George Wanje

Treatment with antiretroviral therapy is not associated with increased sexual risk behavior in Kenyan female sex workers.

Objective:The objective of this study was to test the hypothesis that sexual risk behavior would increase following initiation of antiretroviral therapy (ART) in Kenyan female sex workers (FSWs). Design:Prospective cohort study. Setting:FSW cohort in Mombasa, Kenya, 1993–2008. Subjects:Eight hundred and ninety-eight women contributed HIV-1-seropositive follow-up visits, of whom 129 initiated ART. Intervention:Beginning in March 2004, ART was provided to women qualifying for treatment according to Kenyan National Guidelines. Participants received sexual risk reduction education and free condoms at every visit. Main outcome measures:Main outcome measures included unprotected intercourse, abstinence, 100% condom use, number of sexual partners, and frequency of sex. Outcomes were evaluated at monthly follow-up visits using a 1-week recall interval. Results:Compared with non-ART-exposed follow-up, visits following ART initiation were not associated with an increase in unprotected sex [adjusted odds ratio (AOR) 0.86, 95% confidence interval (CI) 0.62–1.19, P = 0.4]. There was a nonsignificant decrease in abstinence (AOR 0.81, 95% CI 0.65–1.01, P = 0.07), which was offset by a substantial increase in 100% condom use (AOR 1.54, 95% CI 1.07–2.20, P = 0.02). Numbers of sex partners and frequency of sex were similar before versus after starting ART. A trend for decreased sexually transmitted infections following ART initiation provides additional support for the validity of the self-reported behavioral outcomes (AOR 0.67, 95% CI 0.44–1.02, P = 0.06). Conclusion:In the setting of ongoing risk reduction education and provision of free condoms, initiation of ART was not associated with increased sexual risk behavior in this cohort of Kenyan FSWs.

Understanding the context of HIV risk behavior among HIV-positive and HIV-negative female sex workers and male bar clients following antiretroviral therapy rollout in Mombasa, Kenya

This study explored perceptions of HIV following local introduction of antiretroviral therapy (ART), among 30 HIV-positive and -negative female sex workers (FSWs) and 10 male bar patrons in Mombasa, Kenya. Semi-structured interviews were analyzed qualitatively to identify determinants of sexual risk behaviors. ART was not perceived as a barrier to safer sex and in some cases led to decreased high-risk behaviors. Barriers to safer sex included economic pressure and sexual partnership types. Many women reported that negotiating condom use is more difficult in long-term partnerships. These women favored short-term partnerships to minimize risk through consistent condom use. For women living with HIV, concern about maintaining health and avoiding HIV superinfection was a strong motivator of protective behaviors. For HIV-negative women, a negative HIV test was a powerful motivator. Incorporation of context- and serostatus-specific factors (e.g., self-protection for HIV-positive women) into tailored prevention counseling may support high-risk women to reduce risk behaviors.

A pilot study of the feasibility of a vaginal washing cessation intervention among Kenyan female sex workers

Background Intravaginal practices including vaginal washing have been associated with HIV-1 acquisition. This association may be mediated by mucosal disruption, changes in vaginal flora or genital tract inflammatory responses. Reducing vaginal washing could lower womens risk of HIV-1 acquisition. Methods 23 HIV-1 seronegative women who reported current vaginal washing were recruited from a prospective cohort study of high-risk women in Mombasa, Kenya. A theoretical framework including information–motivation–behavioural skills and harm reduction was implemented to encourage participants to reduce or eliminate vaginal washing. At baseline and after 1 month, we evaluated vaginal epithelial lesions by colposcopy, vaginal microbiota by Nugents criteria and vaginal cytokine milieu using ELISA on cervicovaginal lavage specimens. Results The most commonly reported vaginal washing substance was soap with water (N=14, 60.9%). The median frequency of vaginal washing was 7 (IQR 7–14) times per week. After 1 month, all participants reported cessation of vaginal washing (p=0.01). The probability of detecting cervicovaginal epithelial lesions was lower (OR 0.48; 95% CI 0.20 to 1.16; p=0.10) and the likelihood of detecting Lactobacillus by culture was higher (OR 3.71, 95% CI 0.73 to 18.76, p=0.11) compared with baseline, although these results were not statistically significant. There was no change in the prevalence of bacterial vaginosis. Most cytokine levels were reduced, but these changes were not statistically significant. Conclusions A theory-based intervention appeared to have a positive effect in reducing vaginal washing over 1 month. Larger studies with longer follow-up are important to further characterise the effects of vaginal washing cessation on biological markers.

