Impact of coronavirus disease 2019-related clinic closures on HIV incidence in young adult MSM and transgender women in Kenya

INTRODUCTION

Little is known about the impact that the COVID-19 pandemic had on risk of HIV acquisition in sub-Saharan Africa. We assessed the impact of COVID-19-related clinic closures on HIV incidence in a cohort of gay, bisexual, and other men who have sex with men (MSM) and transgender women in Kenya.

METHODS

MSM and transgender women enrolled in a prospective, multicentre cohort study were followed quarterly for HIV testing, behaviour assessments, and risk. We estimated the HIV incidence rate and its 95% credible intervals (CrI) among participants who were HIV-negative before COVID-19-related clinic closure, comparing incidence rate and risk factors associated with HIV acquisition before vs. after clinic reopening, using a Bayesian Poisson model with weakly informative priors.

RESULTS

A total of 690 (87%) participants returned for follow-up after clinic reopening (total person-years 664.3 during clinic closure and 1013.3 after clinic reopening). HIV incidence rate declined from 2.05/100 person-years (95% CrI = 1.22-3.26, n  = 14) during clinic closures to 0.96/100 person-years (95% CrI = 0.41-2.07, n  = 10) after clinic reopening (IRR = 0.47, 95% CrI = 0.20-1.01). The proportion of participants reporting hazardous alcohol use and several sexual risk behaviours was higher during clinic closures than after clinic reopening. In multivariable analysis adjusting for study site and participant characteristics, HIV incidence was lower after clinic reopening (IRR 0.57, 95% CrI = 0.23-1.33). Independent risk factors for HIV acquisition included receptive anal intercourse (IRR 1.94, 95% CrI = 0.88-4.80) and perceived risk of HIV (IRR 3.03, 95% CRI = 1.40-6.24).

CONCLUSION

HIV incidence during COVID-19-related clinic closures was moderately increased and reduced after COVID-19 restrictions were eased. Ensuring access to services for key populations is important during public health emergencies.

The Effect of the Shikamana Peer-and-Provider Intervention on Depressive Symptoms, Alcohol Use, and Other Drug Use Among Gay, Bisexual, and Other Men Who Have Sex with Men in Kenya

Kenyan gay, bisexual, and other men who have sex with men (GBMSM) face stigma and discrimination, which may adversely impact mental health and limit antiretroviral therapy (ART) adherence among GBMSM living with HIV. We evaluated whether the Shikamana peer-and-provider intervention, which improved ART adherence among participants in a small randomized trial, was associated with changes in mental health or substance use. The intervention was associated with a significant decrease in PHQ-9 score between baseline and month 6 (estimated change - 2.7, 95% CI - 5.2 to - 0.2, p = 0.037) compared to standard care. In an exploratory analysis, each one-point increment in baseline HIV stigma score was associated with a - 0.7 point (95% CI - 1.3 to - 0.04, p = 0.037) greater decrease in PHQ-9 score over the study period in the intervention group. Additional research is required to understand factors that influence this intervention's effects on mental health outcomes.

Transgender women in Kenya experience greater stigma, depressive symptoms, alcohol and drug use and risky sexual practices than cis-gendered men who have sex with men

BACKGROUND

Worldwide, sexual and gender minority individuals have disproportionate burden of HIV. There are limited quantitative data from sub-Saharan Africa on the intersection of risks experienced by transgender women (TGW) in comparison to cis-men who have sex with men (MSM). This analysis addresses this gap by comparing reported stigma, psychosocial measures of health, and sexual risk practices between TGW and cis-MSM in Kenya.

METHODS

We analyzed data from the baseline visit of an ongoing prospective cohort study taking place in three diverse metropolitan areas. Eligible participants were HIV-negative, assigned male at birth, ages 18-29 years, and reported anal intercourse in the past 3 months with a man or TGW. Data collected by audio computer assisted self-interview included sociodemographic measures, and sexual practices occurring in the past 3 months. Multivariable regressions assessed differences between TGW and cis-MSM in selected sexual practices, depressive symptoms, alcohol and drug use, and stigma.

RESULTS

From September, 2019, through May, 2021, 838 participants were enrolled: 108 (12.9%) TGW and 730 (87.1%) cis-MSM. Adjusting for sociodemographic variables, TGW were more likely than cis-MSM to report: receptive anal intercourse (RAI; adjusted prevalence ratio [aPR] = 1.59, 95% CI: 1.32 - 1.92), engaging in group sex (aPR = 1.15, 95% CI: 1.04 - 1.27), 4 or more male sex partners (aPR = 3.31, 95% CI: 2.52 - 4.35), and 3 or more paying male sex partners (aPR = 1.58, 95% CI: 1.04 - 2.39). TGW were also more likely to report moderate to severe depressive symptoms (aPR = 1.42, 95% CI: 1.01 - 1.55), and had similar alcohol and drug abuse scores as cis-MSM. In sensitivity analysis, similar to TGW, male-identifying individuals taking feminizing gender affirming therapy had an increased likelihood of reporting RAI and group sex, and greater numbers of male sex partners and paying male sex partners relative to cis-MSM.

CONCLUSIONS

Across three metropolitan areas in Kenya, TGW were more likely to report depressive symptoms and increased sexual risk taking. We identified a need for research that better characterizes the range of gender identities. Our analysis affirms the need for programmatic gender-affirming interventions specific to transgender populations in Kenya and elsewhere in Africa.

Role of Human Epicardial Adipose Tissue-Derived miR-92a-3p in Myocardial Redox State

BACKGROUND

Visceral obesity is directly linked to increased cardiovascular risk, including heart failure.

OBJECTIVES

This study explored the ability of human epicardial adipose tissue (EAT)-derived microRNAs (miRNAs) to regulate the myocardial redox state and clinical outcomes.

METHODS

This study screened for miRNAs expressed and released from human EAT and tested for correlations with the redox state in the adjacent myocardium in paired EAT/atrial biopsy specimens from patients undergoing cardiac surgery. Three miRNAs were then tested for causality in an in vitro model of cardiomyocytes. At a clinical level, causality/directionality were tested using genome-wide association screening, and the underlying mechanisms were explored using human biopsy specimens, as well as overexpression of the candidate miRNAs and their targets in vitro and in vivo using a transgenic mouse model. The final prognostic value of the discovered targets was tested in patients undergoing cardiac surgery, followed up for a median of 8 years.

