Anders Ragnarsson

Challenges for Scaling up ART in a Resource-Limited Setting : A Retrospective Study in Kibera, Kenya

Objective:To determine levels of dropout and adherence in an antiretroviral treatment (ART) program in sub-Saharan Africas largest urban informal settlement, Kibera, in Nairobi, Kenya. Method:Retrospective cohort study. Results:Of 830 patients that started ART between January 2005 and September 2007, 29% dropped out of the program for more than 90 days at least once after the last prescribed dose. The dropout rate was 23 per 100 person-years, and the probability of retention in the program at 6, 12, and 24 months was 0.83, 0.74, and 0.65, respectively. Twenty-seven percent of patients had an overall mean adherence below 95%. Being a resident of Kibera was significantly associated with 11 times higher risk of dropout. Conclusion:Despite free drugs and low associated costs, dropout probabilities in this study are higher and adherence to ART is lower compared with other studies from sub-Saharan Africa. Our results illustrate that ART programs in resource-limited settings, such as Kibera, risk low adherence and retention rates when expanding services. Specific and intensified patient support is needed to minimize the risk of dropout and nonadherence causing future significant health threats not only to individuals but also to public health.

Social networks and concurrent sexual relationships – a qualitative study among men in an urban South African community

Abstract The aim was to explore and describe characteristics of males’ social and sexual networks in a South African peri-urban community. Twenty in-depth interviews were conducted with men participating in a larger quantitative study where the median age of the men was 28.7 years and almost 56% had some high-school education, 17.2% were unemployed and 94.7% were not married. A Thematic Question Guide with open-ended questions was used for the interviews. A thematic content analysis was conducted to explore the characteristics and dynamics of social and sexual relationships among these men. A high number of temporary and stable concurrent female sexual partners, geographic mobility and high levels of unprotected sex were common. Increased status as a man and lack of trust in womens fidelity were given as important reasons for concurrent female sexual relationships. Strong social networks within male core groups provided economic and social support for the pursuit and maintenance of this behaviour. Concurrent sexual relationships in combination with high viral loads among newly infected individuals unaware of their HIV status create an extremely high-risk environment for the spread of HIV in this population. Interventions targeting men at high risk of HIV need to challenge current societal norms of masculinity to help promote individual sexual risk reduction strategies. Such strategies should go beyond increasing condom use, to include a reduction in the number of concurrent sexual partners.

“Taking Care of Business”: Alcohol as Currency in Transactional Sexual Relationships Among Players in Cape Town, South Africa

In this article we examine the dynamics of social relationships in which alcohol use and risky sexual behaviors cooccur. As part of a larger biological and behavioral HIV surveillance survey, 20 men who lived in an urban, informal settlement on the outskirts of Cape Town, South Africa participated in in-depth interviews. Interview transcripts were analyzed according to a latent content analysis. Findings highlight the latent association between alcohol and transactional sex, and enable an in-depth examination of the normative role that alcohol plays in the formation of casual sexual partnerships characterized by exchange. We build on an existing conceptual model that traces the potential pathways by which alcohol use and transactional sex are linked to sexual risk behaviors. The study findings point to the need for multilevel HIV risk-reduction interventions among men to reduce excessive alcohol use, risky sexual behaviors, and underlying perceptions of ideal masculinity.

The construction of an idealised urban masculinity among men with concurrent sexual partners in a South African township

Background : The perspectives of heterosexual males who have large sexual networks comprising concurrent sexual partners and who engage in high-risk sexual behaviours are scarcely documented. Yet these perspectives are crucial to understanding the high HIV prevalence in South Africa where domestic violence, sexual assault and rape are alarmingly high, suggesting problematic gender dynamics. Objective : To explore the construction of masculinities and mens perceptions of women and their sexual relationships, among men with large sexual networks and concurrent partners. Design : This qualitative study was conducted in conjunction with a larger quantitative survey among men at high risk of HIV, using respondent-driven sampling to recruit participants, where long referral chains allowed us to reach far into social networks. Twenty in-depth, open-ended interviews with South African men who had multiple and concurrent sexual partners were conducted. A latent content analysis was used to explore the characteristics and dynamics of social and sexual relationships. Results : We found dominant masculine ideals characterised by overt economic power and multiple sexual partners. Reasons for large concurrent sexual networks were the perception that women were too empowered, could not be trusted, and lack of control over women. Existing masculine norms encourage concurrent sexual networks, ignoring the high risk of HIV transmission. Biological explanations and determinism further reinforced strong and negative perceptions of women and female sexuality, which helped polarise mens interpretation of gender constructions. Conclusions : Our results highlight the need to address sexuality and gender dynamics among men in growing, informal urban areas where HIV prevalence is strikingly high. Traditional structures that could work as focal entry points should be explored for effective HIV prevention aimed at normative change among hard-to-reach men in high-risk urban and largely informal contexts.

