guthrie B, Richardson BA, Owens T, Bukusi D, Inwani I, John-Stewart G, Wamalwa D. Simulated patient training to improve youth engagement in HIV care in Kenya: A stepped wedge cluster randomized controlled trial. PLOS Glob Public Health 2023; 3:e0001765. [PMID: 37074998 PMCID: PMC10115282 DOI: 10.1371/journal.pgph.0001765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 03/06/2023] [Indexed: 04/20/2023]
Abstract
Youth living with HIV (YLHIV) report that negative interactions with health care workers (HCWs) affects willingness to return to care. This stepped wedge randomized trial evaluated effectiveness of a standardized patient actor (SP) HCW training intervention on adolescent engagement in care in Kenya. HCWs caring for YLHIV at 24 clinics received training on adolescent care, values clarification, communication, and motivational interviewing, with 7 SP encounters followed by facilitated feedback of videotaped interactions. Facilities were randomized to timing of the intervention. The primary outcome was defined as return within 3 months after first visit (engagement) among YLHIV who were either newly enrolled or who returned to care after >3 months out of care. Visit data was abstracted from electronic medical records. Generalized linear mixed models adjusted for time, being newly enrolled, and clustering by facility. YLHIV were surveyed regarding satisfaction with care. Overall, 139 HCWs were trained, and medical records were abstracted for 4,595 YLHIV. Median YLHIV age was 21 (IQR 19-23); 82% were female, 77% were newly enrolled in care, and 75% returned within 3 months. Half (54%) of trained HCWs remained at their clinics 9 months post-training. YLHIV engagement improved over time (global Wald test, p = 0.10). In adjusted models, the intervention showed no significant effect on engagement [adjusted Prevalence Ratio (aPR) = 0.95, 95% Confidence Interval (CI): 0.88-1.02]. Newly enrolled YLHIV had significantly higher engagement than those with prior lapses in care (aPR = 1.18, 95%CI: 1.05-1.33). Continuous satisfaction with care scores were significantly higher by wave 3 compared to baseline (coefficient = 0.38, 95%CI: 0.19-0.58). Despite provider skill improvement, there was no effect of SP training on YLHIV engagement in care. This may be due to temporal improvements or turnover of trained HCWs. Strategies to retain SP-training benefits need to address HCW turnover. YLHIV with prior gaps in care may need more intensive support. Registration CT #: NCT02928900. https://clinicaltrials.gov/ct2/show/NCT02928900.
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Affiliation(s)
- Pamela K Kohler
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Child, Family, and Population Health Nursing, Seattle, Washington, United States of America
| | - Cyrus Mugo
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Kate S Wilson
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Hellen Moraa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Kenyatta National Hospital, Nairobi, Kenya
| | - Alvin Onyango
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Kenyatta National Hospital, Nairobi, Kenya
| | - Kenneth Tapia
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Kenneth Pike
- Department of Child, Family, and Population Health Nursing, Seattle, Washington, United States of America
| | - Caren Mburu
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Margaret Nduati
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Brandon Guthrie
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Biostatistics, University of Washington, Seattle, Washington, United States of America
- Division of Vaccine and Infectious Disease, Fred Hutch Cancer Center, Seattle, Washington, United States of America
| | - Tamara Owens
- Howard University, Washington, DC, United States of America
| | - David Bukusi
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Kenyatta National Hospital, Nairobi, Kenya
| | | | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Driver M, Katz DA, Manyeki V, Mungala C, Otiso L, Mugo C, McClelland S, Kohler P, Simoni JM, Inwani I, Wilson K. Condom Use Behaviors, Risk Perception, and Partner Communication Following Oral HIV Self-testing Among Adolescents and Young Adults in Kenya: A Cohort Study. AIDS Behav 2022; 27:1727-1740. [PMID: 36520337 DOI: 10.1007/s10461-022-03904-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2022] [Indexed: 12/23/2022]
Abstract
HIV self-testing (HIVST) can improve testing completion among adolescents and young adults (AYA), although its influence on sexual behaviors is unclear. We evaluated whether HIVST was associated with changes in talking with sexual partners about HIVST, condom use, and HIV risk perception among AYA ages 15-24 years in a study of HIVST distribution through homes, pharmacies, and nightclubs in Nairobi, Kenya. All participants had negative HIVST results. Regression models were used to evaluate changes between pre-HIVST and 4 months post-HIVST. Overall, there was a significant increase in talking with sexual partners about HIVST. There was a significant reduction in number of condomless sex acts among AYA recruited through pharmacies and homes. Unexpectedly, among females, there was a significant decrease in consistent condom use with casual partners. HIVST services for AYA may benefit from including strategies to support condom use and partner communication about self-testing adapted to specific populations and partnerships.
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Affiliation(s)
- Matthew Driver
- Department of Epidemiology, University of Washington, Seattle, USA
| | - David A Katz
- Department of Global Health, University of Washington, Seattle, USA
| | - Vivianne Manyeki
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Caroline Mungala
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | | | - Cyrus Mugo
- Department of Global Health, University of Washington, Seattle, USA
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Scott McClelland
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Global Health, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Pamela Kohler
- Department of Global Health, University of Washington, Seattle, USA
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, USA
| | - Jane M Simoni
- Department of Global Health, University of Washington, Seattle, USA
- Department of Psychology, University of Washington, Seattle, USA
| | - Irene Inwani
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Kate Wilson
- Department of Global Health, University of Washington, Seattle, USA.
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Njuguna IN, Beima-Sofie K, Mburu CW, Mugo C, Itindi J, Onyango A, Neary J, Richardson BA, Oyiengo L, Wamalwa D, John-Stewart G. Transition to independent care for youth living with HIV: a cluster randomised clinical trial. Lancet HIV 2022; 9:e828-e837. [PMID: 36309040 PMCID: PMC10308660 DOI: 10.1016/s2352-3018(22)00244-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 01/31/2022] [Revised: 08/11/2022] [Accepted: 08/18/2022] [Indexed: 05/18/2023]
Abstract
BACKGROUND Transitioning youth living with HIV to adult care is a crucial step in the HIV care continuum; however, tools to support transition in sub-Saharan Africa are insufficient. We assessed the effectiveness of an adolescent transition package (ATP) to improve youth readiness for transition to independent HIV care. METHODS In this hybrid type 1, multicentre, cluster randomised clinical trial, we assessed the effectiveness of an ATP (administered by routine clinic staff, which included standardised assessments and chapter books to guide discussions at scheduled clinic visits) in four counties in Kenya, with HIV clinics randomly assigned 1:1 to ATP or control (standard-of-care practice). Clinics were eligible to participate if they had at least 50 youth (aged 10-24 years) living with HIV enrolled in care. We used restricted randomisation to achieve cluster balance and an independent biostatistician used computer-generated random numbers to assign clinics. We excluded very large clinics with more than 1000 youth, clinics with fewer than 50 youth, paediatric-only clinics, clinics with logistical challenges, and the smallest clinics in Homa Bay county. Youth were eligible for the transition intervention if they were enrolled in participating clinics, were aged 15-24 years, and were aware of their positive HIV diagnosis. Study staff assessed transition readiness scores overall and by four domains (HIV literacy, self-management, communication, and support) in youth with HIV, which were then compared between groups by use of mixed-effects linear regression models. Analysis was by intention-to-treat and was adjusted for multiple comparisons. This trial is registered with ClinicalTrials.gov, NCT03574129. FINDINGS We identified 35 clinics in four counties; of these, ten were assigned to the intervention group and ten to the control group. Of 1066 youth with HIV enrolled between Nov 1, 2019, and March 18, 2020, 578 (54%) were in intervention and 488 (46%) in control sites. Mean baseline transition readiness score was 12·1 (SD 3·4) in ATP sites and 11·4 (3·7) in control sites. At 1 year, adjusting for baseline scores, age, and months since HIV disclosure, participants in the ATP group had significantly higher overall transition readiness scores (adjusted mean difference 1·7, 95% CI 0·3-3·1, p=0·024), and higher scores in HIV literacy domain (adjusted mean difference 1·0, 0·2-1·7, p=0·011). At 12 months, 15 serious adverse events were recorded, none of which were thought to be related to study participation. INTERPRETATION Integrating ATP approaches could enhance long-term HIV care in youth with HIV as they age into adulthood. FUNDING US National Institutes of Health.