RESULTS

EAT miR-92a-3p was related to lower oxidative stress in human myocardium, a finding confirmed by using genetic regulators of miR-92a-3p in the human heart and EAT. miR-92a-3p reduced nicotinamide adenine dinucleotide phosphate (NADPH)-oxidase-derived superoxide (O2.-) by targeting myocardial expression of WNT5A, which regulated Rac1-dependent activation of NADPH oxidases. Finally, high miR-92a-3p levels in EAT were independently related with lower risk of adverse cardiovascular events.

CONCLUSIONS

EAT-derived miRNAs exert paracrine effects on the human heart. Indeed miR-92a-3p suppresses the wingless-type MMTV integration site family, member 5a/Rac1/NADPH oxidase axis and improves the myocardial redox state. EAT-derived miR-92a-3p is related to improved clinical outcomes and is a rational therapeutic target for the prevention and treatment of obesity-related heart disease.

Stopping and restarting PrEP and loss to follow-up among PrEP-taking men who have sex with men and transgender women at risk of HIV-1 participating in a prospective cohort study in Kenya

OBJECTIVE

To assess frequency and predictors of switching between being on and off PrEP and being lost to follow-up (LTFU) among men who have sex with men (MSM) and transgender women (TGW) with access to PrEP services in Sub-Saharan Africa.

METHODS

This was a prospective cohort study of MSM and TGW from coastal Kenya who initiated daily oral PrEP from June 2017 to June 2019. Participants were followed monthly for HIV-1 testing, PrEP refill, risk assessment and risk reduction counselling. Follow-up was censored at the last visit before 30 June 2019, or the last HIV-1-negative visit (for those with HIV-1 seroconversion), whichever occurred first. We estimated transition intensities (TI) and predictors of switching: (i) between being off and on PrEP; and (ii) from either PrEP state and being LTFU (i.e. not returning to the clinic for > 90 days) using a multi-state Markov model.

RESULTS

In all, 134 participants starting PrEP were followed for a median of 20.3 months [interquartile range (IQR): 7.7-22.1]. A total of 49 (36.6%) people stopped PrEP 73 times [TI = 0.6/person-year (PY), 95% confidence interval (CI): 0.5-0.7] and, of these, 25 (51.0%) restarted PrEP 38 times (TI = 1.2/PY, 95% CI: 0.9-1.7). In multivariable analysis, stopping PrEP was related to anal sex ≤ 3 months, substance-use disorder and travelling. Restarting PrEP was related to non-Christian or non-Muslim religion and travelling. A total of 54 participants were LTFU: on PrEP (n = 47, TI = 0.3/PY, 95% CI: 0.3-0.5) and off PrEP (n = 7, TI = 0.2/PY, 95% CI: 0.1-0.4). In multivariable analysis, becoming LTFU while on PrEP was associated with secondary education or higher, living in the area for ≤ 1 year, residence outside the immediate clinic area and alcohol-use disorder.

CONCLUSIONS

Switching between being on and off PrEP or becoming LTFU while on PrEP was frequent among individuals at risk of HIV-1 acquisition. Alternative PrEP options (e.g. event-driven PrEP) may need to be considered for MSM and TGW with PrEP-taking challenges, while improved engagement with care is needed for all MSM and TGW regardless of PrEP regimen.

Validity and reliability of the Neilands sexual stigma scale among Kenyan gay, bisexual, and other men who have sex with men

Background

We evaluated the validity and reliability of the Neilands sexual stigma scale administered to 871 gay, bisexual, and other men who have sex with men (GBMSM) at two research locations in Kenya.

Methods

Using cross-validation, exploratory factor analysis (EFA) was performed on a randomly selected subset of participants and validated using confirmatory factor analysis (CFA) on the remaining participants. Associations of the initial and final stigma scale factors with depressive symptoms, alcohol use, and other substance use were examined for the entire dataset.

Results

EFA produced a two-factor scale of perceived and enacted stigma. The CFA model fit to the two-factor scale was improved after removing three cross-loaded items and adding correlated errors (chi-squared = 26.5, df 17, p = 0.07). Perceived stigma was associated with depressive symptoms (beta = 0.34, 95% CI 0.24, 0.45), alcohol use (beta = 0.14, 95% CI 0.03, 0.25) and other substance use (beta = 0.19, 95% CI 0.07, 0.31), while enacted stigma was associated with alcohol use (beta = 0.17, 95% CI 0.06, 0.27).

Conclusions

Our findings suggest enacted and perceived sexual stigma are distinct yet closely related constructs among GBMSM in Kenya and are associated with poor mental health and substance use.

Quantifying rates of HIV-1 flow between risk groups and geographic locations in Kenya: A country-wide phylogenetic study

In Kenya, HIV-1 key populations including men having sex with men (MSM), people who inject drugs (PWID) and female sex workers (FSW) are thought to significantly contribute to HIV-1 transmission in the wider, mostly heterosexual (HET) HIV-1 transmission network. However, clear data on HIV-1 transmission dynamics within and between these groups are limited. We aimed to empirically quantify rates of HIV-1 flow between key populations and the HET population, as well as between different geographic regions to determine HIV-1 'hotspots' and their contribution to HIV-1 transmission in Kenya. We used maximum-likelihood phylogenetic and Bayesian inference to analyse 4058 HIV-1 pol sequences (representing 0.3 per cent of the epidemic in Kenya) sampled 1986-2019 from individuals of different risk groups and regions in Kenya. We found 89 per cent within-risk group transmission and 11 per cent mixing between risk groups, cyclic HIV-1 exchange between adjoining geographic provinces and strong evidence of HIV-1 dissemination from (i) West-to-East (i.e. higher-to-lower HIV-1 prevalence regions), and (ii) heterosexual-to-key populations. Low HIV-1 prevalence regions and key populations are sinks rather than major sources of HIV-1 transmission in Kenya. Targeting key populations in Kenya needs to occur concurrently with strengthening interventions in the general epidemic.

