Kevin Owuor

Towards Elimination of Mother-to-Child Transmission of HIV: The Impact of a Rapid Results Initiative in Nyanza Province, Kenya.

Many HIV-positive pregnant women and infants are still not receiving optimal services, preventing the goal of eliminating mother-to-child transmission (MTCT) and improving maternal child health overall. A Rapid Results Initiative (RRI) approach was utilized to address key challenges in delivery of prevention of MTCT (PMTCT) services including highly active antiretroviral therapy (HAART) uptake for women and infants. The RRI was conducted between April and June 2011 at 119 health facilities in five districts in Nyanza Province, Kenya. Aggregated site-level data were compared at baseline before the RRI (Oct 2010–Jan 2011), during the RRI, and post-RRI (Jul–Sep 2011) using pre-post cohort analysis. HAART uptake amongst all HIV-positive pregnant women increased by 40% (RR 1.4, 95% CI 1.2–1.7) and continued to improve post-RRI (RR 1.6, 95% CI 1.4–1.8). HAART uptake in HIV-positive infants remained stable (RR 1.1, 95% CI 0.9–1.4) during the RRI and improved by 30% (RR 1.3, 95% CI 1.0–1.6) post-RRI. Significant improvement in PMTCT services can be achieved through introduction of an RRI, which appears to lead to sustained benefits for pregnant HIV-infected women and their infants.

The Role of Maternal, Health System, and Psychosocial Factors in Prevention of Mother-to-Child Transmission Failure in the Era of Programmatic Scale Up in Western Kenya: A Case Control Study

The aim of this study was to identify factors associated with prevention of mother-to-child transmission (PMTCT) in an area of Kenya with widely accessible free PMTCT services. A matched case-control study was conducted at 31 public facilities in western Kenya. HIV-infected mothers with infants aged 6 weeks to 6 months were interviewed and medical charts were reviewed. Cases were mothers of infants with a definitive diagnosis of HIV. Controls were mothers of infants testing HIV negative. Cases and controls were matched in a 1:3 ratio on socio-demographic factors. Fifty cases and 135 controls were enrolled. Conditional (matched) logistic regression analysis was conducted. Odds of being a case were higher for women who first learned their HIV status during pregnancy [OR:2.85, 95%CI:1.41-5.78], did not adhere to antiretroviral therapy (ART) [OR:3.35, 95%CI:1.48-7.58], or had a home delivery [OR:2.42, 95%CI:1.01-5.80]. Based on medical record review, cases had higher odds of their provider not following guidelines for prescription of ART for mothers [OR:8.61, 95%CI:2.83-26.15] and infants [OR:9.72, 95%CI:2.75-34.37]. Stigma from the community [OR:0.37, 95% CI:0.14-1.02] or facility [OR:0.38, 95%CI:0.04-3.41], did not increase the odds of MTCT. Poor adherence to PMTCT guidelines and recommendations by both infected women and health care providers hamper efforts to attain elimination of MTCT.

Implementation and Operational Research: Effects of Antenatal Care and HIV Treatment Integration on Elements of the PMTCT Cascade: Results From the SHAIP Cluster-Randomized Controlled Trial in Kenya.

Background:Integrating antenatal care (ANC) and HIV care may improve uptake and retention in services along the prevention of mother-to-child transmission (PMTCT) cascade. This study aimed to determine whether integration of HIV services into ANC settings improves PMTCT service utilization outcomes. Methods:ANC clinics in rural Kenya were randomized to integrated (6 clinics, 569 women) or nonintegrated (6 clinics, 603 women) services. Intervention clinics provided all HIV services, including highly active antiretroviral therapy (HAART), whereas control clinics provided PMTCT services but referred women to HIV care clinics within the same facility. PMTCT utilization outcomes among HIV-infected women (maternal HIV care enrollment, HAART initiation, and 3-month infant HIV testing uptake) were compared using generalized estimating equations and Cox regression. Results:HIV care enrollment was higher in intervention compared with control clinics [69% versus 36%; odds ratio = 3.94, 95% confidence interval (CI): 1.14 to 13.63]. Median time to enrollment was significantly shorter among intervention arm women (0 versus 8 days, hazard ratio = 2.20, 95% CI: 1.62 to 3.01). Eligible women in the intervention arm were more likely to initiate HAART (40% versus 17%; odds ratio = 3.22, 95% CI: 1.81 to 5.72). Infant testing was more common in the intervention arm (25% versus 18%), however, not statistically different. No significant differences were detected in postnatal service uptake or maternal retention. Conclusions:Service integration increased maternal HIV care enrollment and HAART uptake. However, PMTCT utilization outcomes were still suboptimal, and postnatal service utilization remained poor in both study arms. Further improvements in the PMTCT cascade will require additional research and interventions.