An Integrated Approach for Antiretroviral Adherence and Secondary HIV Transmission Risk-Reduction Support by Nurses in Kenya

&NA; Ongoing antiretroviral therapy (ART) adherence and secondary HIV transmission‐risk reduction (positive prevention) support are needed in resource‐limited settings. We evaluated a nurse‐delivered counseling intervention in Kenya. We trained 90 nurses on a brief counseling algorithm that comprised ART and sexual‐risk assessment, risk‐reduction messages, and health‐promotion planning. Self‐reported measures were assessed before, immediately after, and 2 months post‐training. Consistent ART adherence assessment was reported by 29% of nurses at baseline and 66% at 2 months post‐training ( p < .001). Assessment of patient sexual behaviors was 25% at baseline and 60% at 2 months post‐training ( p < .001). Nurse practice behaviors recommended in the counseling algorithm improved significantly at 2 months post‐training compared with baseline, odds ratios 4.30–10.50. We found that training nurses in clinical counseling for ART adherence and positive prevention is feasible. Future studies should test impact of nurse counseling on patient outcomes in resource‐limited settings.

Parents’ and teachers’ views on sexual health education and screening for sexually transmitted infections among in-school adolescent girls in Kenya: a qualitative study

BackgroundTo successfully develop and implement school-based sexual health interventions for adolescent girls, such as screening for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis, it is important to understand parents’ and teachers’ attitudes towards sexual health education and acceptability of sexually transmitted infection (STI) screening interventions.MethodsIn this qualitative study, we approached parents and teachers from three high schools to participate in in-depth interviews (IDIs) and focus-group discussions (FGDs). Parents and teachers were asked about their general knowledge of STIs and sexual health education. In addition, they were asked whether they would support utilizing outreach to schools to facilitate provision of sexual health education and screening for STIs in adolescent girls. Data were audio-recorded, transcribed, and translated into English. An initial coding matrix was developed and refined throughout the coding process. Transcripts were coded by two researchers and analyzed using the content analysis approach.ResultsWe conducted 10 IDIs (5 parents and 5 teachers) and 4 FGDs (2 with parents, 2 with teachers, total of 26 participants). Most parents reported few or no discussions regarding STIs with their adolescent girls. Parents were more comfortable discussing consequences of sexual activity including loss of virginity and the potential for pregnancy. Parents tended to place responsibility for sexual health education with teachers. The teachers, in turn, provided basic sexual and reproductive health education including puberty, abstinence, and overview of STIs. Both parents and teachers found the idea of screening for STIs in adolescent girls to be acceptable, and were comfortable with research staff contacting girls through informational meetings at schools. Parents felt that adolescents’ STI screening results should be shared with their parents.ConclusionIn this African setting, parents and teachers provide limited sexual health education, with a focus on negative consequences including loss of virginity, pregnancy, and risk for STIs. Nonetheless, both parents and teachers were supportive of STI screening for adolescent girls, beginning with school-based informational meetings for the girls. Research and programs that aim to provide STI screening in this setting must offer treatment and address the issue of whether results will be disclosed to parents.