Trends and predictors of HIV positivity and time since last test at voluntary counselling and testing encounters among adults in Kilifi, Kenya, 2006-2017

Background: Little is known about HIV retesting uptake among key populations (KP) and general populations (GP) in Kenya. We assessed trends and predictors of first-time testing (FTT), late retesting (previous test more than one year ago for GP or three months for KP), and test positivity at three voluntary counselling and testing (VCT) centres in coastal Kenya. Methods: Routine VCT data covering 2006-2017 was collected from three VCT centres in Kilifi County. We analysed HIV testing history and test results from encounters among adults 18-39 years, categorized as GP men, GP women, men who have sex with men (MSM), and female sex workers (FSW).     Results: Based on 24,728 test encounters (32% FTT), we observed declines in HIV positivity (proportion of encounters where the result was positive) among GP men, GP women, first-time testers and MSM but not among FSW. The proportion of encounters for FTT and late retesting decreased for both GP and KP but remained much higher in KP than GP. HIV positivity was higher at FTT and late retesting encounters; at FSW and MSM encounters; and at encounters with clients reporting lower educational attainment and sexually transmitted infection (STI) symptoms. HIV positivity was lower in GP men, never married clients and those less than 35 years of age. FTT was associated with town, risk group, age 18-24 years, never-married status, low educational attainment, and STI symptoms. Late retesting was less common among encounters with GP individuals who were never married, had Muslim or no religious affiliation, had lower educational attainment, or reported STI symptoms. Conclusions: HIV positive test results were most common at encounters with first-time testers and late re-testers. While the proportion of encounters at which late retesting was reported decreased steadily over the period reviewed, efforts are needed to increase retesting among the most at-risk populations.

Trends and predictors of HIV positivity and time since last test at voluntary counselling and testing encounters among adults in Kilifi, Kenya, 2006-2017

Background: Little is known about HIV retesting uptake among key populations (KP) and general populations (GP) in Kenya. We assessed trends and predictors of first-time testing (FTT), late retesting (previous test more than one year ago for GP or three months for KP), and test positivity at three voluntary counselling and testing (VCT) centres in coastal Kenya. Methods: Routine VCT data covering 2006-2017 was collected from three VCT centres in Kilifi County. We analysed HIV testing history and test results from encounters among adults 18-39 years, categorized as GP men, GP women, men who have sex with men (MSM), and female sex workers (FSW).     Results: Based on 24,728 test encounters (32% FTT), we observed declines in HIV positivity (proportion of encounters where the result was positive) among GP men, GP women, first-time testers and MSM but not among FSW. The proportion of encounters for FTT and late retesting decreased for both GP and KP but remained much higher in KP than GP. HIV positivity was higher at FTT and late retesting encounters; at FSW and MSM encounters; and at encounters with clients reporting lower educational attainment and sexually transmitted infection (STI) symptoms. HIV positivity was lower in GP men, never married clients and those less than 35 years of age. FTT was associated with town, risk group, age 18-24 years, never-married status, low educational attainment, and STI symptoms. Late retesting was less common among encounters with GP individuals who were never married, had Muslim or no religious affiliation, had lower educational attainment, or reported STI symptoms. Conclusions: HIV positive test results were most common at encounters with first-time testers and late re-testers. While the proportion of encounters at which late retesting was reported decreased steadily over the period reviewed, efforts are needed to increase retesting among the most at-risk populations.

"I wish to remain HIV negative": Pre-exposure prophylaxis adherence and persistence in transgender women and men who have sex with men in coastal Kenya

BACKGROUND

Transgender women (TGW) and men who have sex with men (MSM) in sub-Saharan Africa have high HIV acquisition risks and can benefit from daily pre-exposure prophylaxis (PrEP). We assessed PrEP adherence by measuring tenofovir-diphosphate (TFV-DP) levels and explore motives for PrEP persistence in TGW and MSM.

METHODS

Participants were enrolled in a one-year PrEP programme and made quarterly visits irrespective of whether they were still using PrEP. At their month 6 visit, participants provided a dried blood spot to test for TFV-DP levels; protective levels were defined as those compatible with ≥4 pills per week (700-1249 fmol/punch). Before TFV-DP levels were available, a sub-set of these participants were invited for an in-depth interview (IDI). Semi-structured IDI topic guides were used to explore motives to uptake, adhere to, and discontinue PrEP. IDI data were analyzed thematically.

RESULTS

Fifty-three participants (42 MSM and 11 TGW) were enrolled. At month 6, 11 (20.7%) participants (8 MSM and 3 TGW) were lost to follow up or stopped taking PrEP. Any TFV-DP was detected in 62.5% (5/8) of TGW vs. 14.7% of MSM (5/34, p = 0.01). Protective levels were detected in 37.5% of TGW (3/8), but not in any MSM. Nineteen IDI were conducted with 7 TGW and 9 MSM on PrEP, and 1 TGW and 2 MSM off PrEP. Unplanned or frequent risky sexual risk behaviour were the main motives for PrEP uptake. Among participants on PrEP, TGW had a more complete understanding of the benefits of PrEP. Inconsistent PrEP use was attributed to situational factors. Motives to discontinue PrEP included negative reactions from partners and stigmatizing healthcare services.

CONCLUSION

While MSM evinced greater adherence challenges in this PrEP programme, almost 40% of TGW were protected by PrEP. Given high HIV incidences in TGW these findings hold promise for TGW PrEP programming in the region.

Rectal gonorrhoea and chlamydia among men who have sex with men in coastal Kenya

Background: Men who have sex with men (MSM) have a higher prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections compared to the rest of the population, often remaining undiagnosed. In Kenya, prevalence of rectal CT and NG infection and NG antimicrobial sensitivity are poorly described. Methods: MSM who reported receptive anal intercourse (RAI) were recruited from an ongoing human immunodeficiency virus acquisition and treatment study in coastal Kenya in 2016-2017. Rectal swabs were collected at two time points 6 months apart to estimate prevalence and incidence of CT/NG infection using a molecular point-of-care assay. Participants positive for CT or NG were treated according to national guidelines. NG culture and antimicrobial susceptibility testing was performed. Participant and risk behaviour characteristics were collected and association with baseline CT/NG prevalence assessed by multivariable regression analysis. Results: Prevalence of CT/NG in 104 MSM was 21.2% (CT 13.5%, NG 9.6%, dual infection 1.9%) at baseline and 25.9% in 81 MSM at follow-up (CT 14.8%, NG 14.8%, dual infection 3.7%). CT/NG incidence was estimated at 53.0 (95% CI, 34.5-81.3) per 100 person-years. Most CT/NG positive participants were asymptomatic: 95.5% at baseline and 100% at follow-up. CT/NG infection was associated with being paid for sex [adjusted odds ratio (aOR)=6.2, 95% CI (1.7-22.9)] and being in formal employment [aOR=7.5, 95% CI (1.1-49.2)]. Six NG isolates were obtained at follow-up; all were susceptible to ceftriaxone and cefixime and all were resistant to penicillin, tetracycline and ciprofloxacin. Conclusions: There is a high prevalence and incidence of asymptomatic rectal CT and NG in MSM reporting RAI in coastal Kenya. MSM who were paid for sex or had formal employment were more likely to be infected with CT/NG suggesting increased risk behaviour during transactional sex. Antimicrobial susceptibility results suggest that current antibiotic choices in Kenya are appropriate for NG treatment.