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Affiliation(s)
- Irene N Njuguna
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya; Department of Global Health, University of Washington, Seattle, WA, USA.
| | | | - Caren W Mburu
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Cyrus Mugo
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya; Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Janet Itindi
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Alvin Onyango
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Jillian Neary
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Laura Oyiengo
- Neonatal and Child Health Services, Ministry of Health, Nairobi, Kenya
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA; 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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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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25
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Osoro E, Inwani I, Mugo C, Hunsperger E, Verani JR, Omballa V, Wamalwa D, Rhee C, Nduati R, Kinuthia J, Jin H, Okutoyi L, Mwaengo D, Maugo B, Otieno NA, Mirieri H, Shabibi M, Munyua P, Njenga MK, Widdowson MA. Prevalence of microcephaly and Zika virus infection in a pregnancy cohort in Kenya, 2017-2019. BMC Med 2022; 20:291. [PMID: 36100910 PMCID: PMC9470235 DOI: 10.1186/s12916-022-02498-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 02/10/2022] [Accepted: 07/25/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Zika virus (ZIKV), first discovered in Uganda in 1947, re-emerged globally in 2013 and was later associated with microcephaly and other birth defects. We determined the incidence of ZIKV infection and its association with adverse pregnancy and fetal outcomes in a pregnancy cohort in Kenya. METHODS From October 2017 to July 2019, we recruited and followed up women aged ≥ 15 years and ≤ 28 weeks pregnant in three hospitals in coastal Mombasa. Monthly follow-up included risk factor questions and a blood sample collected for ZIKV serology. We collected anthropometric measures (including head circumference), cord blood, venous blood from newborns, and any evidence of birth defects. Microcephaly was defined as a head circumference (HC) < 2 standard deviations (SD) for sex and gestational age. Severe microcephaly was defined as HC < 3 SD for sex and age. We tested sera for anti-ZIKV IgM antibodies using capture enzyme-linked immunosorbent assay (ELISA) and confirmed positives using the plaque reduction neutralization test (PRNT90) for ZIKV and for dengue (DENV) on the samples that were ZIKV neutralizing antibody positive. We collected blood and urine from participants reporting fever or rash for ZIKV testing. RESULTS Of 2889 pregnant women screened for eligibility, 2312 (80%) were enrolled. Of 1916 recorded deliveries, 1816 (94.6%) were live births and 100 (5.2%) were either stillbirths or spontaneous abortions (< 22 weeks of gestation). Among 1236 newborns with complete anthropometric measures, 11 (0.9%) had microcephaly and 3 (0.2%) had severe microcephaly. A total of 166 (7.2%) participants were positive for anti-ZIKV IgM, 136 of whom became seropositive during follow-up. Among the 166 anti-ZIKV IgM positive, 3 and 18 participants were further seropositive for ZIKV and DENV neutralizing antibodies, respectively. Of these 3 and 18 pregnant women, one and 13 (72.2%) seroconverted with antibodies to ZIKV and DENV, respectively. All 308 samples (serum and urine samples collected during sick visits and samples that were anti-ZIKV IgM positive) tested by RT-PCR were negative for ZIKV. No adverse pregnancy or neonatal outcomes were reported among the three participants with confirmed ZIKV exposure. Among newborns from pregnant women with DENV exposure, four (22.2%) were small for gestational age and one (5.6%) had microcephaly. CONCLUSIONS The prevalence of severe microcephaly among newborns in coastal Kenya was high relative to published estimates from facility-based studies in Europe and Latin America, but little evidence of ZIKV transmission. There is a need for improved surveillance for microcephaly and other congenital malformations in Kenya.
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Affiliation(s)
- Eric Osoro
- Washington State University Global Health Kenya, One Padmore Place, George Padmore Road, Off Ngong Road, Nairobi, Kenya. .,Paul G. Allen School of Global Health, Washington State University, Pullman, USA.
| | - Irene Inwani
- Department of Pediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Cyrus Mugo
- Department of Pediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Elizabeth Hunsperger
- Division of Global Health Protection, Centers for Disease Control and Prevention, CDC Kenya, Nairobi, Kenya
| | - Jennifer R Verani
- Division of Global Health Protection, Centers for Disease Control and Prevention, CDC Kenya, Nairobi, Kenya
| | - Victor Omballa
- Center for Global Health Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Chulwoo Rhee
- Division of Global Health Protection, CentersforDiseaseControlandPrevention, Atlanta, USA
| | - Ruth Nduati
- Department of Pediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - John Kinuthia
- Research and Programs Department, Kenyatta National Hospital/University of Nairobi, Nairobi, Kenya
| | - Hafsa Jin
- Coast General Hospital, Mombasa, Kenya
| | - Lydia Okutoyi
- Department of Obstetrics and Gynecology/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Dufton Mwaengo
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - Brian Maugo
- Department of Pediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Nancy A Otieno
- Center for Global Health Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Harriet Mirieri
- Washington State University Global Health Kenya, One Padmore Place, George Padmore Road, Off Ngong Road, Nairobi, Kenya
| | | | - Peninah Munyua
- Division of Global Health Protection, Centers for Disease Control and Prevention, CDC Kenya, Nairobi, Kenya
| | - M Kariuki Njenga
- Washington State University Global Health Kenya, One Padmore Place, George Padmore Road, Off Ngong Road, Nairobi, Kenya.,Paul G. Allen School of Global Health, Washington State University, Pullman, USA
| | - Marc-Alain Widdowson
- Division of Global Health Protection, Centers for Disease Control and Prevention, CDC Kenya, Nairobi, Kenya.,Institute of Tropical Medicine, Antwerp, Belgium
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26
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Mugo C, Nduati R, Osoro E, Nyawanda BO, Mirieri H, Hunsperger E, Verani JR, Jin H, Mwaengo D, Maugo B, Machoki J, Otieno NA, Ombok C, Shabibi M, Okutoyi L, Kinuthia J, Widdowson MA, Njenga K, Inwani I, Wamalwa D. Comparable Pregnancy Outcomes for HIV-Uninfected and HIV-Infected Women on Antiretroviral Treatment in Kenya. J Infect Dis 2022; 226:678-686. [PMID: 35403695 PMCID: PMC10155227 DOI: 10.1093/infdis/jiac128] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 10/28/2021] [Accepted: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The impact of human immunodeficiency virus (HIV) on pregnancy outcomes for women on antiretroviral therapy (ART) in sub-Saharan Africa remains unclear. METHODS Pregnant women in Kenya were enrolled in the second trimester and followed up to delivery. We estimated effects of treated HIV with 3 pregnancy outcomes: loss, premature birth, and low birth weight and factors associated with HIV-positive status. RESULTS Of 2113 participants, 311 (15%) were HIV infected and on ART. Ninety-one of 1762 (5%) experienced a pregnancy loss, 169/1725 (10%) a premature birth (<37 weeks), and 74/1317 (6%) had a low-birth-weight newborn (<2500 g). There was no evidence of associations between treated HIV infection and pregnancy loss (adjusted relative risk [aRR], 1.19; 95% confidence interval [CI], .65-2.16; P = .57), prematurity (aRR, 1.09; 95% CI, .70-1.70; P = .69), and low birth weight (aRR, 1.36; 95% CI, .77-2.40; P = .27). Factors associated with an HIV-positive status included older age, food insecurity, lower education level, higher parity, lower gestation at first antenatal clinic, anemia, and syphilis. Women who were overweight or underweight were less likely to be HIV infected compared to those with normal weight. CONCLUSIONS Currently treated HIV was not significantly associated with adverse pregnancy outcomes. HIV-infected women, however, had a higher prevalence of other factors associated with adverse pregnancy outcomes.
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Affiliation(s)
- Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Ruth Nduati
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Eric Osoro
- Washington State University Global Health Kenya, Nairobi, Kenya
- Paul G. Allen School of Global Health, Washington State University, Pullman, USA
| | | | - Harriet Mirieri
- Washington State University Global Health Kenya, Nairobi, Kenya
| | | | - Jennifer R Verani
- CDC-Kenya, Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Hafsa Jin
- Coast Referral and Teaching Hospital, Mombasa, Kenya
| | - Dufton Mwaengo
- University of Nairobi Institute of Tropical and Infectious Diseases, Nairobi, Kenya
| | - Brian Maugo
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - James Machoki
- University of Nairobi Institute of Tropical and Infectious Diseases, Nairobi, Kenya
| | | | - Cynthia Ombok
- Washington State University Global Health Kenya, Nairobi, Kenya
| | | | - Lydia Okutoyi
- Department of Health Care Quality, Kenyatta National Hospital, Nairobi, Kenya
| | - John Kinuthia
- Research and Programs Department, Kenyatta National Hospital, Nairobi, Kenya
| | - Marc Alain Widdowson
- CDC-Kenya, Centers for Disease Control and Prevention, Nairobi, Kenya
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Kariuki Njenga
- Washington State University Global Health Kenya, Nairobi, Kenya
- Paul G. Allen School of Global Health, Washington State University, Pullman, USA
| | - Irene Inwani
- Department of Pediatrics, Kenyatta National Hospital, Nairobi, Kenya
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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27
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Shulock K, Beima-Sofie K, Apriyanto H, Njuguna I, Mburu C, Mugo C, Itindi J, Onyango A, Wamalwa D, John-Stewart G, O'Malley G. "It's about making adolescents in charge of their health": policy-makers' perspectives on optimizing the health care transition among adolescents living with HIV in Kenya. AIDS Care 2022; 34:1127-1134. [PMID: 34482776 DOI: 10.1080/09540121.2021.1971606] [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] [Indexed: 01/26/2023]
Abstract
ABSTRACTThe health care transition (HCT) from pediatric to adult care is a potential contributor to poor clinical outcomes among adolescents living with HIV (ALHIV). In sub-Saharan Africa (SSA), there is limited information on effective tools and processes to prepare and support ALHIV through this transition. This study elicited perspectives of policy-makers regarding barriers and facilitators to successful HCT among ALHIV in Kenya. Twenty in-depth interviews (IDIs) were conducted with policy-makers using a semi-structured guide. Using the socio-ecological model (SEM) as an organizing framework, directed content and thematic network analyses methods were used to characterize themes related to key influences on HCT processes and to describe actionable recommendations for improved tools and resources. Policy-makers identified multilevel support, including the development of a triadic relationship between the caregiver, healthcare worker (HCW) and adolescent, as an essential strategy for improved HCT success. Across the SEM, policy-makers described the importance of actively engaging adolescents in their care to promote increased ownership and autonomy over health decisions. At the structural level, the need for more comprehensive HCT guidelines and improved HCW training was highlighted. Expanded HCT tools and guidelines, that emphasize supportive relationships and intensified adolescent engagement, may improve HCT processes and outcomes.
