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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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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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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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Wiggins L, O’Malley G, Wagner AD, Mutisya I, Wilson KS, Lawrence S, Moraa H, Kinuthia J, Itindi J, Muhenje O, Chen TH, Singa B, Mcgrath CJ, Ngugi E, Katana A, Ng′ang′a L, John-Stewart G, Kholer P, Beima-Sofie K. 'They can stigmatize you': a qualitative assessment of the influence of school factors on engagement in care and medication adherence among adolescents with HIV in Western Kenya. Health Educ Res 2022; 37:355-363. [PMID: 36053049 PMCID: PMC9502837 DOI: 10.1093/her/cyac018] [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] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 07/08/2022] [Accepted: 08/01/2022] [Indexed: 06/15/2023]
Abstract
School-related factors may influence retention in care and adherence to antiretroviral therapy (ART) among adolescents with human immunodeficiency virus (HIV). We analyzed data from in-depth interviews with 40 adolescents with HIV (aged 14 -19 years), 40 caregivers of adolescents with HIV, and 4 focus group discussions with healthcare workers to evaluate contextual factors affecting adherence to ART and clinic attendance among adolescents, with a focus on the school environment. Informed by Anderson's Model of Health Services Utilization, transcripts were systematically coded and synthesized to identify school-related themes. All groups identified the school environment as a critical barrier to engagement in HIV care and medication adherence for adolescents with HIV. Adolescent participants reported inflexible school schedules and disclosure to school staff as the biggest challenges adhering to clinic appointments and ART. Adolescents described experiencing stigma and discrimination by peers and school staff and would adjust when, where and how often they took ART to avoid inadvertent disclosure. Boarding school students faced challenges because they had limited private space or time. Caregivers were often instrumental in navigating school permissions, including identifying a treatment supporter among school staff. Additional research engaging school staff may guide interventions for schools to reduce stigma and improve adherence and retention.
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Affiliation(s)
- Lisa Wiggins
- Department of Child Family and Population Health Nursing
| | - Gabrielle O’Malley
- Department of Global Health, University of Washington, Seattle, Washington
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, Washington
| | - Immaculate Mutisya
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Kate S Wilson
- Department of Global Health, University of Washington, Seattle, Washington
| | - Sarah Lawrence
- Department of Global Health, University of Washington, Seattle, Washington
| | - Hellen Moraa
- Department of Pediatrics, University of Nairobi, Nairobi, Kenya
| | - John Kinuthia
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Janet Itindi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Odylia Muhenje
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Tai-Ho Chen
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Benson Singa
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Evelyn Ngugi
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Abraham Katana
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Lucy Ng′ang′a
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Pediatrics, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Pamela Kholer
- Department of Child Family and Population Health Nursing
- Department of Global Health, University of Washington, Seattle, Washington
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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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Neary J, Langat A, Singa B, Kinuthia J, Itindi J, Nyaboe E, Ng'anga' LW, Katana A, John-Stewart GC, McGrath CJ. Higher prevalence of stunting and poor growth outcomes in HIV-exposed uninfected than HIV-unexposed infants in Kenya. AIDS 2022; 36:605-610. [PMID: 34750290 PMCID: PMC8985586 DOI: 10.1097/qad.0000000000003124] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [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: 11/25/2022]
Abstract
BACKGROUND With the growing population of HIV-exposed uninfected (HEU) children globally, it is important to determine population-level growth differences between HEU and HIV-unexposed uninfected (HUU) children. METHODS We analyzed data from a population-level survey enrolling mother-infant pairs attending 6-week and 9-month immunizations in 140 clinics across Kenya. Weight-for-age (WAZ), length-for-age (LAZ), head circumference-for-age (HCAZ) z-scores and underweight (WAZ < -2), stunting (LAZ < -2), and microcephaly (HCAZ < -2), were compared between HEU and HUU. Correlates of growth faltering and poor growth were assessed using generalized Poisson and linear regression models. RESULTS Among 2457 infants, 456 (19%) were HEU. Among mothers living with HIV, 64% received antiretroviral therapy (ART) and 22% were on antiretroviral prophylaxis during pregnancy. At 9 months, 72% of HEU and 98% of HUU were breastfeeding. At 6 weeks, HEU had lower mean WAZ (-0.41 vs. -0.09; P < 0.001) and LAZ (-0.99 vs. -0.31; P = 0.001) than HUU. Stunting was higher in HEU than HUU at 6 weeks (34% vs. 18%, P < 0.001) and 9 months (20% vs. 10%, P < 0.001). In multivariable analyses, HEU had lower mean LAZ at 6 weeks (-0.67, 95% confidence interval [CI]: -1.07, -0.26) and 9 months (-0.57, 95% CI: -0.92, -0.21) and HEU had higher stunting prevalence (week-6 adjusted prevalence ratio [aPR]: 1.88, 95% CI: 1.35, 2.63; month-9 aPR: 2.10, 95% CI: 1.41, 3.13). HEU had lower mean head circumference (-0.49, 95% CI: -0.91, -0.07) and higher prevalence of microcephaly (aPR: 2.21, 95% CI: 1.11, 4.41) at 9 months. CONCLUSION Despite high maternal ART coverage, HEU had poorer growth than HUU in this large population-level comparison. Optimizing breastfeeding practices in HEU may be useful to improve growth.