Assessment of PrEP eligibility and uptake among at-risk MSM participating in a HIV-1 vaccine feasibility cohort in coastal Kenya

Introduction: Pre-exposure prophylaxis (PrEP) is provided free of costs to at-risk populations in Kenya, including men who have sex with men (MSM), but anal intercourse is not an eligibility criterion. We set out to determine PrEP eligibility, uptake and predictors of PrEP uptake among MSM enrolled in an HIV-1 vaccine feasibility cohort in coastal Kenya. Methods: We compared the number of MSM identified as eligible for PrEP from June-December 2017 by Kenyan Ministry of Health (MoH) criteria, which do not include reported anal intercourse, to those identified as eligible by a published MSM cohort-derived HIV-1 risk score (CDHRS). We determined PrEP uptake and assessed factors associated with uptake at first offer among eligible MSM followed up monthly. Results: Out of 167 MSM assessed for PrEP eligibility, 118 (70.7%) were identified by both MoH and CDHRS eligibility criteria; 33 (19.8%) by CDHRS alone, 11 (6.6%) by MoH criteria alone, and 5 (3.0%) by neither criterion. Of the men identified by CDHRS alone, the majority (24 or 72.7%) reported receptive anal intercourse (RAI). Of the 162 MSM eligible for PrEP, 113 (69.7%) accepted PrEP at first offer. Acceptance of PrEP was higher for men reporting RAI (adjusted prevalence ratio [aPR], 1.4; 95% confidence interval [CI], 1.0-1.9), having paid for sex (aPR, 1.3; 95% CI, 1.1-1.6) and group sex (aPR, 1.4; 95% CI, 1.1-1.8), after adjustment for sociodemographic factors. Conclusions: Assessing PrEP eligibility using the CDHRS identified 20% more at-risk MSM for PrEP initiation than when Kenyan MoH criteria were used. Approximately 70% of eligible men accepted PrEP at first offer, suggesting that PrEP is acceptable among at-risk MSM. MSM reporting RAI, group sex, or paying for sex were more likely to accept PrEP. Incorporating RAI into MoH PrEP eligibility criteria would enhance the impact of PrEP programming in Kenya.

Assessment of PrEP eligibility and uptake among at-risk MSM participating in a HIV-1 vaccine feasibility cohort in coastal Kenya

Introduction: Pre-exposure prophylaxis (PrEP) is provided free of costs to at-risk populations in Kenya, including men who have sex with men (MSM), but anal intercourse is not an eligibility criterion. We set out to determine PrEP eligibility, uptake and predictors of PrEP uptake among MSM enrolled in an HIV-1 vaccine feasibility cohort in coastal Kenya. Methods: We compared the number of MSM identified as eligible for PrEP from June-December 2017 by Kenyan Ministry of Health (MoH) criteria, which do not include reported anal intercourse, to those identified as eligible by a published MSM cohort-derived HIV-1 risk score (CDHRS). We determined PrEP uptake and assessed factors associated with uptake at first offer among eligible MSM followed up monthly. Results: Out of 167 MSM assessed for PrEP eligibility, 118 (70.7%) were identified by both MoH and CDHRS eligibility criteria; 33 (19.8%) by CDHRS alone, 11 (6.6%) by MoH criteria alone, and 5 (3.0%) by neither criterion. Of the men identified by CDHRS alone, the majority (24 or 72.7%) reported receptive anal intercourse (RAI). Of the 162 MSM eligible for PrEP, 113 (69.7%) accepted PrEP at first offer. Acceptance of PrEP was higher for men reporting RAI (adjusted prevalence ratio [aPR], 1.4; 95% confidence interval [CI], 1.0-1.9), having paid for sex (aPR, 1.3; 95% CI, 1.1-1.6) and group sex (aPR, 1.4; 95% CI, 1.1-1.8), after adjustment for sociodemographic factors. Conclusions: Assessing PrEP eligibility using the CDHRS identified 20% more at-risk MSM for PrEP initiation than when Kenyan MoH criteria were used. Approximately 70% of eligible men accepted PrEP at first offer, suggesting that PrEP is acceptable among at-risk MSM. MSM reporting RAI, group sex, or paying for sex were more likely to accept PrEP. Incorporating RAI into MoH PrEP eligibility criteria would enhance the impact of PrEP programming in Kenya.

Rectal gonorrhoea and chlamydia among men who have sex with men in coastal Kenya

Background: Men who have sex with men (MSM) have a higher prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections compared to the rest of the population, often remaining undiagnosed. In Kenya, prevalence of rectal CT and NG infection and NG antimicrobial sensitivity are poorly described. Methods: MSM who reported receptive anal intercourse (RAI) were recruited from an ongoing human immunodeficiency virus acquisition and treatment study in coastal Kenya in 2016-2017. Rectal swabs were collected at two time points 6 months apart to estimate prevalence and incidence of CT/NG infection using a molecular point-of-care assay. Participants positive for CT or NG were treated according to national guidelines. NG culture and antimicrobial susceptibility testing was performed. Participant and risk behaviour characteristics were collected and association with baseline CT/NG prevalence assessed by multivariable regression analysis. Results: Prevalence of CT/NG in 104 MSM was 21.2% (CT 13.5%, NG 9.6%, dual infection 1.9%) at baseline and 25.9% in 81 MSM at follow-up (CT 14.8%, NG 14.8%, dual infection 3.7%). CT/NG incidence was estimated at 53.0 (95% CI, 34.5-81.3) per 100 person-years. Most CT/NG positive participants were asymptomatic: 95.5% at baseline and 100% at follow-up. CT/NG infection was associated with being paid for sex [adjusted odds ratio (aOR)=6.2, 95% CI (1.7-22.9)] and being in formal employment [aOR=7.5, 95% CI (1.1-49.2)]. Six NG isolates were obtained at follow-up; all were susceptible to ceftriaxone and cefixime and all were resistant to penicillin, tetracycline and ciprofloxacin. Conclusions: There is a high prevalence and incidence of asymptomatic rectal CT and NG in MSM reporting RAI in coastal Kenya. MSM who were paid for sex or had formal employment were more likely to be infected with CT/NG suggesting increased risk behaviour during transactional sex. Antimicrobial susceptibility results suggest that current antibiotic choices in Kenya are appropriate for NG treatment.

