FACTORS INFLUENCING VOLUNTARY MEDICAL MALE CIRCUMCISION AMONG MEN AGED 18-50 YEARS IN KIBERA DIVISION

BACKGROUND

Voluntary Medical Male Circumcision (VMMC) is the surgical removal of all or part of the foreskin from the penis. It is done for medical reasons as it has been shown to reduce the risk of female to male transmission of HIV by up to 60%. It has also been associated with lower transmission of sexually transmitted infections. Voluntary Medical Male Circumcision services have been scaled up in countries with high prevalence, generalised heterosexual HIV epidemics and low rates of male circumcision. Kibera is inhabited by a multi-ethnic community with a sizeable number of un-circumcising ethnic groups.

OBJECTIVES

To determine the uptake of voluntary medical male circumcision among men in Kibera Division and to identify factors associated with circumcision preference.

DESIGN

Descriptive cross-sectional study.

SETTING

Kibera Division of Nairobi County.

SUBJECTS

Simple random sampling was used to enrol 387 participants. A 42-item questionnaire was administered to the participants for determining the uptake of VMMC. It had three sub-sections: demographic characteristics, general knowledge about VMMC and AIDS and acceptability of VMMC, which collected data on the main outcome measures. Data captured was entered into EpiInfo and converted to Stata13 for validation and analysis. Bivariate statistics were generated for all the variables in accordance to the study questions. Categorical variables were analysed using chi-square tests, while the qualitative variables were analysed using the t-test. Multivariate logistic regression analysis was performed to identify factors associated with the acceptability of male circumcision.

RESULTS

The study analysed data for a sample of 341 individuals whose mean age was 31 years (95% = 31 ± 9.1) and 62% were married. A total of 54% of the respondents had completed secondary and tertiary level of education. The level of understanding about VMMC was above average. Fifty nine percent of the respondents (95% CI = 0.54-0.64) knew about VMMC. Of these, 31% had obtained information about VMMC from TV and radio. The most frequently mentioned reason for undergoing VMMC was prevention of HIV and sexually transmitted infections. The level of uptake of VMMC was high at 75%. The study established that the prefered age group for circumcision was during adolescence. Using multivariate logistic regression, the factors associated with uptake of VMMC were education level, medical and hygiene reasons for VMMC. Barriers for uptake were cost, pain and long recovery period after the operation.

CONCLUSION

The uptake and acceptability of male circumcision is high among the general population in Kibera. Participant understanding of HIV and VMMC was also high. There is need for heightened awareness creation in educational institutes. This will specifically target young men before or shortly after their sexual debut when they may still be free of HIV and HSV-2 infections. Circumcision by medical providers should be increased in traditionally circumcising regions to reduce incidence of adverse events.

The detection of antibodies againstSchistosoma mansonisoluble egg antigens (SEA) and CEF6 in ELISA, before and after chemotherapy

Circulating IgG antibody reactivity and excreted egg counts were investigated in 489 Kenyans given chemotherapy for schistosomiasis mansoni. Antibody reactivity was measured in ELISA, using either unfractionated aqueous soluble constituents of Schistosoma mansoni eggs (SEA) or CEF6 (a soluble fraction of S. mansoni eggs containing two cationic antigens) as the antigen source. Antibody reactivity for each antigen source was strongly associated with egg counts, both pre- and post-treatment. Approximately 6 months after chemotherapy, egg counts were zero in 84% of the subjects. The mean optical densities (OD) measured in the post-treatment ELISA were 60% (CEF6) or 45% (SEA) lower than the pre-treatment values, the reduction in the OD with CEF6 as antigen source being significantly greater than that observed with SEA (P <0.001). The usefulness of an assay for antibody reactivity in monitoring the effects of the treatment of schistosomiasis is discussed.