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Affiliation(s)
| | - Agnes Langat
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Nairobi
| | | | - John Kinuthia
- Departments of Reproductive Health, Research & Programs, Kenyatta National Hospital, Kenya
| | | | | | - Lucy W Ng'anga'
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Nairobi
| | - Abraham Katana
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Nairobi
| | - Grace C John-Stewart
- Department of Epidemiology
- Department of Global Health
- Department of Medicine
- Pediatrics University of Washington, Seattle, WA, USA
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Lawrence S, Moraa H, Wilson K, Mutisya I, Neary J, Kinuthia J, Itindi J, Nyaboe E, Muhenje O, Chen TH, Singa B, McGrath CJ, Ngugi E, Kohler P, Roxby AC, Katana A, Ng'ang'a L, John-Stewart GC, Beima-Sofie K. “They Just Tell Me to Abstain:” Variable Access to and Uptake of Sexual and Reproductive Health Services Among Adolescents Living With HIV in Kenya. Front Reprod Health 2021; 3:644832. [PMID: 36303968 PMCID: PMC9580776 DOI: 10.3389/frph.2021.644832] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background: To improve holistic care for adolescents living with HIV (ALHIV), including integration of sexual and reproductive health services (SRHS), the Kenya Ministry of Health implemented an adolescent package of care (APOC). To inform optimized SRH service delivery, we sought to understand the experiences with SRHS for ALHIV, their primary caregivers, and health care workers (HCWs) following APOC implementation. Methods: We completed a mixed methods evaluation to characterize SRHS provided and personal experiences with access and uptake using surveys conducted with facility managers from 102 randomly selected large HIV treatment facilities throughout Kenya. Among a subset of 4 APOC-trained facilities in a high burden county, we conducted in-depth interviews (IDIs) with 40 ALHIV and 40 caregivers of ALHIV, and 4 focus group discussions (FGDs) with HCWs. Qualitative data was analyzed using thematic analysis. Facility survey data was analyzed using descriptive statistics. Results: Of 102 surveyed facilities, only 56% reported training in APOC and 12% reported receiving additional adolescent-related SRHS training outside of APOC. Frequency of condom provision to ALHIV varied, with 65% of facilities providing condoms daily and 11% never providing condoms to ALHIV. Family planning (FP) was provided to ALHIV daily in 60% of facilities, whereas 14% of facilities reported not providing any FP services to ALHIV. Screening and treatment for STIs for adolescents were provided at all clinics, with 67% providing STI services daily. Three key themes emerged characterizing experiences with adolescent SRHS access and uptake: (1) HCWs were the preferred source for SRH information, (2) greater adolescent autonomy was a facilitator of SRH discussions with HCWs, and (3) ALHIV had variable access to and limited uptake of SRHS within APOC-trained health facilities. The primary SRHS reported available to ALHIV were abstinence and condom use education. There was variable access to FP, condoms, pregnancy and STI testing, and partner services. Adolescents reported limited utilization of SRHS beyond education. Conclusions: Our results indicate a gap in SRHS offered within APOC trained facilities and highlight the importance of adolescent autonomy when providing SRHS and further HCW training to improve SRHS integration within HIV care for ALHIV.
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Affiliation(s)
- Sarah Lawrence
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Hellen Moraa
- Department of Paediatrics, University of Nairobi, Nairobi, Kenya
| | - Kate Wilson
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Immaculate Mutisya
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Jillian Neary
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - John Kinuthia
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Janet Itindi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Edward Nyaboe
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Odylia Muhenje
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Tai-Ho Chen
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Benson Singa
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Christine J. McGrath
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Evelyn Ngugi
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Pamela Kohler
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, United States
| | - Alison C. Roxby
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
| | - Abraham Katana
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Lucy Ng'ang'a
- Division of Global HIV & Tuberculosis, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Grace C. John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Kristin Beima-Sofie
- Department of Global Health, University of Washington, Seattle, WA, United States
- *Correspondence: Kristin Beima-Sofie
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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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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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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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Cho H, Hallfors DD, Mbai II, Itindi J, Milimo BW, Halpern CT, Iritani BJ. Keeping adolescent orphans in school to prevent human immunodeficiency virus infection: evidence from a randomized controlled trial in Kenya. J Adolesc Health 2011; 48:523-6. [PMID: 21501814 PMCID: PMC3079907 DOI: 10.1016/j.jadohealth.2010.08.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Revised: 08/10/2010] [Accepted: 08/10/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE We report the findings from a pilot study in western Kenya, using an experimental design to test whether comprehensive support used to keep adolescent orphans in school can reduce risk factors associated with infection with human immunodeficiency virus. METHODS Adolescent orphans aged 12-14 years (N = 105) in Nyanza Province were randomized to condition, after stratifying by household, gender, and baseline survey report of sexual behavior. The intervention comprised school fees, uniforms, and a "community visitor" who monitored school attendance and helped to resolve problems that would lead to absence or dropout. Data were analyzed using generalized estimating equations over two time points, controlling for gender and age. RESULTS Compared with the control group, intervention students were less likely to drop out of school, commence sexual intercourse, or report attitudes supporting early sex. School support also increased prosocial bonding and gender equity attitudes. CONCLUSIONS After 1 year of exposure to the intervention, we found evidence suggesting that comprehensive school support can prevent school dropout, delay sexual debut, and reduce risk factors associated with infection with human immunodeficiency virus. Further research, with much larger samples, is needed to better understand factors that mediate the association between educational support and delayed sexual debut, and how gender might moderate these relationships.
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Affiliation(s)
- Hyunsan Cho
- Pacific Institute for Research and Evaluation, 1516 E. Franklin Street, Chapel Hill, NC 27514, USA.
| | | | | | | | | | - Carolyn T. Halpern
- Department of Maternal and Child Health, University of North Carolina, Chapel Hill, NC, USA
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