Rectal gonorrhoea and chlamydia among men who have sex with men in coastal Kenya

Background: Men who have sex with men (MSM) have a higher prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections compared to the rest of the population, often remaining undiagnosed. In Kenya, prevalence of rectal CT and NG infection and NG antimicrobial sensitivity are poorly described. Methods: MSM who reported receptive anal intercourse (RAI) were recruited from an ongoing human immunodeficiency virus acquisition and treatment study in coastal Kenya in 2016-2017. Rectal swabs were collected at two time points 6 months apart to estimate prevalence and incidence of CT/NG infection using a molecular point-of-care assay. Participants positive for CT or NG were treated according to national guidelines. NG culture and antimicrobial susceptibility testing was performed. Participant and risk behaviour characteristics were collected and association with baseline CT/NG prevalence assessed by multivariable regression analysis. Results: Prevalence of CT/NG in 104 MSM was 21.2% (CT 13.5%, NG 9.6%, dual infection 1.9%) at baseline and 25.9% in 81 MSM at follow-up (CT 14.8%, NG 14.8%, dual infection 3.7%). CT/NG incidence was estimated at 53.0 (95% CI, 34.5-81.3) per 100 person-years. Most CT/NG positive participants were asymptomatic: 95.5% at baseline and 100% at follow-up. CT/NG infection was associated with being paid for sex [adjusted odds ratio (aOR)=6.2, 95% CI (1.7-22.9)] and being in formal employment [aOR=7.5, 95% CI (1.1-49.2)]. Six NG isolates were obtained at follow-up; all were susceptible to ceftriaxone and cefixime and all were resistant to penicillin, tetracycline and ciprofloxacin. Conclusions: There is a high prevalence and incidence of asymptomatic rectal CT and NG in MSM reporting RAI in coastal Kenya. MSM who were paid for sex or had formal employment were more likely to be infected with CT/NG suggesting increased risk behaviour during transactional sex. Antimicrobial susceptibility results suggest that current antibiotic choices in Kenya are appropriate for NG treatment.

Trends and predictors of new HIV diagnosis and time since last test at testing encounters among adults in Kilifi, Kenya, 2006-2017

Background: Little is known about HIV retesting uptake among key populations (KP) and general populations (GP) in Kenya. We assessed trends and predictors of new HIV diagnosis, first-time testing (FTT), and late retesting (previous test more than one year ago for GP or three months for KP). Methods: Data was collected routinely at three voluntary counselling and testing (VCT) centres in Kilifi County between 2006 and 2017. We analysed test encounters among adults 18-39 years, categorized as GP men, GP women, men who have sex with men (MSM), and female sex workers (FSW).     Results: Based on 25,670 test encounters (32% FTT), we observed significant declines in HIV positivity (proportion of encounters with a new HIV diagnosis) among GP men, GP women, and first-time testers, but not among MSM and FSW. FTT and late retesting decreased for both GP and KP, but remained much higher in KP than GP. In 2017, less than 20% of KP were testing quarterly as recommended. HIV positivity was higher at FTT and late retesting encounters (relative to on-time retesting); at FSW and MSM encounters; and at encounters with clients reporting lower educational attainment, sexually transmitted infection (STI) symptoms, or no religious affiliation. HIV positivity was lower in GP men and younger clients. FTT was associated with town, risk group, age 18-24 years, never-married status, low educational attainment, and STI symptoms. Late retesting was less common among encounters with GP individuals who were never married, had Muslim or no religious affiliation, had lower educational attainment, or reported STI symptoms. Conclusions: New HIV diagnoses were most common among first-time testers and late re-testers. While late retesting decreased steadily over the period reviewed, achievement of the county's 90% HIV diagnosis target will require redoubled efforts to increase retesting among the most at risk populations.

PrEP interest and HIV-1 incidence among MSM and transgender women in coastal Kenya

INTRODUCTION

There is emerging data on HIV-1 incidence among MSM in sub-Saharan Africa (SSA), but no known estimate of HIV-1 incidence among transgender women (TGW) in the region has yet been reported. We assessed HIV-1 incidence and pre-exposure prophylaxis (PrEP) interest in men who have sex with men exclusively (MSME), men who have sex with men and women (MSMW) and TGW in coastal Kenya.

METHODS

HIV-1-seronegative individuals who had participated in an HIV testing study in 2016 were traced and retested in 2017 according to Kenyan guidelines. All participants were assigned male sex at birth and had male sex partners; additional data on gender identity and sexual orientation were obtained. We assessed the factors associated with HIV-1 acquisition using Poisson regression and calculated HIV-1 incidence in MSME, MSMW and TGW. PrEP interest was assessed through focus group discussions to characterize subcategories' perceived PrEP needs.

RESULTS

Of the 168 cohort participants, 42 were classified as MSME, 112 as MSMW and 14 as TGW. Overall, HIV-1 incidence was 5.1 (95% confidence interval (CI): 2.6 to 9.8) per 100 person-years (PY): 4.5 (95% CI: 1.1 to 17.8] per 100 PY among MSME, 3.4 (95% CI: 1.3 to 9.1) per 100 PY among MSMW and 20.6 (95% CI: 6.6 to 63.8] per 100 PY among TGW. HIV-1 acquisition was associated with exclusive receptive anal intercourse (aIRR 13.0, 95% CI 1.9 to 88.6), history of an STI in preceding six months (aIRR 10.3, 95% CI 2.2 to 49.4) and separated/divorced marital status (aIRR 8.2 (95%: 1.1 to 62.2). Almost all (98.8%) participants were interested in initiating PrEP. MSME and TGW felt that PrEP would lead to increases in condomless anal or group sex.

CONCLUSIONS

TGW had a very high HIV-1 incidence compared with MSME and MSMW. Subcategories of MSM anticipated different PrEP needs and post-PrEP risk behaviour. Further studies should assess if TGW may have been wrongly categorized as MSM in other HIV-1 incidence studies in the region.