Effects of antenatal care and HIV treatment integration on elements of the PMTCT cascade: Results from the SHAIP cluster-randomized controlled trial in Kenya

Background:Integrating antenatal care (ANC) and HIV care may improve uptake and retention in services along the prevention of mother-to-child transmission (PMTCT) cascade. This study aimed to determine whether integration of HIV services into ANC settings improves PMTCT service utilization outcomes. Methods:ANC clinics in rural Kenya were randomized to integrated (6 clinics, 569 women) or nonintegrated (6 clinics, 603 women) services. Intervention clinics provided all HIV services, including highly active antiretroviral therapy (HAART), whereas control clinics provided PMTCT services but referred women to HIV care clinics within the same facility. PMTCT utilization outcomes among HIV-infected women (maternal HIV care enrollment, HAART initiation, and 3-month infant HIV testing uptake) were compared using generalized estimating equations and Cox regression. Results:HIV care enrollment was higher in intervention compared with control clinics [69% versus 36%; odds ratio = 3.94, 95% confidence interval (CI): 1.14 to 13.63]. Median time to enrollment was significantly shorter among intervention arm women (0 versus 8 days, hazard ratio = 2.20, 95% CI: 1.62 to 3.01). Eligible women in the intervention arm were more likely to initiate HAART (40% versus 17%; odds ratio = 3.22, 95% CI: 1.81 to 5.72). Infant testing was more common in the intervention arm (25% versus 18%), however, not statistically different. No significant differences were detected in postnatal service uptake or maternal retention. Conclusions:Service integration increased maternal HIV care enrollment and HAART uptake. However, PMTCT utilization outcomes were still suboptimal, and postnatal service utilization remained poor in both study arms. Further improvements in the PMTCT cascade will require additional research and interventions.

Implementation and Operational Research: Effect of Integration of HIV Care and Treatment Into Antenatal Care Clinics on Mother-to-Child HIV Transmission and Maternal Outcomes in Nyanza Kenya: Results From the SHAIP Cluster Randomized Controlled Trial.

Background:Many HIV-infected pregnant women identified during antenatal care (ANC) do not enroll in long-term HIV care, resulting in deterioration of maternal health and continued risk of HIV transmission to infants. Methods:We performed a cluster randomized trial to evaluate the effect of integrating HIV care into ANC clinics in rural Kenya. Twelve facilities were randomized to provide either integrated services (ANC, prevention of mother-to-child transmission, and HIV care delivered in the ANC clinic; n = 6 intervention facilities) or standard ANC services (including prevention of mother-to-child transmission and referral to a separate clinic for HIV care; n = 6 control facilities). Results:There were high patient attrition rates over the course of this study. Among study participants who enrolled in HIV care, there was 12-month follow-up data for 256 of 611 (41.8%) women and postpartum data for only 325 of 1172 (28%) women. By 9 months of age, 382 of 568 (67.3%) infants at intervention sites and 338 of 594 (57.0%) at control sites had tested for HIV [odds ratio (OR) 1.45, 95% confidence interval (CI): 0.71 to 2.82]; 7.3% of infants tested HIV positive at intervention sites compared with 8.0% of infants at control sites (OR 0.89, 95% CI: 0.56 to 1.43). The composite clinical/immunologic progression into AIDS was similar in both arms (4.9% vs. 5.1%, OR 0.83, 95% CI: 0.41 to 1.68). Conclusions:Despite the provision of integrated services, patient attrition was substantial in both arms, suggesting barriers beyond lack of service integration. Integration of HIV services into the ANC clinic was not associated with a reduced risk of HIV transmission to infants and did not appear to affect short-term maternal health outcomes.

Impact of family planning health talks by lay health workers on contraceptive knowledge and attitudes among HIV-infected patients in rural Kenya.