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Affiliation(s)
- Katherine Shulock
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Haris Apriyanto
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Irene Njuguna
- Department of Global Health, University of Washington, Seattle, WA, USA
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
| | - Caren Mburu
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Cyrus Mugo
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | | | - Alvin Onyango
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA
- 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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28
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Kumar M, Atwoli L, Burgess RA, Gaddour N, Huang KY, Kola L, Mendenhall E, Mugo C, Mutamba BB, Nakasujja N, Njuguna I, Obasi A, Petersen I, Shidhaye R. What should equity in global health research look like? Lancet 2022; 400:145-147. [PMID: 35597247 DOI: 10.1016/s0140-6736(22)00888-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/10/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Manasi Kumar
- Brain and Mind Institute, Aga Khan University, Nairobi 00100, Kenya.
| | - Lukoye Atwoli
- Brain and Mind Institute, Aga Khan University, Nairobi 00100, Kenya; School of Medicine, Aga Khan University, Nairobi 00100, Kenya
| | | | - Naoufel Gaddour
- Department of Psychiatry, University of Monastir, Monastir, Tunisia
| | - Keng Yen Huang
- Department of Population Health, NYU Grossman School of Medicine, New York University, New York, NY, USA
| | - Lola Kola
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Emily Mendenhall
- Edmund A Walsh School of Foreign Service, Georgetown University, Washington DC, USA
| | - Cyrus Mugo
- Research Department, Kenyatta National Hospital, Nairobi, Kenya
| | | | | | - Irene Njuguna
- Research Department, Kenyatta National Hospital, Nairobi, Kenya
| | - Angela Obasi
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Inge Petersen
- Center for Rural Health, College of Health Sciences, University of KwaZulu Natal, Durban, South Africa
| | - Rahul Shidhaye
- Department of Psychiatry, Pravara Institute of Medical Sciences, Loni, Ahmednagar, Maharashtra, India
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29
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Neary J, Mugo C, Wagner A, Ogweno V, Otieno V, Otieno A, Richardson BA, Maleche-Obimbo E, Wamalwa D, John-Stewart G, Slyker J, Njuguna I. Caregiver fears and assumptions about child HIV status drive not testing children for HIV. AIDS 2022; 36:1323-1325. [PMID: 35833687 PMCID: PMC9298673 DOI: 10.1097/qad.0000000000003266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Jillian Neary
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Cyrus Mugo
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Anjuli Wagner
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Vincent Ogweno
- Kenya Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Verlinda Otieno
- Kenya Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Anita Otieno
- Kenya Pediatric Research Consortium, Kenya Pediatric Association, Nairobi, Kenya
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Departments of Pediatrics and Medicine, University of Washington, Seattle, WA, USA
| | - Jennifer Slyker
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Irene Njuguna
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, USA
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30
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Wang J, Mugo C, Omondi VO, Njuguna IN, Maleche-Obimbo E, Inwani I, Hughes JP, Slyker JA, John-Stewart G, Wamalwa D, Wagner AD. Home-based HIV Testing for Children: A Useful Complement for Caregivers with More Children, Who are Male, and with an HIV Negative Partner. AIDS Behav 2022; 26:3045-3055. [PMID: 35306611 DOI: 10.1007/s10461-022-03643-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 11/01/2022]
Abstract
Expanding index and family-based testing (HBT) is a priority for identifying children living with HIV. Our study characterizes predictors that drive testing location choice for children of parents living with HIV. Kenyan adults living with HIV were offered a choice of HBT or clinic-based testing (CBT) for any of their children (0-12 years) of unknown HIV status. Multilevel generalized linear models were used to identify correlates of choosing HBT or CBT for children and testing all versus some children within a family, including caregiver demographics, HIV history, social support, cost, and child demographics and HIV prevention history. Among 244 caregivers living with HIV and their children of unknown HIV status, most (72%) caregivers tested children using CBT. In multivariate analysis, female caregivers [aRR 0.52 (95% CI 0.34-0.80)] were less likely to choose HBT than male caregivers. Caregivers with more children requiring testing [aRR 1.23 (95% CI 1.05-1.44)] were more likely to choose HBT than those with fewer children requiring testing. In subgroup univariate analysis, female caregivers with a known HIV negative spouse were significantly more likely to choose HBT over CBT than those with a known HIV positive spouse [RR 2.57 (95% CI 1.28-5.14), p = 0.008], no association was found for male caregivers. Child demographics and clinical history was not associated with study outcomes. Caregiver-specific factors were more influential than child-specific factors in caregiver choice of pediatric HIV testing location. Home-based testing may be preferable to families with higher child care needs and may encourage pediatric HIV testing if offered as an alternative to clinic testing.
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31
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Wilson KS, Mugo C, Katz DA, Manyeki V, Mungwala C, Otiso L, Bukusi D, McClelland RS, Simoni JM, Driver M, Masyuko S, Inwani I, Kohler PK. High Acceptance and Completion of HIV Self-testing Among Diverse Populations of Young People in Kenya Using a Community-Based Distribution Strategy. AIDS Behav 2022; 26:964-974. [PMID: 34468968 PMCID: PMC8409270 DOI: 10.1007/s10461-021-03451-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 02/01/2023]
Abstract
Oral HIV self-testing (HIVST) may expand access to testing among hard-to-reach reach adolescents and young adults (AYA). We evaluated community-based HIVST services for AYA in an urban settlement in Kenya. Peer-mobilizers recruited AYA ages 15-24 through homes, bars/clubs, and pharmacies. Participants were offered oral HIVST, optional assistance and post-test counseling. Outcomes were HIVST acceptance and completion (self-report and returned kits). Surveys were given at enrollment, post-testing, and 4 months. Log-binomial regression evaluated HIVST preferences by venue. Among 315 reached, 87% enrolled. HIVST acceptance was higher in bars/clubs (94%) than homes (86%) or pharmacies (75%). HIVST completion was 97%, with one confirmed positive result. Participants wanted future HIVST at multiple locations, include PrEP, and cost ≤ $5USD. Participants from bars/clubs and pharmacies were more likely to prefer unassisted testing and peer-distributers compared to participants from homes. This differentiated community-based HIVST strategy could facilitate engagement in HIV testing and prevention among AYA.
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Affiliation(s)
- Kate S Wilson
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA.
| | - Cyrus Mugo
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - David A Katz
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA
| | - Vivianne Manyeki
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Carol Mungwala
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | | | | | - R Scott McClelland
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Jane M Simoni
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA
- Department of Psychology, University of Washington, Seattle, USA
| | - Matt Driver
- Department of Cardiology, Cedar Sinai Medical Center, Los Angeles, USA
| | - Sarah Masyuko
- National AIDS and STI Control Program (NASCOP), Nairobi, Kenya
| | - Irene Inwani
- University of Nairobi/Kenyatta National Hospital, Nairobi, Kenya
| | - Pamela K Kohler
- Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA
- Department of Child, Family, and Population Health, Nursing, University of Washington, Seattle, USA
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32
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Kharono B, Kaggiah A, Mugo C, Seeh D, Guthrie BL, Moreno M, John-Stewart G, Inwani I, Ronen K. Mobile technology access and use among youth in Nairobi, Kenya: implications for mobile health intervention design. Mhealth 2022; 8:7. [PMID: 35178438 PMCID: PMC8800198 DOI: 10.21037/mhealth-21-23] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 06/12/2021] [Accepted: 10/20/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Social media can be used to support the health of underserved youth beyond clinical settings. Young people are avid users of social media, but estimates of smartphone access among youth in sub-Saharan Africa are lacking, making it difficult to determine context-appropriateness of online and social media interventions. METHODS We conducted a cross-sectional observational survey assessing technology access and use among youth aged 14-24 receiving general outpatient or human immunodeficiency virus (HIV) care in three hospitals in Nairobi, Kenya. Correlates of smartphone access and social media use were evaluated by Poisson regression. RESULTS Of 600 youth, 301 were receiving general outpatient care and 299 HIV care. Median age was 18 years. Overall, 416 (69%) had access to a mobile phone and 288 (48%) to a smartphone. Of those with smartphones, 260 (90%) used social media. Smartphone access varied by facility (40% at the sub-county hospital vs. 55% at the national referral hospital, P=0.004) and was associated with older age [65% in 20-24-year-old vs. 37% in 14-19-year-old, adjusted prevalence ratio (aPR) 1.58, 95% CI: 1.30-1.92], secondary vs. primary education (aPR 2.59, 95% CI: 1.76-3.81), and HIV vs. general outpatient care (aPR 1.18, 95% CI: 1.01-1.38). Social media use was similarly associated with facility, older age, higher education, and male gender. CONCLUSIONS These data suggest that smartphone-based and social media interventions are accessible in Nairobi, Kenya, in the general population and youth living with HIV, and most appropriate for older youth. Intervention developers and policymakers should consider smartphone and social media interventions as candidates for youth health programs, while noting that heterogeneity of access between and within communities requires tailoring to the specific intervention context to avoid excluding the most vulnerable youth.