Association Between Alcohol Use and Sexually Transmitted Infection Incidence Among Kenyan Women Engaged in Transactional Sex

Few prospective studies have evaluated the association between alcohol use and STI acquisition among African women. We examined the association between baseline drinking frequency and STIs in a cohort of Kenyan women reporting transactional sex. The association between alcohol use and STI differed significantly by HIV status. Among 139 HIV-positive women, STI acquisition was significantly associated with consuming 1–7 drinks/week and marginally associated with ≥8 drinks/week in unadjusted analyses. However, no association between alcohol use and STIs was observed among 335 HIV-negative women. Addressing alcohol use within comprehensive HIV care may also reduce the burden of STIs among high-risk women.ResumenPocos estudios prospectivos han evaluado la asociación entre el consumo de alcohol y la adquisición de ITS entre mujeres africanas. Examinamos la asociación entre la frecuencia de consumo de bebidas alcohólicas reportada en una línea base y ITS en una cohorte de mujeres kenianas que reportaron haber tenido sexo transaccional. La asociación entre el consumo de alcohol y el riesgo para ITS presentó una diferencia significativa con respecto al estatus de VIH. Entre las 139 mujeres VIH positivas que fueron analizadas, el riesgo de contraer una ITS está asociado significativamente al consumo de 1 a 7 bebidas alcohólicas, y marginalmente asociado al con consumo semanal de 8 o más bebidas alcohólicas, de acuerdo al análisis sin ajuste. En contraste, el consumo de alcohol no está asociado al riesgo de ITS, en las 335 mujeres VIH negativas. Abordar el consumo de alcohol en el contexto de la atención integral a las personas que viven con VIH puede reducir la carga que suponen las ITS entre mujeres de alto riesgo.

Screening for Sexually Transmitted Infections in Adolescent Girls and Young Women in Mombasa, Kenya: Feasibility, Prevalence, and Correlates

Introduction As adolescents and young women become sexually active, they are at risk of adverse reproductive health outcomes including sexually transmitted infections (STIs). We assessed feasibility and acceptability of STI screening among 15- to 24-year-old women in Mombasa, Kenya. Methods After sensitization activities, participants were recruited from 3 high schools and 1 university. Study staff conducted informational sessions. Students interested in participating were given consent forms to take home, and invited to visit our clinic for STI screening. During clinic visits, participants completed a self-administered questionnaire and provided a urine specimen for STI testing using a nucleic acid amplification test. Results Between August 2014 and March 2015, 463 high school and 165 university students collected consent forms. Of these, 293 (63%) from high schools versus 158 (95%) from university attended clinic for STI screening (P < 0.001). Of the 150 (33%) who reported any history of insertive vaginal sex, 78 (52.0%) reported condom use at the last sex act, 31 (20.7%) reported using modern nonbarrier contraceptive methods, and 37 (24.7%) reported not using any contraception at the last sex act. Twenty-six (5.8%) participants were diagnosed with STIs (7 [1.6%] Neisseria gonorrhoeae, 16 [3.6%] Chlamydia trachomatis, 3 [0.7%] Trichomonas vaginalis). In multivariable analyses, reporting receptive vaginal sex without a condom was associated with having a laboratory confirmed STI (odds ratio, 6.21; 95% confidence interval, 1.72–22.28). Conclusions These findings support the need for reproductive health interventions to reduce the risk of STIs in a population of adolescent girls and young women in East Africa.

Risky Business: condom failures as experienced by female sex workers in Mombasa, Kenya.

Abstract Limited research exists about condom failure as experienced by female sex workers. We conducted a qualitative study to examine how female sex workers in Mombasa, Kenya contextualise and explain the occurrence of condom failure. In-depth, semi-structured interviews were conducted with thirty female sex workers to ascertain their condom failure experiences. We qualitatively analysed interview transcripts to determine how the women mitigate risk and cope with condom failure. Condom failure was not uncommon, but women mitigated the risk by learning about correct use, and by supplying and applying condoms themselves. Many female sex workers felt that men intentionally rupture condoms. Few women were aware of or felt empowered to prevent HIV, STIs, and pregnancy after condom failure. Interventions to equip female sex workers with strategies for minimising the risk of HIV, STIs, and pregnancy in the aftermath of a condom failure should be investigated.