Factors associated with non-adherence to highly active antiretroviral therapy in Nairobi, Kenya

BACKGROUND

Antiretroviral therapy (ART) requires high-level (> 95%) adherence. Kenya is rolling out ART access programmes and, issue of adherence to therapy is therefore imperative. However, published data on adherence to ART in Kenya is limited. This study assessed adherence to ART and identified factors responsible for non adherence in Nairobi.

METHODS

This is a multiple facility-based cross-sectional study, where 416 patients aged over 18 years were systematically selected and interviewed using a structured questionnaire about their experience taking ART. Additional data was extracted from hospital records. Patients were grouped into adherent and non-adherent based on a composite score derived from a three questions adherence tool developed by Center for Adherence Support Evaluation (CASE). Multivariate regression model was used to determine predictors of non-adherence.

RESULTS

Overall, 403 patients responded; 35% males and 65% females, 18% were non-adherent, and main (38%) reason for missing therapy were being busy and forgetting. Accessing ART in a clinic within walking distance from home (OR = 2.387, CI.95 = 1.155-4.931; p = 0.019) and difficulty with dosing schedule (OR = 2.310, CI.95 = 1.211-4.408, p = 0.011) predicted non-adherence.

CONCLUSIONS

The study found better adherence to HAART in Nairobi compared to previous studies in Kenya. However, this can be improved further by employing fitting strategies to improve patients' ability to fit therapy in own lifestyle and cue-dose training to impact forgetfulness. Further work to determine why patients accessing therapy from ARV clinics within walking distance from their residence did not adhere is recommended.

Mycoplasma pneumoniae in children with pneumonia at Mbagathi District Hospital, Nairobi

OBJECTIVE

To determine the prevalence of mycoplasma pneumoniae in nasopharyngeal aspirates of children under five years of age suffering from pneumonia.

DESIGN

Cross-sectional survey.

METHODS

Two primer sets targeting the genes coding for adhesion protein and 16S rRNA were used in PCR and M. pneumoniae specific antibodies were detected using commercial article agglutination kit. Microbiological investigations to isolate common acute respiratory infectious pathogens were also carried out.

RESULTS

M. pneumoniae was detected in nasopharyngeal aspirates of 33.7% of the cases by PCR while serology was positive in only 4.1%. M. pneumoniae alone (single detection) was detected in 25% of the cases while 75% occurred with other acute respiratory infectious (ARI) pathogens. However, the results did not correlate with clinical outcome or the severity of pneumonia. No significant aetiology was found in 28% of the cases investigated, however microbiological investigations by culture revealed the presence of other aetiological agents as follows: Streptococcus pneumoniae (26%), Klebsiella pneumoniae (1%), Staphylococcus aureus (3%), E. coli (2%), parainfluenza viruses (5%), Salmonella(1%), adenovirus (4%), RSV (22%) and Candida spp(13%), Mycoplasma pneumoniae was more prevalent in children aged between six months and three years. Cases of M. pneumoniae PCR positive and S. pneumoniae exhibited similar seasonal distribution with peaks in May and September. However, there was no relationship between M. pneumoniae PCR positive and the severity of pneumonia.

CONCLUSION

More investigation is required to establish the significance of atypical pathogens in respiratory infections in Kenya.

Utilisation of antenatal and maternity services by mothers seeking child welfare services in Mbeere District, Eastern Province, Kenya

BACKGROUND

Utilisation of antenatal and maternity services is an important maternal health indicator. Increasing the proportion of mothers who are cared for in health facilities during pregnancy, childbirth and puerperium reduces the health risks to mothers and their children.

OBJECTIVE

To determine the utilisation of antenatal and maternity services by mothers of Mbeere District bringing their children to the child welfare clinic.

DESIGN

Cross-sectional, descriptive study.

SETTING

Four rural health centres in Mbeere district.

SUBJECTS

Two hundred mothers bringing their children aged one year and below to the child welfare clinic between September and December 2000.