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Affiliation(s)
- Brenda Kharono
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Anne Kaggiah
- Department of Paediatrics and Child Health, Kenyatta National Hospital, Nairobi, Kenya
| | - Cyrus Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Paediatrics and Child Health, Kenyatta National Hospital, Nairobi, Kenya
| | - David Seeh
- Department of Paediatrics and Child Health, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Megan Moreno
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI, USA
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA
- Departments of Epidemiology, Medicine, Pediatrics, University of Washington, Seattle, WA, USA
| | - Irene Inwani
- Department of Paediatrics and Child Health, Kenyatta National Hospital, Nairobi, Kenya
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, WA, USA
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Wilson K, Onyango A, Mugo C, Guthrie B, Slyker J, Richardson B, John-Stewart G, Inwani I, Bukusi D, Wamalwa D, Kohler P. Kenyan HIV Clinics With Youth-Friendly Services and Trained Providers Have a Higher Prevalence of Viral Suppression Among Adolescents and Young Adults: Results From an Observational Study. J Assoc Nurses AIDS Care 2022; 33:45-53. [PMID: 34939987 PMCID: PMC10329499 DOI: 10.1097/jnc.0000000000000302] [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: 09/18/2020] [Indexed: 11/25/2022]
Abstract
ABSTRACT Sustained viral suppression in adolescents and young adults living with HIV (AYALWH) is necessary for epidemic control. We evaluated facility and individual correlates of viral suppression using programmatic data from AYALWH between ages 10 and 24 years at 24 HIV clinics in Kenya. Binomial regression was used to evaluate correlates of viral load (VL) suppression (<1,000 copies/ml). Of 5,316 AYALWH on antiretroviral therapy ≥6 months, 2,081 (39%) had VLs available in the medical record, of which 76% were virally suppressed. In multivariable analyses, antiretroviral therapy initiation among AYALWH older than 10 years was associated with higher viral suppression than initiation younger than 10 years (adjusted risk ratio [aRR] 10-14 = 1.03, 95% confidence interval [CI] 0.97-1.10; aRR 15-19 = 1.30, 95% CI 1.19-1.41; aRR 20-24 = 1.43, 95% CI 1.24-1.63). Facilities with both youth-friendly services (YFS) and trained providers had significantly higher VL suppression compared with facilities without YFS or trained providers (adjusted odds ratio: 2.07, 95% CI: 1.71-2.52). Viral suppression remains suboptimal among AYALWH. YFS and trained providers plus greater use of VL data may help increase viral suppression among AYALWH.
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Affiliation(s)
- Kate Wilson
- Kate Wilson, PhD, MPH, is a Clinical Assistant Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Alvin Onyango, BSN, is a Study Coordinator, Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Cyrus Mugo, MBChB, MPH, is a Doctoral Student, Department of Global Health, University of Washington, Seattle, Washington, USA
- Brandon Guthrie, PhD, MPH, is an Assistant Professor, Departments of Global Health and Epidemiology, University of Washington, Seattle, Washington, USA
- Jennifer Slyker, PhD, is an Associate Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Barbra Richardson, PhD, is a Research Professor, Departments of Biostatistics and Global Health, University of Washington, Seattle, Washington, USA
- Grace John-Stewart, PhD, MD, is a Professor, Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
- Irene Inwani, MBChB, MPH, is an Assistant Director, Kenyatta National Hospital, Nairobi, Kenya
- David Bukusi, MBChB, MMED, is the Director of the VCT and HIV Prevention Unit, Kenyatta National Hospital, Nairobi, Kenya
- Dalton Wamalwa, MBChB, MPH, is an Associate Professor in the Department of Paediatrics, University of Nairobi, Nairobi, Kenya
- Pamela Kohler, PhD, MPH, RN, is an Associate Professor, Department of Global Health, and the Department of Child, Family, and Population Health, School of Nursing, University of Washington, Seattle, Washington, USA
| | - Alvin Onyango
- Kate Wilson, PhD, MPH, is a Clinical Assistant Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Alvin Onyango, BSN, is a Study Coordinator, Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Cyrus Mugo, MBChB, MPH, is a Doctoral Student, Department of Global Health, University of Washington, Seattle, Washington, USA
- Brandon Guthrie, PhD, MPH, is an Assistant Professor, Departments of Global Health and Epidemiology, University of Washington, Seattle, Washington, USA
- Jennifer Slyker, PhD, is an Associate Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Barbra Richardson, PhD, is a Research Professor, Departments of Biostatistics and Global Health, University of Washington, Seattle, Washington, USA
- Grace John-Stewart, PhD, MD, is a Professor, Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
- Irene Inwani, MBChB, MPH, is an Assistant Director, Kenyatta National Hospital, Nairobi, Kenya
- David Bukusi, MBChB, MMED, is the Director of the VCT and HIV Prevention Unit, Kenyatta National Hospital, Nairobi, Kenya
- Dalton Wamalwa, MBChB, MPH, is an Associate Professor in the Department of Paediatrics, University of Nairobi, Nairobi, Kenya
- Pamela Kohler, PhD, MPH, RN, is an Associate Professor, Department of Global Health, and the Department of Child, Family, and Population Health, School of Nursing, University of Washington, Seattle, Washington, USA
| | - Cyrus Mugo
- Kate Wilson, PhD, MPH, is a Clinical Assistant Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Alvin Onyango, BSN, is a Study Coordinator, Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Cyrus Mugo, MBChB, MPH, is a Doctoral Student, Department of Global Health, University of Washington, Seattle, Washington, USA
- Brandon Guthrie, PhD, MPH, is an Assistant Professor, Departments of Global Health and Epidemiology, University of Washington, Seattle, Washington, USA
- Jennifer Slyker, PhD, is an Associate Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Barbra Richardson, PhD, is a Research Professor, Departments of Biostatistics and Global Health, University of Washington, Seattle, Washington, USA
- Grace John-Stewart, PhD, MD, is a Professor, Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
- Irene Inwani, MBChB, MPH, is an Assistant Director, Kenyatta National Hospital, Nairobi, Kenya
- David Bukusi, MBChB, MMED, is the Director of the VCT and HIV Prevention Unit, Kenyatta National Hospital, Nairobi, Kenya
- Dalton Wamalwa, MBChB, MPH, is an Associate Professor in the Department of Paediatrics, University of Nairobi, Nairobi, Kenya
- Pamela Kohler, PhD, MPH, RN, is an Associate Professor, Department of Global Health, and the Department of Child, Family, and Population Health, School of Nursing, University of Washington, Seattle, Washington, USA
| | - Brandon Guthrie
- Kate Wilson, PhD, MPH, is a Clinical Assistant Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Alvin Onyango, BSN, is a Study Coordinator, Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Cyrus Mugo, MBChB, MPH, is a Doctoral Student, Department of Global Health, University of Washington, Seattle, Washington, USA
- Brandon Guthrie, PhD, MPH, is an Assistant Professor, Departments of Global Health and Epidemiology, University of Washington, Seattle, Washington, USA
- Jennifer Slyker, PhD, is an Associate Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Barbra Richardson, PhD, is a Research Professor, Departments of Biostatistics and Global Health, University of Washington, Seattle, Washington, USA
- Grace John-Stewart, PhD, MD, is a Professor, Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
- Irene Inwani, MBChB, MPH, is an Assistant Director, Kenyatta National Hospital, Nairobi, Kenya
- David Bukusi, MBChB, MMED, is the Director of the VCT and HIV Prevention Unit, Kenyatta National Hospital, Nairobi, Kenya
- Dalton Wamalwa, MBChB, MPH, is an Associate Professor in the Department of Paediatrics, University of Nairobi, Nairobi, Kenya
- Pamela Kohler, PhD, MPH, RN, is an Associate Professor, Department of Global Health, and the Department of Child, Family, and Population Health, School of Nursing, University of Washington, Seattle, Washington, USA
| | - Jennifer Slyker
- Kate Wilson, PhD, MPH, is a Clinical Assistant Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Alvin Onyango, BSN, is a Study Coordinator, Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Cyrus Mugo, MBChB, MPH, is a Doctoral Student, Department of Global Health, University of Washington, Seattle, Washington, USA
- Brandon Guthrie, PhD, MPH, is an Assistant Professor, Departments of Global Health and Epidemiology, University of Washington, Seattle, Washington, USA
- Jennifer Slyker, PhD, is an Associate Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Barbra Richardson, PhD, is a Research Professor, Departments of Biostatistics and Global Health, University of Washington, Seattle, Washington, USA
- Grace John-Stewart, PhD, MD, is a Professor, Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
- Irene Inwani, MBChB, MPH, is an Assistant Director, Kenyatta National Hospital, Nairobi, Kenya
- David Bukusi, MBChB, MMED, is the Director of the VCT and HIV Prevention Unit, Kenyatta National Hospital, Nairobi, Kenya
- Dalton Wamalwa, MBChB, MPH, is an Associate Professor in the Department of Paediatrics, University of Nairobi, Nairobi, Kenya
- Pamela Kohler, PhD, MPH, RN, is an Associate Professor, Department of Global Health, and the Department of Child, Family, and Population Health, School of Nursing, University of Washington, Seattle, Washington, USA
| | - Barbra Richardson
- Kate Wilson, PhD, MPH, is a Clinical Assistant Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Alvin Onyango, BSN, is a Study Coordinator, Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Cyrus Mugo, MBChB, MPH, is a Doctoral Student, Department of Global Health, University of Washington, Seattle, Washington, USA
- Brandon Guthrie, PhD, MPH, is an Assistant Professor, Departments of Global Health and Epidemiology, University of Washington, Seattle, Washington, USA