Rectal gonorrhoea and chlamydia among men who have sex with men in coastal Kenya

Background: Men who have sex with men (MSM) experience a high burden of Chlamydia trachomatis (CT) and Neisseria gonorrhoea (NG) infections. These remain largely undiagnosed in the context of syndromic treatment. In Kenya, prevalence of rectal CT and NG infection and NG antimicrobial sensitivity are poorly described. Methods: MSM who reported receptive anal intercourse (RAI) were recruited from an ongoing human immunodeficiency virus acquisition and treatment study in coastal Kenya in 2016-2017. Rectal swabs were collected at two time points 6 months apart to estimate prevalence of CT/NG using a molecular point-of-care assay. Participants positive for CT or NG were treated according to national guidelines. NG culture and antimicrobial susceptibility testing was performed. Participant and risk behaviour characteristics were collected and association with baseline CT/NG prevalence was assessed by multivariable regression analysis. Results: Prevalence of CT/NG in 104 MSM was 21.2% (CT 13.5%, NG 9.6%, dual infection 1.9%) at baseline and 25% in 84 MSM at follow-up (CT 14.3%, NG 14.3%, dual infection 3.6%). Most CT/NG positive participants were asymptomatic: 95.5% at baseline and 100% at follow-up. CT/NG infection was associated with being paid for sex (aOR=6.2, 95%CI (1.7-22.9)) and being in formal employment (aOR=7.5, 95%CI (1.14-49.2)). Six NG isolates were obtained at follow-up; all isolates were susceptible to ceftriaxone and cefixime (1 st line treatment for NG) and all were resistant to penicillin, tetracycline and ciprofloxacin. Conclusions: The high prevalence of asymptomatic rectal CT and NG in MSM reporting RAI demonstrates the need for frequent screening or presumptive treatment. MSM who were paid for sex or had formal employment were more likely to be infected with CT/NG, suggesting increased risk behaviour during transactional sex. Antimicrobial susceptibility results suggest that current antibiotic choices in Kenya are appropriate for NG treatment.

Pilot testing of an online training module about screening for acute HIV infection in adult patients seeking urgent healthcare

BACKGROUND

Acute HIV infection (AHI) is the phase of HIV infection immediately after acquisition, during which many patients develop symptoms and often seek healthcare. However, clinicians in sub-Saharan Africa are not currently taught about AHI.

METHODS

This study pilot-tested a self-directed AHI training module among clinical officers (COs) in coastal Kenya and assessed knowledge gained and challenges to instituting screening. The training module included four domains: AHI definition and importance of AHI recognition; symptoms and screening algorithms; diagnostic strategies; and management. AHI knowledge was assessed before and immediately after training. Participants' ability to utilize an AHI screening algorithm was evaluated with a case-based exercise.

RESULTS

Self-directed training was completed by 45 COs. Pre-test scores were low (median score 35% IQR 30-45%), but improved significantly after training (median post-test score 75%, IQR 70-85%, Wilcoxon signed-rank test p<0.0001). Participants had challenges in understanding the utility and application of a screening algorithm to identify patients for whom AHI testing would be indicated. Knowledge of AHI was poor at baseline, but improved with self-directed learning. Based on these findings, we revised and improved the AHI training module and pre- and post-assessments, which are now freely available online at www.marps-africa.org.

CONCLUSIONS

Guidelines on AHI screening and diagnosis are urgently needed in high HIV transmission areas.

HIV-1 subtype diversity, transmission networks and transmitted drug resistance amongst acute and early infected MSM populations from Coastal Kenya

Background

HIV-1 molecular epidemiology amongst men who have sex with men (MSM) in sub-Saharan Africa remains not well characterized. We aimed to determine HIV-1 subtype distribution, transmission clusters and transmitted drug resistance (TDR) in acute and early infected MSM from Coastal Kenya.

Methods

Analysis of HIV-1 partial pol sequences from MSM recruited 2005–2017 and sampled within six months of the estimated date of infection. Volunteers were classified as men who have sex with men exclusively (MSME) or with both men and women (MSMW). HIV-1 subtype and transmission clusters were determined by maximum-likelihood phylogenetics. TDR mutations were determined using the Stanford HIV drug resistance database.

Results

Of the 97 volunteers, majority (69%) were MSMW; 74%, 16%, 9% and 1% had HIV-1 subtypes A1, D, C or G, respectively. Overall, 65% formed transmission clusters, with substantial mixing between MSME and MSMW. Majority of volunteer sequences were either not linked to any reference sequence (56%) or clustered exclusively with sequences of Kenyan origin (19%). Eight (8% [95% CI: 4–16]) had at least one TDR mutation against nucleoside (n = 2 [2%]) and/or non-nucleoside (n = 7 [7%]) reverse transcriptase inhibitors. The most prevalent TDR mutation was K103N (n = 5), with sequences forming transmission clusters of two and three taxa each. There were no significant differences in HIV-1 subtype distribution and TDR between MSME and MSMW.

Conclusions

This HIV-1 MSM epidemic was predominantly sub-subtype A1, of Kenyan origin, with many transmission clusters and having intermediate level of TDR. Targeted HIV-1 prevention, early identification and care interventions are warranted to break the transmission cycle amongst MSM from Coastal Kenya.

Adjustment to acute or early HIV-1 infection diagnosis to prompt linkage to care and ART initiation: qualitative insights from coastal Kenya

Diagnosing and treating patients with acute or early HIV-1 infection (AEHI) is an important strategy to prevent HIV-1 transmission. We used qualitative methods to understand factors that facilitate adjustment to AEHI diagnosis, prompt linkage to care and initiation of antiretroviral treatment (ART). Twenty-three AEHI patients (12 women, 11 men) included 18 participants identified at health facilities, and 5 participants identified in a sex worker cohort. Of these, 17 participants (9 women, 8 men) participated in qualitative interviews about their AEHI status 2 weeks after diagnosis. Thirteen participants (7 women, 6 men) returned for a second interview 12 weeks after diagnosis. Interviews explored participants’ experiences at the time of and following their diagnosis, and examined perceptions about ART initiation and behavior change recommendations, including disclosure and partner notification. A grounded theory framework was used for analysis, eliciting three important needs that should be addressed for AEHI patients: 1) the need to better understand AEHI and accept one’s status; 2) the need to develop healthy strategies and adjust to the reality of AEHI status; and 3) the need to protect self and others through ART initiation, adherence, safer sex, and disclosure. A preliminary conceptual framework to guide further intervention and research with AEHI populations is proposed.

An Empiric Risk Score to Guide PrEP Targeting Among MSM in Coastal Kenya

Men who have sex with men (MSM), who have heterogeneous HIV-acquisition risks are not specifically targeted in Kenyan pre-exposure prophylaxis (PrEP) guidelines. We used data from an open cohort, which followed 753 initially HIV-negative MSM participants for more than 1378.5 person-years, to develop an empiric risk score for targeting PrEP delivery. Independent predictors of incident HIV-1 infection in this cohort were an age of 18-24 years, having only male sex partners, having receptive anal intercourse, having any unprotected sex, and having group sex. Poisson model coefficients were used to assign a numeric score to each statistically significant predictor. A risk score of ≥ 1 corresponded to an HIV-1 incidence of ≥ 2.2 [95% confidence interval (CI) 1.2-4.1] and identified 81.3% of the cohort participants as being at high risk for HIV-1 acquisition. The area under the receiver operating characteristic curve was 0.76 (95% CI 0.71-0.80). This empiric risk score may help Kenyan health care providers to assess HIV-1 acquisition risk and encourage PrEP uptake by high-risk MSM.