RESULTS

The proportion of mothers who utilised health facilities for antenatal and maternity services was 97.5% and 52%, respectively. Utilisation of health facilities for maternity services was significantly influenced by number of children and distance to health facility in that, as number of children increased, utilisation of maternity services reduced (chi2=8.99; p=0.027; df=1). Mothers living less than 5 km to a health facility utilised the services better than those living 5 km and beyond (chi2=7.57; p=0.0059; df=1). Among the reasons given by the mothers (individual respondents and through Focus Group Discussions) regarding dissatisfaction with the services offered included shortage of drugs and essential supplies, lack of commitment by staff, poor quality of food and lack of cleanliness in the health facilities.

CONCLUSION

Coverage for antenatal services was high among mothers during their last pregnancy. However, only about half of the mothers interviewed utilised health facilities for maternity services (labour and delivery). The major constraints experienced by the mothers as they sought for the services (as reported by individual respondents and through Focus Group Discussions) included lack of transport, lack of money for transport and hospital fee and delay in admission to health facility once mothers report in labour. Lack of satisfaction with quality of care given could be the major demotivating factor in the use of health facilities for maternity services.

Efficacy of oxamniquine and praziquantel in school children from two Schistosoma mansoni endemic areas

OBJECTIVE

To determine the relative susceptibility of Schistosoma mansoni infections to treatment with the oxamniquine (OXA) and praziquantel (PZQ).

DESIGN AND SETTING

Three separate cross sectional studies were performed in six primary schools located in two Schistosoma mansoni endemic areas in Eastern Kenya: Kangundo (low morbidity) and Kibwezi (high morbidity).

SUBJECTS

One thousand two hundred and fourteen infected children aged 6-20 years were involved.

INTERVENTION

Each child received either 15-mg OXA/kg body weight twice within an interval of six hours or a single dose of 40 or 60 mg PZQ/kg body weight. Three duplicate Kato stool examinations were done before and four or five weeks after treatment to assess treatment efficacy.

RESULTS

The cure rates in different schools with OXA were 71.7-79.7% in Kangundo and 56.7-61.9% in Kibwezi. In children treated with PZQ, the 40-mg/kg-dose regimen achieved cure rates of 77.6-87.2% in Kangundo and 67.1-81.1% in Kibwezi, whereas the 60-mg/kg dose regimen attained cure rates of 93.2% in Kangundo and 76.3% in Kibwezi. Both OXA and PZQ efficacy declined significantly with age in Kangundo, whereas the age effect was not seen in Kibwezi.

CONCLUSION

The poorer cure rates in Kibwezi than in the Kangundo children were not due to known previous drug exposure to either OXA or PZQ. The varying efficacy may be attributed to innate low drug susceptibility, possibly related to schistosome strain differences between the two areas.

High Levels of TNF, Soluble TNF Receptors, Soluble ICAM-1, and IFN-γ, but Low Levels of IL-5, Are Associated with Hepatosplenic Disease in Human Schistosomiasis Mansoni

In a case-control study based in two areas of Kenya, hepatosplenic schistosomiasis mansoni was shown to be linked with low levels of IL-5 and with correspondingly high IFN-γ, TNF, and circulating soluble TNF receptor I (sTNFR-I), sTNFR-II, and sICAM-1. PBMC from the hepatosplenic cases responded to in vitro Ag stimulation with significantly higher levels of IFN-γ and TNF, but lower levels of IL-5, compared with nonhepatosplenic controls matched for age and infection intensity. Most of these correlations were confounded by differences between geographical areas. However, principle component analysis identified a high IFN-γ and TNF, and low IL-5 axis in the data as the first principle component; this was significantly associated with hepatosplenomegaly (p &lt; 0.0005) even after controlling for area. High plasma levels of sTNFR-I (p &lt; 0.001), sTNFR-II, (p &lt; 0.0001), and sICAM-1 (p &lt; 0.009) were also significantly associated with hepatosplenomegaly, independently of area, in the case of the soluble forms of both TNF receptors. These parameters were negatively related to IL-5. These results suggest that proinflammatory cytokines are involved in the hepatosplenic disease process in infected individuals who have low anti-inflammatory Th2 responses and that sTNFR may be a useful circulating marker for this disease process, perhaps reflecting the level of TNF activity in hepatic tissues.