- Jennifer Slyker, PhD, is an Associate Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Barbra Richardson, PhD, is a Research Professor, Departments of Biostatistics and Global Health, University of Washington, Seattle, Washington, USA
- Grace John-Stewart, PhD, MD, is a Professor, Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
- Irene Inwani, MBChB, MPH, is an Assistant Director, Kenyatta National Hospital, Nairobi, Kenya
- David Bukusi, MBChB, MMED, is the Director of the VCT and HIV Prevention Unit, Kenyatta National Hospital, Nairobi, Kenya
- Dalton Wamalwa, MBChB, MPH, is an Associate Professor in the Department of Paediatrics, University of Nairobi, Nairobi, Kenya
- Pamela Kohler, PhD, MPH, RN, is an Associate Professor, Department of Global Health, and the Department of Child, Family, and Population Health, School of Nursing, University of Washington, Seattle, Washington, USA
| | - Grace John-Stewart
- Kate Wilson, PhD, MPH, is a Clinical Assistant Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Alvin Onyango, BSN, is a Study Coordinator, Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Cyrus Mugo, MBChB, MPH, is a Doctoral Student, Department of Global Health, University of Washington, Seattle, Washington, USA
- Brandon Guthrie, PhD, MPH, is an Assistant Professor, Departments of Global Health and Epidemiology, University of Washington, Seattle, Washington, USA
- Jennifer Slyker, PhD, is an Associate Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Barbra Richardson, PhD, is a Research Professor, Departments of Biostatistics and Global Health, University of Washington, Seattle, Washington, USA
- Grace John-Stewart, PhD, MD, is a Professor, Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
- Irene Inwani, MBChB, MPH, is an Assistant Director, Kenyatta National Hospital, Nairobi, Kenya
- David Bukusi, MBChB, MMED, is the Director of the VCT and HIV Prevention Unit, Kenyatta National Hospital, Nairobi, Kenya
- Dalton Wamalwa, MBChB, MPH, is an Associate Professor in the Department of Paediatrics, University of Nairobi, Nairobi, Kenya
- Pamela Kohler, PhD, MPH, RN, is an Associate Professor, Department of Global Health, and the Department of Child, Family, and Population Health, School of Nursing, University of Washington, Seattle, Washington, USA
| | - Irene Inwani
- Kate Wilson, PhD, MPH, is a Clinical Assistant Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Alvin Onyango, BSN, is a Study Coordinator, Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Cyrus Mugo, MBChB, MPH, is a Doctoral Student, Department of Global Health, University of Washington, Seattle, Washington, USA
- Brandon Guthrie, PhD, MPH, is an Assistant Professor, Departments of Global Health and Epidemiology, University of Washington, Seattle, Washington, USA
- Jennifer Slyker, PhD, is an Associate Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Barbra Richardson, PhD, is a Research Professor, Departments of Biostatistics and Global Health, University of Washington, Seattle, Washington, USA
- Grace John-Stewart, PhD, MD, is a Professor, Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
- Irene Inwani, MBChB, MPH, is an Assistant Director, Kenyatta National Hospital, Nairobi, Kenya
- David Bukusi, MBChB, MMED, is the Director of the VCT and HIV Prevention Unit, Kenyatta National Hospital, Nairobi, Kenya
- Dalton Wamalwa, MBChB, MPH, is an Associate Professor in the Department of Paediatrics, University of Nairobi, Nairobi, Kenya
- Pamela Kohler, PhD, MPH, RN, is an Associate Professor, Department of Global Health, and the Department of Child, Family, and Population Health, School of Nursing, University of Washington, Seattle, Washington, USA
| | - David Bukusi
- Kate Wilson, PhD, MPH, is a Clinical Assistant Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Alvin Onyango, BSN, is a Study Coordinator, Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Cyrus Mugo, MBChB, MPH, is a Doctoral Student, Department of Global Health, University of Washington, Seattle, Washington, USA
- Brandon Guthrie, PhD, MPH, is an Assistant Professor, Departments of Global Health and Epidemiology, University of Washington, Seattle, Washington, USA
- Jennifer Slyker, PhD, is an Associate Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Barbra Richardson, PhD, is a Research Professor, Departments of Biostatistics and Global Health, University of Washington, Seattle, Washington, USA
- Grace John-Stewart, PhD, MD, is a Professor, Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
- Irene Inwani, MBChB, MPH, is an Assistant Director, Kenyatta National Hospital, Nairobi, Kenya
- David Bukusi, MBChB, MMED, is the Director of the VCT and HIV Prevention Unit, Kenyatta National Hospital, Nairobi, Kenya
- Dalton Wamalwa, MBChB, MPH, is an Associate Professor in the Department of Paediatrics, University of Nairobi, Nairobi, Kenya
- Pamela Kohler, PhD, MPH, RN, is an Associate Professor, Department of Global Health, and the Department of Child, Family, and Population Health, School of Nursing, University of Washington, Seattle, Washington, USA
| | - Dalton Wamalwa
- Kate Wilson, PhD, MPH, is a Clinical Assistant Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Alvin Onyango, BSN, is a Study Coordinator, Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Cyrus Mugo, MBChB, MPH, is a Doctoral Student, Department of Global Health, University of Washington, Seattle, Washington, USA
- Brandon Guthrie, PhD, MPH, is an Assistant Professor, Departments of Global Health and Epidemiology, University of Washington, Seattle, Washington, USA
- Jennifer Slyker, PhD, is an Associate Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Barbra Richardson, PhD, is a Research Professor, Departments of Biostatistics and Global Health, University of Washington, Seattle, Washington, USA
- Grace John-Stewart, PhD, MD, is a Professor, Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
- Irene Inwani, MBChB, MPH, is an Assistant Director, Kenyatta National Hospital, Nairobi, Kenya
- David Bukusi, MBChB, MMED, is the Director of the VCT and HIV Prevention Unit, Kenyatta National Hospital, Nairobi, Kenya
- Dalton Wamalwa, MBChB, MPH, is an Associate Professor in the Department of Paediatrics, University of Nairobi, Nairobi, Kenya
- Pamela Kohler, PhD, MPH, RN, is an Associate Professor, Department of Global Health, and the Department of Child, Family, and Population Health, School of Nursing, University of Washington, Seattle, Washington, USA
| | - Pamela Kohler
- Kate Wilson, PhD, MPH, is a Clinical Assistant Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Alvin Onyango, BSN, is a Study Coordinator, Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Cyrus Mugo, MBChB, MPH, is a Doctoral Student, Department of Global Health, University of Washington, Seattle, Washington, USA
- Brandon Guthrie, PhD, MPH, is an Assistant Professor, Departments of Global Health and Epidemiology, University of Washington, Seattle, Washington, USA
- Jennifer Slyker, PhD, is an Associate Professor, Department of Global Health, University of Washington, Seattle, Washington, USA
- Barbra Richardson, PhD, is a Research Professor, Departments of Biostatistics and Global Health, University of Washington, Seattle, Washington, USA
- Grace John-Stewart, PhD, MD, is a Professor, Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
- Irene Inwani, MBChB, MPH, is an Assistant Director, Kenyatta National Hospital, Nairobi, Kenya
- David Bukusi, MBChB, MMED, is the Director of the VCT and HIV Prevention Unit, Kenyatta National Hospital, Nairobi, Kenya
- Dalton Wamalwa, MBChB, MPH, is an Associate Professor in the Department of Paediatrics, University of Nairobi, Nairobi, Kenya
- Pamela Kohler, PhD, MPH, RN, is an Associate Professor, Department of Global Health, and the Department of Child, Family, and Population Health, School of Nursing, University of Washington, Seattle, Washington, USA
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Kumar M, Osborn TL, Mugo C, Akbarialiabad H, Warfa O, Mbuthia WM, Wambugu C, Ngunu C, Gohar F, Mwaniga S, Njuguna S, Saxena S. A Four-Component Framework Toward Patient-Centered, Integrated Mental Healthcare in Kenya. Front Public Health 2021; 9:756861. [PMID: 34926382 PMCID: PMC8671159 DOI: 10.3389/fpubh.2021.756861] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/11/2021] [Indexed: 11/27/2022] Open
Abstract
Background: How can we fast-track the global agenda of integrated mental healthcare in low- and middle-income countries (LMICs) such as Kenya? This is a question that has become increasingly important for individuals with lived experiences, policymakers, mental health advocates and health care providers at the local and international levels. Discussion: This narrative synthesis and perspective piece encompasses an overview of mental health care competencies, best practices and capacity building needed to fast track patient responsive services. In that vein we also review key policy developments like UHC to make a case for fast-tracking our four-step framework. Results: While there is an increasingly global impetus for integrated mental healthcare, there is a lack of clarity around what patient-responsive mental healthcare services should look like and how to measure and improve provider readiness appropriately. Here, our collaborative team of local and international experts proposes a simple four-step approach to integrating responsive mental healthcare in Kenya. Our recommended framework prioritizes a clear understanding and demonstration of multidimensional skills by the provider. The four steps are (1) provider sensitization, (2) continuous supervision, (3) continuous professional training, and (4) leadership empowerment. Conclusion: Our proposed framework can provide pointers to embracing patient-centered and provider empowerment focused quality of care improvements. Though elements of our proposed framework are well-known, it has not been sufficiently intertwined and therefore not been integrated. We think in the current times our integrated framework offers an opportunity to “building back better” mental health for all.