High prevalence of curable sexually transmitted infections among pregnant women in a rural county hospital in Kilifi, Kenya

Background

Women attending antenatal care (ANC) in resource-limited countries are frequently screened for syphilis and HIV, but rarely for other sexually transmitted infections (STIs). We assessed the prevalence of curable STIs, defined as infection with either Chlamydia trachomatis or Neisseria gonorrhoeae or Trichomonas vaginalis, from July to September 2015.

Methods

In a cross-sectional study, women attending ANC at the Kilifi County Hospital, Kenya, had a urine sample tested for C. trachomatis/N. gonorrhoeae by GeneXpert^® and a vaginal swab for T. vaginalis by culture. Bacterial vaginosis (BV) was defined as a Nugent score of 7–10 of the Gram stain of a vaginal smear in combination with self-reported vaginal discharge. Genital ulcers were observed during collection of vaginal swabs. All women responded to questions on socio-demographics and sexual health and clinical symptoms of STIs. Predictors for curable STIs were assessed in multivariable logistic regression.

Results

A total of 42/202 (20.8%, 95% confidence interval (CI):15.4–27.0) women had a curable STI. The prevalence was 14.9% for C. trachomatis (95% CI:10.2–20.5), 1.0% for N. gonorrhoeae (95% CI: 0.1–3.5), 7.4% for T. vaginalis (95% CI:4.2–12.0), 19.3% for BV (95% CI: 14.1–25.4) and 2.5% for genital ulcers (95% CI: 0.8–5.7). Predictors for infection with curable STIs included women with a genital ulcer (adjusted odds ratio (AOR) = 35.0, 95% CI: 2.7–461.6) compared to women without a genital ulcer, women who used water for cleaning after visiting the toilet compared to those who used toilet paper or other solid means (AOR = 4.1, 95% CI:1.5–11.3), women who reported having sexual debut ≤ 17 years compared to women having sexual debut ≥18 years (AOR = 2.7, 95% CI:1.1–6.6), and BV-positive women (AOR = 2.7, 95% CI:1.1–6.6) compared to BV-negative women.

Conclusion

One in five women attending ANC had a curable STI. These infections were associated with genital ulcers, hygiene practices, early sexual debut and bacterial vaginosis.

Hepatitis B Virus Incidence and Risk Factors Among Human Immunodeficiency Virus-1 Negative Men Who Have Sex With Men in Kenya

No data exist on hepatitis B virus (HBV) incidence among African men who have sex with men (MSM). We tested plasma samples archived between 2005 and 2014 for HBV core antibody or surface antigen seroconversion in a cohort of 312 initially human immunodeficiency virus (HIV)-1-negative MSM with no evidence of prior HBV infection. Hepatitis B virus incidence was 6.0/100 person-years (95% confidence interval [CI], 3.9–9.1). Hepatitis B virus acquisition was associated with being uncircumcised (adjusted incidence rate ratio [aIRR], 5.0; 95% CI, 1.5–16.8), recent HIV-1 acquisition (aIRR, 2.9; 95% CI, 1.1–7.7), rape (aIRR, 5.0; 95% CI, 1.2–20.4), and any tertiary education (aIRR, 3.2; 95% CI, 1.1–9.7). African MSM have a substantial risk of HBV acquisition and require vaccination urgently.

Targeted screening of at-risk adults for acute HIV-1 infection in sub-Saharan Africa

BACKGROUND

Patients with acute HIV-1 infection (AHI) have elevated infectivity, but cannot be diagnosed using antibody-based testing. Approaches to screen patients for AHI are urgently needed to enable counselling and treatment to reduce onward transmission.

METHODS

We pooled data from four African studies of high-risk adults that evaluated symptoms and signs compatible with acute retroviral syndrome and tested for HIV-1 at each visit. AHI was defined as detectable plasma viral load or p24 antigen in an HIV-1-antibody-negative patient who subsequently seroconverted. Using generalized estimating equation, we identified symptoms, signs, and demographic factors predictive of AHI, adjusting for study site. We assigned a predictor score to each statistically significant predictor based on its beta coefficient, summing predictor scores to calculate a risk score for each participant. We evaluated the performance of this algorithm overall and at each site.

RESULTS

We compared 122 AHI visits with 45 961 visits by uninfected patients. Younger age (18-29 years), fever, fatigue, body pains, diarrhoea, sore throat, and genital ulcer disease were independent predictors of AHI. The overall area under the receiver operating characteristics curve (AUC) for the algorithm was 0.78, with site-specific AUCs ranging from 0.61 to 0.89. A risk score of at least 2 would indicate AHI testing for 5-50% of participants, substantially decreasing the number needing testing.

CONCLUSION

Our targeted risk score algorithm based on seven characteristics reduced the number of patients needing AHI testing and had good performance overall. We recommend this risk score algorithm for use by HIV programs in sub-Saharan Africa with capacity to test high-risk patients for AHI.

Tuberculosis treatment outcomes among hospital workers at a public teaching and national referral hospital in Kenya

SETTING

Kenyatta National Hospital (KNH), Nairobi, Ken-ya, a large referral and teaching hospital.

OBJECTIVE

1) To document tuberculosis (TB) case notification rates and trends; 2) to describe demographic, clinical and workplace characteristics and treatment outcomes; and 3) to examine associations between demographic and clinical characteristics, HIV/AIDS (human immunodeficiency virus/acquired immune-deficiency syndrome) treatment and anti-tuberculosis treatment outcomes among hospital workers with TB at KNH during the period 2006-2011.

DESIGN

A retrospective cohort study involving a review of medical records.

RESULTS

The TB case notification rate among hospital staff ranged between 413 and 901 per 100 000 staff members per year; 51% of all cases were extra-pulmonary TB; 74% of all cases were among medical, paramedical and support staff. The TB-HIV coinfection rate was 60%. Only 75% had a successful treatment outcome. Patients in the retreatment category, those with unknown HIV status and those who were support staff had a higher risk of poor treatment outcomes.

CONCLUSION

The TB case rate among hospital workers was unacceptably high compared to that of the general population, and treatment outcomes were poor. Infection control in the hospital and management of staff with TB requires urgent attention.