Sexual risk taking among patients on antiretroviral therapy in an urban informal settlement in Kenya: a cross-sectional survey

BackgroundOur intention was to analyze demographic and contextual factors associated with sexual risk taking among HIV-infected patients on antiretroviral treatment (ART) in Africas largest informal urban settlement, Kibera in Nairobi, Kenya.MethodsWe used a cross-sectional survey in a resource-poor, urban informal settlement in Nairobi; 515 consecutive adult patients on ART attending the African Medical and Research Foundation clinic in Kibera in Nairobi were included in the study. Interviewers used structured questionnaires covering socio-demographic characteristics, time on ART, number of sexual partners during the previous six months and consistency of condom use.ResultsTwenty-eight percent of patients reported inconsistent condom use. Female patients were significantly more likely than men to report inconsistent condom use (aOR 3.03; 95% CI 1.60-5.72). Shorter time on ART was significantly associated with inconsistent condom use. Multiple sexual partners were more common among married men than among married women (adjusted OR 4.38; 95% CI 1.82-10.51).ConclusionsInconsistent condom use was especially common among women and patients who had recently started ART, i.e., when the risk of HIV transmission is higher. Having multiple partners was quite common, especially among married men, with the potential of creating sexual networks and an increased risk of HIV transmission. ART needs to be accompanied by other preventive interventions to reduce the risk of new HIV infections among sero-discordant couples and to increase overall community effectiveness.

The influence of traditional medicine and religion on discontinuation of ART in an urban informal settlement in Nairobi, Kenya.

Abstract Objective. The objective of this study was to explore the influence of traditional medicine and religion on discontinuation of antiretroviral therapy (ART) in one of Africas largest informal urban settlement, Kibera, in Nairobi, Kenya. Methods. Semi-structured face-to-face interviews were conducted with 20 patients discontinuing the African Medical and Research Foundation (AMREF) ART program in Kibera due to issues related to traditional medicine and religion. Results. Traditional medicine and religion remain important in many peoples lives after ART initiation, but these issues are rarely addressed in a positive way during ART counseling. Many patients found traditional medicine and their religious beliefs to be in conflict with clinic treatment advice. Patients described a decisional process, prior to the actual drop-out from the ART program that involved a trigger event, usually a specific religious event, or a meeting with someone using traditional medicine that influenced them to take the decision to stop ART. Conclusion. Discontinuation of ART could be reduced if ART providers acknowledged and addressed the importance of religious issues and traditional medicine in the lives of patients, especially in similar resource-poor settings. Telling patients not to mix ART and traditional medicine appeared counter-productive in this setting. Introducing an open discussion around religious beliefs and the pros and cons of traditional medicine as part of standard counseling, may prevent drop-out from ART when side effects or opportunistic infections occur.

Young people's understanding of HIV: A qualitative study among school students in Mankweng, South Africa

Aims: This article describes young peoples interpretation of HIV, AIDS and sexually transmitted illness in a rural South African community in Mankweng, Limpopo Province. Method: The study was based on 19 focus group discussions with adolescents aged 12—14 years. Results: Our participants had limited knowledge about HIV from a biomedical perspective. Their understanding and interpretations of HIV and other sexually transmitted diseases were largely informed by traditional and religious belief systems that explain how and why people contract an illness via sexual intercourse. Based on these interpretations, they also expressed distrust towards the medical health system, and where to go for care, support and treatment. Local traditional healers were often mentioned as the only people who could cure several of the sexually transmitted diseases described by our informants. Conclusions: The ways of understanding HIV, AIDS and other sexually transmitted illnesses may weaken efforts of health education interventions based solely on a medical and modern notion of disease. The authors emphasise the importance of exploring traditional and religious belief systems and taking these into account when planning and designing behaviour change interventions.