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Affiliation(s)
- Manasi Kumar
- Department of Psychiatry, University of Nairobi, Nairobi, Kenya.,Department of Psychology, University College London, London, United Kingdom
| | - Thomas L Osborn
- Shamiri Institute, Nairobi, Kenya.,Department of Psychology, Harvard University, Cambridge, MA, United States
| | - Cyrus Mugo
- Kenyatta National Hospital, Nairobi, Kenya
| | - Hossein Akbarialiabad
- Research Center for Psychiatry and Behavioral Sciences, Department of Psychiatry, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.,Student Research Committee, Shiraz School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Osman Warfa
- Health Service Coordination, Ministry of Health, Nairobi, Kenya
| | | | | | - Carol Ngunu
- Preventive and Promotive Health, Nairobi Metropolitan Services, Nairobi, Kenya
| | - Fatima Gohar
- United Nations Children's Fund (UNICEF), ESARO, Nairobi, Kenya
| | - Shillah Mwaniga
- Adolescents and Key Populations, Nairobi Metropolitan Services, Nairobi, Kenya
| | - Simon Njuguna
- Mental Health and Substance Use Department, Ministry of Health, Nairobi, Kenya
| | - Shekhar Saxena
- Department of Global Health and Population, Harvard TC Chan School of Public Health, Harvard University, Cambridge, MA, United States
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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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36
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Mugo C, Seeh D, Guthrie B, Moreno M, Kumar M, John-Stewart G, Inwani I, Ronen K. Association of experienced and internalized stigma with self-disclosure of HIV status by youth living with HIV. AIDS Behav 2021; 25:2084-2093. [PMID: 33389374 PMCID: PMC8768004 DOI: 10.1007/s10461-020-03137-0] [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: 12/12/2020] [Indexed: 01/07/2023]
Abstract
We examined patterns of disclosure among youth living with HIV (YLHIV) in Kenya, and the association between self-disclosure and antiretroviral therapy adherence, stigma, depression, resilience, and social support. Of 96 YLHIV, 78% were female, 33% were ages 14-18, and 40% acquired HIV perinatally. Sixty-three (66%) YLHIV had self-disclosed their HIV status; 67% to family and 43% to non-family members. Older YLHIV were 75% more likely to have self-disclosed than those 14-18 years. Of the 68 either married or ever sexually active, 45 (66%) did not disclose to their partners. Those who had self-disclosed were more likely to report internalized stigma (50% vs. 21%, prevalence ratio [PR] 2.3, 1.1-4.6), experienced stigma (26% vs. 3%, PR 11.0, 1.4-86), and elevated depressive symptoms (57% vs. 30%, PR 1.8, 1.0-3.1). The association with stigma was stronger with self-disclosure to family than non-family. Support should be provided to YLHIV during self-disclosure to mitigate psychosocial harms.
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Affiliation(s)
- Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, P.O. Box 20723-00202, Nairobi, Kenya.
- Department of Epidemiology, University of Washington, Seattle, WA, 98104, USA.
| | - David Seeh
- Department of Research and Programs, Kenyatta National Hospital, P.O. Box 20723-00202, Nairobi, Kenya
| | - Brandon Guthrie
- Department of Global Health, University of Washington, Seattle, WA, 98104, USA
- Department of Epidemiology, University of Washington, Seattle, WA, 98104, USA
| | - Megan Moreno
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, 53705, USA
| | - Manasi Kumar
- Department of Psychiatry, University of Nairobi, P.O. Box 19676-00202, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, 98104, USA
- Department of Epidemiology, University of Washington, Seattle, WA, 98104, USA
- Department of Pediatrics, University of Washington, Seattle, WA, 98104, USA
- Department of Medicine, University of Washington, Seattle, WA, 98104, USA
| | - Irene Inwani
- Department of Pediatrics, Kenyatta National Hospital, P.O. Box 20723-00202, Nairobi, Kenya
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, WA, 98104, USA
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Mugo C, Njuguna I, Nduati M, Omondi V, Otieno V, Nyapara F, Mabele E, Moraa H, Sherr K, Inwani I, Maleche-Obimbo E, Wamalwa D, John-Stewart G, Slyker J, Wagner AD. From research to international scale-up: stakeholder engagement essential in successful design, evaluation and implementation of paediatric HIV testing intervention. Health Policy Plan 2021; 35:1180-1187. [PMID: 32944754 DOI: 10.1093/heapol/czaa089] [Citation(s) in RCA: 3] [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] [Accepted: 07/21/2020] [Indexed: 11/13/2022] Open
Abstract
Stakeholder engagement between researchers, policymakers and practitioners is critical for the successful translation of research into policy and practice. The Counseling and Testing for Children at Home (CATCH) study evaluated a paediatric index case testing model, targeting the children of HIV-infected adults in care in Kenya. Researchers collaborated with stakeholders in the planning, execution and evaluation, and dissemination phases of CATCH. They included a community advisory board, the national HIV programme, County health departments, institutional ethics review bodies, a paediatric bioethics group, facility heads and frontline healthcare workers . Stakeholder analysis considered the power and interest of each stakeholder in the study. All stakeholders had some power to influence the success of the project in the different phases. However, support from institutions with higher hierarchical power increased acceptance of the study by stakeholders lower in the hierarchy. During the planning, execution and evaluation, and dissemination phases, the study benefitted from deliberate stakeholder engagement. Through engagement, changes were made in the approach to recruitment to ensure high external validity, placing recruitment optimally within existing clinic flow patterns. Choices in staffing home visits were made to include the appropriate cadre of staff. Adaptations were made to the consenting process that balanced the child's evolving autonomy and risks of HIV disclosure. Dissemination involved delivering site-specific results in each HIV clinic, local and international conferences and sharing of study tools, resulting in the study approach being scaled up nationally. The deliberate engagement of stakeholders early in intervention development optimized study validity and accelerated adoption of the CATCH approach in nationwide HIV testing campaigns by the Ministry of Health and inclusion of paediatric index-case testing in national HIV testing guidelines. Involving policymakers and frontline healthcare workers throughout the study cycle builds capacity in the implementing team for quick adoption and scale-up of the evidence-based practice.