High levels of TNF, soluble TNF receptors, soluble ICAM-1, and IFN-gamma, but low levels of IL-5, are associated with hepatosplenic disease in human schistosomiasis mansoni

In a case-control study based in two areas of Kenya, hepatosplenic schistosomiasis mansoni was shown to be linked with low levels of IL-5 and with correspondingly high IFN-gamma, TNF, and circulating soluble TNF receptor I (sTNFR-I), sTNFR-II, and sICAM-1. PBMC from the hepatosplenic cases responded to in vitro Ag stimulation with significantly higher levels of IFN-gamma and TNF, but lower levels of IL-5, compared with nonhepatosplenic controls matched for age and infection intensity. Most of these correlations were confounded by differences between geographical areas. However, principle component analysis identified a high IFN-gamma and TNF, and low IL-5 axis in the data as the first principle component; this was significantly associated with hepatosplenomegaly (p < 0.0005) even after controlling for area. High plasma levels of sTNFR-I (p < 0.001), sTNFR-II, (p < 0.0001), and sICAM-1 (p < 0.009) were also significantly associated with hepatosplenomegaly, independently of area, in the case of the soluble forms of both TNF receptors. These parameters were negatively related to IL-5. These results suggest that proinflammatory cytokines are involved in the hepatosplenic disease process in infected individuals who have low anti-inflammatory Th2 responses and that sTNFR may be a useful circulating marker for this disease process, perhaps reflecting the level of TNF activity in hepatic tissues.

Epidemiology of HIV infection among long distance truck drivers in Kenya

A total number of two hundred eighty three long distance truck drivers and their assistants (loaders) who ferry goods between Kenya and Zaire were included in a cross-sectional study between September 1991 and April 1992. Twenty six percent of the study subjects were seropositive for HIV-1 and none were HIV-2 seropositive. Countries of birth and residence were significantly associated with HIV infection (X2 = 23.6, P = 0.0006). Significant associations were also found between HIV seropositivity and level of education from secondary school and above (OR = 3.4, 95% C.I. = 1.01-11.55); being circumcised was more protective, (OR = 0.38; 95% C.I. = 0.19-0.76), history of many years of driving (X2 = 9.3, p = 0.0254) and income (OR = 11.13, 95% C.I. = 1.35-91.95). When a stepwise multiple logistic regression model was fitted to all the variables observed to be significant in the univariate analysis, the following risk factors attained statistical significance: lack of circumcision (OR = 3.75); income greater than Ksh. 2000 (OR = 7.24); being employed in long distance driving more than 11 years (OR = 3.98); and secondary school education and above (OR = 4.06, 95% C.I. = 1.18-13.98). Reference for all the above Odds Ratios was 1.

A survey of Schistosoma mansoni induced kidney disease in children in an endemic area of Machakos District, Kenya

The association between Schistosoma mansoni infection and kidney lesions was investigated in school children selected from three primary schools in Machakos District, Kenya, namely Miu (n = 159), Kitengei (n = 160) and Misuuni (n = 99) schools. The children were examined parasitologically for S. mansoni infection, clinically for enlargement of the liver and spleen, and biochemically for proteinuria and serum and urine creatinine. High prevalences of S. mansoni infection, ranging from 84-96%, were seen in all the schools, but the geometric mean intensity of egg excretion varied, being relatively low in Misuuni (31 eggs/g), medium in Miu (182 eggs/g) and high in Kitengei (413 eggs/g). The prevalence of pathological proteinuria (> or = 200 mg/l) in the schools ranged from 10.1% in Miu to 28.8% in Kitengei. No difference in the levels of proteinuria was noted between age or sex groups. No association between intensity of infection and pathological proteinuria was observed in any of the schools, nor was any correlation between organomegaly and proteinuria observed. However, significant correlations between malaria and organomegaly (p < 0.001) and between malaria and proteinuria (p < 0.05) were observed when pooling data from all schools. These findings suggest that S. mansoni induced nephrotic syndromes are not common in children from this highly endemic area of Kenya.