Sexual risk-reduction strategies among HIV-infected men receiving ART in Kibera, Nairobi

Abstract This paper explores motivational factors and barriers to sexual behaviour change among men receiving antiretroviral treatment (ART). Twenty in-depth interviews were undertaken with male patients enrolled at the African Medical and Research Foundation clinic in Africas largest urban informal settlement, Kibera in Nairobi, Kenya. All participants experienced prolonged and severe illness prior to the initiation of ART. Fear of symptom relapse was the main trigger for sexual behaviour change. Partner reduction was reported as a first option for behaviour change since this decision could be made by the individual. Condom use was perceived as more difficult as it had to be negotiated with female partners. Cultural norms regarding expectations for reproduction and marriage were not supportive of sexual risk-reduction strategies. Thus, local sociocultural contexts of HIV-infected people must be incorporated into the contextual adaptation and design of ART programmes and services as they have an over-riding influence on sexual behaviour and programme effectiveness. Also, HIV-prevention interventions need to address both personal, micro- and macro-level factors of behaviour to encourage individuals to take on sexual risk-reduction strategies. In order to achieve the anticipated preventive effect of ART, these issues are important for the donor community and policy-makers, who are the major providers of ART programme support within weak health systems in sub-Saharan Africa.

Comparing clinic retention between residents and nonresidents of Kibera, Kenya.

treatment (ART) programs in urban slum settings. 1 Our article presented research performed at the African Medical and Research Foundation (AMREF) clinic in Kibera, one of Africa’s largest informal settlements, which showed that being a Kibera resident was significantly associated with ART program drop-out. Additionally, the Cox proportional hazard ratio for dropping-out among Kibera residents was 2.45 (P = 0.05), as compared with non–Kibera residents (result not presented in the original article). Chung et al did not find that Kibera residents who attended their study clinic at the Coptic Hope Centre had a higher loss to follow-up (Cox proportional hazard ratio: 1.02) than non–Kibera residents, and thus ‘‘caution against the conclusion that residing in Kibera or any urban slum is a risk factor for poor retention.’’ However, there are important differences in terms of geographical location, patient catchment area, and resources that make this comparison difficult. First, the Coptic Hope Centre clinic is located outside Kibera, whereas the AMREF clinic is located right in the centre of Kibera. Second Chung et al argue that: ‘‘Some residents are middle class Kenyans with a yearly salary and not necessarily day laborers with low income.’’ The Kibera population has not previously been well described in terms of sociodemographics and in our retrospective study; we lacked valid data on socioeconomic variables. However, our preliminary data from an ongoing prospective cohort study of HIV patients on ART at the AMREF Kibera clinic support our experience that most patients live under extremely poor conditions. Out of 515 ART patients enrolled so far in our prospective study, only 16% are employed, the other 84% are doing casual labor, are unemployed, or self-employed. Further, only 5% of the respondents have higher education (postsecondary school). Hence, our different findings are likely attributable to selection of more motivated and possibly less vulnerable patients from Kibera seeking care at the Coptic Hope Centre. Secondly, Chung et al speculate that patients dropping-out from the AMREF program might have sought care at a PEPFAR-funded clinic instead; however, the AMREF program at the Kibera clinic likewise receives funding from PEPFAR via CDC). We lack quantitative data on reasons for loss to follow-up, but our qualitative in-depth studies among HIV patients who have dropped out from the ART program in Kibera suggest that aside from death, migration, and the occasional patient changing provider, poverty and lack of food appear to be the major barriers to retention in an ART program in Kibera. 2 The time spent on clinic visits is considered better used to look for job opportunities, and taking ART is not perceived compatible with hunger and an empty stomach. In our forthcoming prospective study we will be able to further analyze determinants of retention in care. In addition, we used a more conservative definition of drop-out, 90 days, in order not to over estimate drop-out and to account for short-term migration in the mobile population of Kibera. Chung et al used 30 days as the cut-off. The Coptic Hope Centre clinic included only treatment-naive patients from the age of 15 years, whereas we included both treatmentnaive and treatment-experienced patients above the age of 18 years. Our results might thus