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Affiliation(s)
- Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, PO Box 20723, 00102, Hospital road, Upperhill, Nairobi, Kenya
| | - Irene Njuguna
- Department of Research and Programs, Kenyatta National Hospital, PO Box 20723, 00102, Hospital road, Upperhill, Nairobi, Kenya
| | - Margaret Nduati
- Department of Pediatrics and Child Health, University of Nairobi, PO Box 19676, 00202, Ngong road, Upperhill, Nairobi, Kenya
| | - Vincent Omondi
- Department of Pediatrics and Child Health, University of Nairobi, PO Box 19676, 00202, Ngong road, Upperhill, Nairobi, Kenya
| | - Verlinda Otieno
- Department of Pediatrics and Child Health, University of Nairobi, PO Box 19676, 00202, Ngong road, Upperhill, Nairobi, Kenya
| | - Florence Nyapara
- Department of Pediatrics and Child Health, University of Nairobi, PO Box 19676, 00202, Ngong road, Upperhill, Nairobi, Kenya
| | - Elizabeth Mabele
- Department of Pediatrics, Kenyatta National Hospital, PO Box 20723, 00102, Hospital road, Upperhill, Nairobi, Kenya
| | - Hellen Moraa
- Department of Pediatrics and Child Health, University of Nairobi, PO Box 19676, 00202, Ngong road, Upperhill, Nairobi, Kenya
| | - Kenneth Sherr
- Department of Global Health, University of Washington, PO Box 357965, 1510 San Juan road NE, Seattle, Washington, 98195-7965, USA
| | - Irene Inwani
- Department of Pediatrics, Kenyatta National Hospital, PO Box 20723, 00102, Hospital road, Upperhill, Nairobi, Kenya
| | - Elizabeth Maleche-Obimbo
- Department of Pediatrics and Child Health, University of Nairobi, PO Box 19676, 00202, Ngong road, Upperhill, Nairobi, Kenya
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, PO Box 19676, 00202, Ngong road, Upperhill, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Global Health, University of Washington, PO Box 357965, 1510 San Juan road NE, Seattle, Washington, 98195-7965, USA.,Department of Epidemiology, University of Washington, PO Box 357236, 610 Walnut Street NE, Seattle, Washington, 98195, USA.,Department of Pediatrics, University of Washington, PO Box 356420, 6200 NE 74th St, Seattle, Washington, 98115-8160, USA.,Department of Medicine, University of Washington, PO Box 356420, 1959 NE Pacific St, Seattle, Washington, 98195-6420, USA
| | - Jennifer Slyker
- Department of Global Health, University of Washington, PO Box 357965, 1510 San Juan road NE, Seattle, Washington, 98195-7965, USA.,Department of Epidemiology, University of Washington, PO Box 357236, 610 Walnut Street NE, Seattle, Washington, 98195, USA
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, PO Box 357965, 1510 San Juan road NE, Seattle, Washington, 98195-7965, USA
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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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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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Njuguna IN, Beima-Sofie K, Mburu CW, Mugo C, Neary J, Itindi J, Onyango A, Richardson BA, Rubin Means A, Sharma M, Weiner BJ, Wagner AD, Oyiengo L, Wamalwa D, John-Stewart G. Adolescent transition to adult care for HIV-infected adolescents in Kenya (ATTACH): study protocol for a hybrid effectiveness-implementation cluster randomised trial. BMJ Open 2020; 10:e039972. [PMID: 33268417 PMCID: PMC7713196 DOI: 10.1136/bmjopen-2020-039972] [Citation(s) in RCA: 9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/20/2020] [Accepted: 11/02/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Successfully transitioning adolescents to adult HIV care is critical for optimising outcomes. Disclosure of HIV status, a prerequisite to transition, remains suboptimal in sub-Saharan Africa. Few interventions have addressed both disclosure and transition. An adolescent transition package (ATP) that combines disclosure and transition tools could support transition and improve outcomes. METHODS AND ANALYSIS In this hybrid type 1 effectiveness-implementation cluster randomised controlled trial, 10 HIV clinics with an estimated ≥100 adolescents and young adults age 10-24 living with HIV (ALWHIV) in Kenya will be randomised to implement the ATP and compared with 10 clinics receiving standard of care. The ATP includes provider tools to assist disclosure and transition. Healthcare providers at intervention clinics will receive training on ATP use and support to adapt it through continuous quality improvement cycles over the initial 6 months of the study, with continued implementation for 1 year. The primary outcome is transition readiness among ALWHIV ages 15-24 years, assessed 6 monthly using a 22-item readiness score. Secondary outcomes including retention and viral suppression among ALWHIV at the end of the intervention period (month 18), implementation outcomes (acceptability, feasibility, fidelity, coverage and penetration) and programme costs complement effectiveness outcomes. The primary analysis will be intent to treat, using mixed-effects linear regression models to compare transition readiness scores (overall and by domain (HIV literacy, self-management, communication, support)) over time in control and intervention sites with adjustment for multiple testing, accounting for clustering by clinic and repeated assessments. We will estimate the coefficients and 95% CIs with a two- sided α=0.05. ETHICS AND DISSEMINATION The study was approved by the University of Washington Institutional Review Board and the Kenyatta National Hospital Ethics and Research Committee. Study results will be shared with participating facilities, county and national policy-makers. TRIALS REGISTRATION NUMBER NCT03574129; Pre-results.
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Affiliation(s)
- Irene N Njuguna
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Global Health, University of Washington, Seattle, Washington, USA
| | | | - Caren W Mburu
- Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Cyrus Mugo
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Epidemiology, University of Washington, Seattle, Washington, United States
| | - Jillian Neary
- Global Health, University of Washington, Seattle, Washington, USA
| | - Janet Itindi
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Barbra A Richardson
- Global Health, University of Washington, Seattle, Washington, USA
- Biostatistics, University of Washington, Seattle, Washington, United States
| | | | - Monisha Sharma
- Global Health, University of Washington, Seattle, Washington, USA
| | - Bryan J Weiner
- Global Health, University of Washington, Seattle, Washington, USA
- Department of Health Services, University of Washington, Seattle, Washington, USA
| | - Anjuli D Wagner
- Global Health, University of Washington, Seattle, Washington, USA
| | - Laura Oyiengo
- Neonatal and Child Health Services, Ministry of Health, Nairobi, Kenya
| | - Dalton Wamalwa
- Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace John-Stewart
- Global Health, University of Washington, Seattle, Washington, USA
- Epidemiology, University of Washington, Seattle, Washington, United States
- Pediatrics, University of Washington, Seattle, Washington, United States
- Medicine, University of Washington, Seattle, Washington, United States
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Culhane J, Sharma M, Wilson K, Roberts D, Mugo C, Wamalwa D, Inwani I, Barnabas RV, Kohler PK. Modeling the health impact and cost threshold of long-acting ART for adolescents and young adults in Kenya. EClinicalMedicine 2020; 25:100453. [PMID: 32954235 PMCID: PMC7486332 DOI: 10.1016/j.eclinm.2020.100453] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 06/17/2020] [Accepted: 06/24/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Despite high efficacy of oral antiretroviral therapy (ART), viral suppression among adolescents and young adults (AYA) living with HIV in sub-Saharan Africa (SSA) remains low. Compared to daily oral ART, bimonthly long-acting injectable ART (LA-ART) may simplify adherence, improve clinical outcomes, and decrease HIV transmission in this priority population. However, LA-ART will likely cost more than oral ART and the cost threshold at which LA-ART will be cost effective in SSA has not been evaluated. METHODS We adapted a mathematical model of HIV transmission and progression in Kenya to include HIV acquisition and viral suppression among AYA (age 10-24). We projected the population-level health and economic impact of providing LA-ART to AYA over a 10-year time horizon assuming oral ART costs of US$233 annually and a two-month duration of viral suppression per LA-ART injection. We calculated the maximum cost at which switching from oral to LA-ART would be considered cost-effective, using thresholds of $500 and $1,508 per disability-adjusted life year averted (WHO's threshold of HIV treatment interventions and Kenya's gross domestic product per capita). FINDINGS Assuming 85% of AYA switch from oral to injectable formulations, LA-ART is estimated to prevent 40,540 infections and 20,480 deaths over 10 years. The maximum increase in the annual per-person cost of receiving LA-ART is estimated to be $89 and $236 for LA-ART to be cost-effective under the thresholds of $500 and $1,508 per DALY averted, respectively. The cost threshold was lower when non-adherent oral ART AYA users were assumed to be less likely to switch to LA-ART. INTERPRETATION Providing LA-ART to AYA can be cost-effective in Kenya if it is less than twice the cost of oral ART. Long-acting injectable ART for priority populations with low viral suppression has the potential to cost-effectively avert disability and death. FUNDING National Institutes of Health (R01 HD085807; PI: Kohler).
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Affiliation(s)
- Jessica Culhane
- Department of Epidemiology,University of Washington, 1959 NE Pacific Street, Health Sciences Bldg, Box 357236, Seattle, WA, United States
| | - Monisha Sharma
- Department of Epidemiology,University of Washington, 1959 NE Pacific Street, Health Sciences Bldg, Box 357236, Seattle, WA, United States
| | - Kate Wilson
- Department of Epidemiology,University of Washington, 1959 NE Pacific Street, Health Sciences Bldg, Box 357236, Seattle, WA, United States
| | - D.Allen Roberts
- Department of Epidemiology,University of Washington, 1959 NE Pacific Street, Health Sciences Bldg, Box 357236, Seattle, WA, United States
| | | | | | | | - Ruanne V. Barnabas
- Department of Epidemiology,University of Washington, 1959 NE Pacific Street, Health Sciences Bldg, Box 357236, Seattle, WA, United States
| | - Pamela K. Kohler
- Department of Epidemiology,University of Washington, 1959 NE Pacific Street, Health Sciences Bldg, Box 357236, Seattle, WA, United States
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Njuguna I, Beima-Sofie K, Mburu C, Black D, Evans Y, Guthrie B, Wagner AD, Mugo C, Neary J, Itindi J, Onyango A, Wamalwa D, John-Stewart G. What happens at adolescent and young adult HIV clinics? A national survey of models of care, transition and disclosure practices in Kenya. Trop Med Int Health 2020; 25:558-565. [PMID: 31984597 DOI: 10.1111/tmi.13374] [Citation(s) in RCA: 8] [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] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Tailored services for adolescents and young adults (AYA) living with HIV may improve treatment outcomes. We surveyed HIV clinics throughout Kenya to determine AYA clinic practices, disclosure and transition services. METHODS We deployed a mobile team to conduct surveys in a random sample of 102 public HIV clinics with> 300 total clients. Data were collected from healthcare workers offering AYA services who had >6 months of experience delivering AYA care. RESULTS Of 102 surveyed HIV clinics, almost all (101/102) had the same staff to provide services to all age groups. AYA-specific services included dedicated clinic days (91%), the majority being on weekends (57%) and designated clinic spaces (20%). Activities to support AYA retention and adherence were common (support groups [97%] and HIV literacy meetings [93%]). Fewer clinics offered more holistic care, including psychosocial support (16%) and career education (2%), posted additional staff during the AYA day (17%), provided food (17%) or had sporting activities (10%) as incentives. Tracking of disclosure of HIV status to AYA was common (87%). In 40% of clinics, disclosure discussions with caregivers or AYA occurred a median of 2 years later in practice than stated in clinic policy. Transition was not routinely tracked, and definitions were heterogeneous. Median age at transition was reported as 20 years (range: 14-30 years). CONCLUSION HIV programmes have implemented varied approaches to enhance AYA services that could be leveraged to support transition to adult services. Research on the impact of these services on health outcomes is needed.