Comparison of different chemotherapy strategies against Schistosoma mansoni in Machakos District, Kenya: effects on human infection and morbidity

A comparison was made of the long-term impact of different methods of administration of chemotherapy (oxamniquine, 30 mg/kg in divided doses; or praziquantel, 40 mg/kg) on prevalence and intensity of Schistosoma mansoni infection in four areas in Kangundo Location, Machakos District, Kenya. In Area A, treatment was offered in October 1983 and again in April 1985 to all infected individuals. In Area H, treatment was offered in April 1985 to individuals excreting greater than or equal to 100 eggs per gram (epg) of faeces. In Area S, treatment was offered in April 1985 to all infected school children, within the framework of the primary schools. In the witness area, Area W, treatment was given in April 1985, for ethical reasons, to a small number of individuals excreting greater than or equal to 800 epg. Prevalence and intensities of infection were subsequently monitored at yearly intervals for three complete post-treatment years. In the Area S schools, clinical examination was also carried out at yearly intervals. Treatment of all infected individuals on two occasions (Area A) was the most effective and long-lasting way of reducing prevalence and intensity of infection. In this area, however, some earlier interventions had been carried out and pre-treatment intensities were lower than in the other areas. Treatment only of infected schoolchildren (Area S) also had a marked and prolonged effect, comparable to or better than treatment of individuals with heavy infections (Area H). Treatment of infected schoolchildren also caused a persistent reduction in the prevalence of hepatomegaly, and there was suggestive evidence from intensities of infection in community stool surveys (but not from incidence rates) of an effect on transmission. In all study areas, reinfection was most rapid and most intense among children. These findings are discussed in the light of theoretical considerations and of results from other studies, both on schistosomiasis and on intestinal helminths. We conclude that, in areas of low morbidity such as Kangundo, chemotherapy of schoolchildren only, at intervals of up to 3 years, is a satisfactory way of producing a long-term reduction in both intensity of infection and morbidity.

Differences in the rate of hepatosplenomegaly due to Schistosoma mansoni infection between two areas in Machakos District, Kenya

The relationship between intensity of Schistosoma mansoni infection and the degree of related morbidity was suspected to differ locally within the Machakos district of Kenya. To test this possibility, prevalences of hepatomegaly and splenomegaly among 1483 school children were compared between 2 areas, Kangundo and Kambu, within this district. These areas, which were similar in many geographical and economic respects and populated by the same tribe (Akamba), had comparable levels of S. mansoni infection and no S. haematobium infection. A relationship was observed between the prevalence of hepatomegaly and intensity of S. mansoni infection, which showed no consistent difference between the 2 areas. In contrast, a relationship between the prevalence of splenomegaly and intensity of S. mansoni infection was observed only in the Kambu schools, and not in the Kangundo schools where the overall prevalence of splenomegaly was much lower. It was possible that part of the splenomegaly observed in Kambu was due to malaria. However, the observation that malaria and schistosomiasis in 2 Kambu schools were not positively correlated allowed approximations to be made of the relative contributions of each to the prevalence of splenomegaly. It was concluded that, in a school close to the river that formed the main transmission site of S. mansoni, schistosomiasis-related hepatosplenomegaly was present in at least 17% of children. The reason for the high prevalence in Kambu of hepatosplenic schistosomiasis remains uncertain, but it could include a synergistic interaction of schistosome infection with malaria.