Prevalence, Incidence, and Clearance of Anogenital Warts in Kenyan Men Reporting High-Risk Sexual Behavior, Including Men Who Have Sex With Men

Background.  Human papillomavirus (HPV) causes a spectrum of disease, ranging from warts to cancer. Prevalence, incidence, and factors associated with anogenital warts in East African men are unknown. Methods.  Kenyan men reporting high-risk sexual behavior were inspected for anogenital warts at enrollment and follow-up visits. Logistic regression was performed to identify associations with anogenital warts at baseline. Cox regression was performed to analyze predictors of incident anogenital warts, and Kaplan-Meier curves were used to estimate clearance. Results.  Baseline anogenital wart prevalence in 1137 men was 2.9% (95% confidence interval [CI], 2.0%-4.0%) overall, 2.0% in human immunodeficiency virus (HIV)-uninfected men, and 9.4% in HIV-1-infected men (adjusted odds ratio, 5.43; 95% CI, 2.03-11.29). Over a median of 1.4 years, anogenital wart incidence among 1104 men was 5.3 (95% CI, 4.3-6.5) per 100 person-years. Having HIV-1 infection at baseline (adjusted hazard ratio [aHR], 1.66; 95% CI, 1.01-2.72) or a genital syndrome during follow-up (aHR, 4.78; 95% CI, 3.03-7.56) was associated with increased wart incidence. Wart clearance was lower in HIV-1-infected men (log-rank P<.001). Conclusions.  Anogenital wart prevalence and incidence were increased in HIV-1-infected men, and anogenital warts co-occurred with other genital syndromes. Quadrivalent HPV vaccination should be recommended for young men in settings with high HIV-1 prevalence.

Diagnosing acute and prevalent HIV-1 infection in young African adults seeking care for fever: a systematic review and audit of current practice

Fever is a common complaint in HIV-1 infected adults and may be a presenting sign of acute HIV-1 infection (AHI). We investigated the extent to which HIV-1 infection was considered in the diagnostic evaluation of febrile adults in sub-Saharan Africa (SSA) through a systematic review of published literature and guidelines in the period 2003–2014. We also performed a detailed audit of current practice for the evaluation of febrile young adults in coastal Kenya. Our review identified 43 studies investigating the aetiology of fever in adult outpatients in SSA. While the guidelines identified recommend testing for HIV-1 infection, none mentioned AHI. In our audit of current practice at nine health facilities, only 189 out of 1173 (16.1%) patients, aged 18–29 years, were tested for HIV-1. In a detailed record review, only 2 out of 39 (5.1%) young adults seeking care for fever were tested for HIV-1, and the possibility of AHI was not mentioned. Available literature on adult outpatients presenting with fever is heavily focused on diagnosing malaria and guidelines are poorly defined in terms of evaluating aetiologies other than malaria. Current practice in coastal Kenya shows poor uptake of provider-initiated HIV-1 testing and AHI is not currently considered in the differential diagnosis.

Evaluation of WHO screening algorithm for the presumptive treatment of asymptomatic rectal gonorrhoea and chlamydia infections in at-risk MSM in Kenya

OBJECTIVES

The WHO recommends that men who have sex with men (MSM) reporting unprotected receptive anal intercourse (RAI) and either multiple partners or a partner with a sexually transmitted infection (STI) in the past 6 months should be presumptively treated for asymptomatic rectal Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) infections. We evaluated this recommendation in a cohort of 'high-risk' MSM in Coastal Kenya.

METHODS

We assessed presence of genitourinary and rectal symptoms, and determined prevalence and 3-month incidence of rectal NG and CT infections. We performed nucleic acid amplification testing of urine and rectal swab samples collected from MSM followed prospectively, and assessed predictive values of the WHO algorithm at baseline screening.

RESULTS

Of 244 MSM screened, 240 (98.4%) were asymptomatic, and 147 (61.3%) reported any RAI in the past 6 months. Among 85 (35.4%) asymptomatic MSM meeting criteria for the WHO presumptive treatment (PT) recommendation, we identified 20 with rectal infections (six NG, 12 CT and two NG-CT co-infections). Among 62 asymptomatic MSM who did not meet criteria, we identified seven who were infected. The sensitivity and specificity of the WHO algorithm were 74.1% (95% CI 53.7% to 88.9%) and 45.8% (95% CI 36.7% to 55.2%), respectively. The 3-month incidence of any rectal NG or CT infection in asymptomatic men reporting any RAI was 39.7 (95% CI 24.3 to 64.8) per 100 person-years.

CONCLUSIONS

About one-third of asymptomatic MSM were eligible to receive PT for NG and CT infections. Among MSM who would qualify for PT of rectal STIs, the number needed to treat in order to treat one infection was four. Our results support the value of the WHO screening algorithm and recommended PT strategy in this population.

Men who have sex with men sensitivity training reduces homoprejudice and increases knowledge among Kenyan healthcare providers in coastal Kenya

INTRODUCTION

Healthcare workers (HCWs) in Africa typically receive little or no training in the healthcare needs of men who have sex with men (MSM), limiting the effectiveness and reach of population-based HIV control measures among this group. We assessed the effect of a web-based, self-directed sensitivity training on MSM for HCWs (www.marps-africa.org), combined with facilitated group discussions on knowledge and homophobic attitudes among HCWs in four districts of coastal Kenya.

METHODS

We trained four district "AIDS coordinators" to provide a two-day training to local HCWs working at antiretroviral therapy-providing facilities in coastal Kenya. Self-directed learning supported by group discussions focused on MSM sexual risk practices, HIV prevention and healthcare needs. Knowledge was assessed prior to training, immediately after training and three months after training. The Homophobia Scale assessed homophobic attitudes and was measured before and three months after training.

RESULTS

Seventy-four HCWs (68% female; 74% clinical officers or nurses; 84% working in government facilities) from 49 health facilities were trained, of whom 71 (96%) completed all measures. At baseline, few HCWs reported any prior training on MSM anal sexual practices, and most HCWs had limited knowledge of MSM sexual health needs. Homophobic attitudes were most pronounced among HCWs who were male, under 30 years of age, and working in clinical roles or government facilities. Three months after training, more HCWs had adequate knowledge compared to baseline (49% vs. 13%, McNemar's test p<0.001); this was most pronounced in those with clinical or administrative roles and in those from governmental health providers. Compared to baseline, homophobic attitudes had decreased significantly three months after training, particularly among HCWs with high homophobia scores at baseline, and there was some evidence of correlation between improvements in knowledge and reduction in homophobic sentiment.

CONCLUSIONS

Scaling up MSM sensitivity training for African HCWs is likely to be a timely, effective and practical means to improve relevant sexual health knowledge and reduce personal homophobic sentiment among HCWs involved in HIV prevention, testing and care in sub-Saharan Africa.