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Affiliation(s)
- Irene Njuguna
- Kenyatta National Hospital, Nairobi, Kenya.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | | | - Caren Mburu
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Danae Black
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | | | - Brandon Guthrie
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Cyrus Mugo
- Kenyatta National Hospital, Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Jillian Neary
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Janet Itindi
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Alvin Onyango
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Global Health, 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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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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Karman E, Wilson KS, Mugo C, Slyker JA, Guthrie BL, Bukusi D, Inwani I, John-Stewart GC, Wamalwa D, Kohler PK. Training Exposure and Self-Rated Competence among HIV Care Providers Working with Adolescents in Kenya. J Int Assoc Provid AIDS Care 2020; 19:2325958220935264. [PMID: 32588709 PMCID: PMC7322818 DOI: 10.1177/2325958220935264] [Citation(s) in RCA: 2] [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: 08/01/2019] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 11/17/2022] Open
Abstract
Lack of health care worker (HCW) training is a barrier to implementing youth-friendly services. We examined training coverage and self-reported competence, defined as knowledge, abilities, and attitudes, of HCWs caring for adolescents living with HIV (ALWH) in Kenya. Surveys were conducted with 24 managers and 142 HCWs. Competence measures were guided by expert input and Kalamazoo II Consensus items. Health care workers had a median of 3 (interquartile range [IQR]: 1-6) years of experience working with ALWH, and 40.1% reported exposure to any ALWH training. Median overall competence was 78.1% (IQR: 68.8-84.4). In multivariable linear regression analyses, more years caring for ALWH and any prior training in adolescent HIV care were associated with significantly higher self-rated competence. Training coverage for adolescent HIV care remains suboptimal. Targeting HCWs with less work experience and training exposure may be a useful and efficient approach to improve quality of youth-friendly HIV services.
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Affiliation(s)
- Elizabeth Karman
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kate S. Wilson
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Cyrus Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Kenya
| | - Jennifer A. Slyker
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Brandon L. Guthrie
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - 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, Kenya
| | - Grace C. John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA
- 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
| | - Dalton Wamalwa
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Kenya
| | - Pamela K. Kohler
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, USA
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Njuguna I, Beima-Sofie K, Mburu C, Mugo C, Black DA, Neary J, Itindi J, Onyango A, Slyker J, Oyiengo L, John-Stewart G, Wamalwa D. Managing the transition from paediatric to adult care for HIV, Kenya. Bull World Health Organ 2019; 97:837-845. [PMID: 31819292 PMCID: PMC6883269 DOI: 10.2471/blt.19.232702] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 03/11/2019] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 01/29/2023] Open
Abstract
Expansion of access to diagnosis and treatment for human immunodeficiency virus (HIV) and a high incidence of HIV infection in adolescence has resulted in a growing population of adolescents and young adults living with HIV. The prevalence of poor retention in care, insufficient viral suppression and loss to follow-up are higher among adolescents and young adults compared with other age groups. Poor outcomes could be attributed to psychosocial changes during adolescence, but also to poor transitional care from paediatric to adult HIV services. In many countries, transition processes remain poorly defined and unstructured, which may jeopardize treatment adherence and retention. We describe existing definitions of transition and transition frameworks, and key elements of transition as proposed by key national stakeholders in Kenya. Our consensus definition of transition is "a planned process by which adolescents and young adults living with HIV, and their caregivers, are empowered with knowledge and skills to enable them to independently manage their health." Transition should begin soon after disclosure of HIV status until an adolescent gains the necessary knowledge and skills and is willing to move to adult services, or by 25 years of age. Proposed key elements of transition are: target ages for milestone achievement; readiness assessment; caregiver involvement and communication with adult clinics; flexibility to return to adolescent or paediatric clinics; group transition; and considerations for adolescents with special needs. Retention in care, linkage to care and viral suppression are important markers of transition success. Proposed definitions and key elements could provide a framework for structuring transition programmes in other countries.
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Affiliation(s)
- Irene Njuguna
- Kenyatta National Hospital, Research and Programs, P.O. Box 20723-00202, Nairobi, Kenya
| | - Kristin Beima-Sofie
- Department of Global Health, University of Washington, Seattle, United States of America (USA)
| | - Caren Mburu
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Cyrus Mugo
- Kenyatta National Hospital, Research and Programs, P.O. Box 20723-00202, Nairobi, Kenya
| | - Danae A Black
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Jillian Neary
- Department of Global Health, University of Washington, Seattle, United States of America (USA)
| | | | - Alvin Onyango
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Jennifer Slyker
- Department of Global Health, University of Washington, Seattle, United States of America (USA)
| | - Laura Oyiengo
- National AIDS and STI Control Program, Ministry of Health, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, United States of America (USA)
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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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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Mugo C, Wilson K, Wagner AD, Inwani IW, Means K, Bukusi D, Slyker J, John-Stewart G, Richardson BA, Nduati M, Moraa H, Wamalwa D, Kohler P. Pilot evaluation of a standardized patient actor training intervention to improve HIV care for adolescents and young adults in Kenya. AIDS Care 2019; 31:1250-1254. [PMID: 30810351 DOI: 10.1080/09540121.2019.1587361] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 10/27/2022]
Abstract
Poor retention in HIV care remains a major problem for Adolescents and Young Adults (AYA). A Standardized Patient (SP) clinical training intervention was developed to improve healthcare worker (HCW) "adolescent-friendly" competencies in Kenya. Professional actors were trained to portray HIV-infected AYA according to standardized scripts. HCWs completed a 2-day SP training that included didactic sessions, 7 video-recorded SP encounters, and group debriefing. AYA health experts rated HCWs by reviewing the video recordings. All HCWs (10/10) reported high satisfaction with the intervention and overall improvement in self-rated competency in caring for HIV-infected AYA. Cases were reported to be realistic and relevant by between 7 and 10 of 10 HCWs. The case on disclosure and adherence was rated as most challenging in communication and making medical decisions by HCWs. Areas identified by SPs for improvement by HCWs included allowing patients time to ask questions, and enabling SP to share sensitive information. The overall ICC by experts was low 0.27 (95% CI: -0.79 to 0.95), however, ICCs in assessment of HIV disclosure 0.78 (95% CI: 0.17-0.98), and sexual behavior 0.97 (95% CI: 0.89-0.99) were high. This intervention was acceptable for Kenyan HCWs and improved self-rated competency in caring for HIV-infected AYA.
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Affiliation(s)
- Cyrus Mugo
- a Department of Research and Programs, Kenyatta National Hospital , Nairobi , Kenya.,b Department of Global Health, University of Washington , Seattle , WA , USA
| | - Kate Wilson
- 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
| | - Irene W Inwani
- c Department of Paediatrics, Kenyatta National Hospital , Nairobi , Kenya
| | - Kevin Means
- d Department of Medicine, University of Washington , Seattle , WA , USA
| | - David Bukusi
- e VCT and HIV Prevention Unit/Youth Centre, Kenyatta National Hospital , Nairobi , Kenya
| | - Jennifer Slyker
- b Department of Global Health, University of Washington , Seattle , WA , USA.,f Department of Epidemiology, University of Washington , Seattle , WA , USA
| | - Grace John-Stewart
- b Department of Global Health, University of Washington , Seattle , WA , USA.,f Department of Epidemiology, University of Washington , Seattle , WA , USA.,g Department of Pediatrics, University of Washington , Seattle , WA , USA
| | - Barbra A Richardson
- b Department of Global Health, University of Washington , Seattle , WA , USA.,h Department of Biostatistics, University of Washington , Seattle , WA , USA
| | - Margaret Nduati
- i Department of Pediatrics and Child Health, University of Nairobi , Nairobi , Kenya
| | - Helen Moraa
- i Department of Pediatrics and Child Health, University of Nairobi , Nairobi , Kenya
| | - Dalton Wamalwa
- i Department of Pediatrics and Child Health, University of Nairobi , Nairobi , Kenya
| | - Pamela Kohler
- b Department of Global Health, University of Washington , Seattle , WA , USA.,j Department of Psychosocial and Community Health, University of Washington , Seattle , WA , 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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