OBJECTIVE To determine if a health talk on family planning (FP) by community clinic health assistants (CCHAs) will improve knowledge, attitudes and behavioral intentions about contraception in HIV-infected individuals. METHODS A 15-min FP health talk was given by CCHAs in six rural HIV clinics to a sample of 49 HIV-infected men and women. Effects of the health talk were assessed through a questionnaire administered before the health talk and after completion of the participants clinic visit. RESULTS Following the health talk, there was a significant increase in knowledge about contraceptives (p<.0001), side-effects (p<.0001), and method-specific knowledge about IUCDs (p<.001), implants (p<.0001), and injectables (p<.05). Out of 31 women and 18 men enrolled, 14 (45%) women and 6 (33%) men intended to try a new contraceptive. Participant attitudes toward FP were high before and after the health talk (median 4 of 4). CONCLUSION A health talk delivered by CCHAs can increase knowledge of contraception and promote the intention to try new more effective contraception among HIV-infected individuals. PRACTICE IMPLICATIONS FP health talks administered by lay-health providers to HIV-infected individuals as they wait for HIV services can influence FP knowledge and intention to use FP.

The effect of integration of HIV care and treatment into antenatal care clinics on mother-to-child HIV transmission and maternal outcomes in Nyanza, Kenya: results from the SHAIP cluster randomized controlled trial

Background:Many HIV-infected pregnant women identified during antenatal care (ANC) do not enroll in long-term HIV care, resulting in deterioration of maternal health and continued risk of HIV transmission to infants. Methods:We performed a cluster randomized trial to evaluate the effect of integrating HIV care into ANC clinics in rural Kenya. Twelve facilities were randomized to provide either integrated services (ANC, prevention of mother-to-child transmission, and HIV care delivered in the ANC clinic; n = 6 intervention facilities) or standard ANC services (including prevention of mother-to-child transmission and referral to a separate clinic for HIV care; n = 6 control facilities). Results:There were high patient attrition rates over the course of this study. Among study participants who enrolled in HIV care, there was 12-month follow-up data for 256 of 611 (41.8%) women and postpartum data for only 325 of 1172 (28%) women. By 9 months of age, 382 of 568 (67.3%) infants at intervention sites and 338 of 594 (57.0%) at control sites had tested for HIV [odds ratio (OR) 1.45, 95% confidence interval (CI): 0.71 to 2.82]; 7.3% of infants tested HIV positive at intervention sites compared with 8.0% of infants at control sites (OR 0.89, 95% CI: 0.56 to 1.43). The composite clinical/immunologic progression into AIDS was similar in both arms (4.9% vs. 5.1%, OR 0.83, 95% CI: 0.41 to 1.68). Conclusions:Despite the provision of integrated services, patient attrition was substantial in both arms, suggesting barriers beyond lack of service integration. Integration of HIV services into the ANC clinic was not associated with a reduced risk of HIV transmission to infants and did not appear to affect short-term maternal health outcomes.

Maximizing adherence and retention for women living with HIV and their infants in Kenya (MOTIVATE! study): study protocol for a randomized controlled trial

BackgroundSuccessful completion and retention throughout the multi-step cascade of prevention of mother-to-child HIV transmission (PMTCT) remains difficult to achieve. The Mother and Infant Visit Adherence and Treatment Engagement study aims to evaluate the effect of mobile text messaging, community-based mentor mothers (cMMs), or both on increasing antiretroviral therapy (ART) adherence, retention in HIV care, maternal viral load suppression, and mother-to-child HIV transmission for mother-infant pairs receiving lifelong ART.Methods/designThis study is a cluster randomized, 2 × 2 factorial, controlled trial. The trial will be undertaken in the western Kenyan counties of Migori, Kisumu, and Homa Bay. Study sites will be randomized into one of four groups: six sites will implement both text messaging and cMM, six sites will implement cMM only, six sites will implement text messaging only, and six sites will implement the existing standard of care. The primary analysis will be based on the intention-to-treat principle and will compare maternal ART adherence and maternal retention in care.DiscussionThis study will determine the impact of long-term (up to 12 months postpartum) text messaging and cMMs on retention in and adherence to ART among pregnant and breastfeeding women living with HIV in Kenya. It will address key gaps in our understanding of what interventions may successfully promote long-term retention in the PMTCT cascade of care.Trial registrationClinicalTrials.gov, NCT02491177. Registered on 11 March 2015.

Factors associated with mother to child transmission of HIV despite overall low transmission rates in HIV-exposed infants in rural Kenya

Despite the availability of efficacious prevention of mother-to-child transmission (PMTCT) interventions and improved access to preventive services in many developing countries, vertical HIV transmission persists. A matched case–control study of HIV-exposed infants between January and June 2012 was conducted at 20 clinics in Kenya. Cases were HIV-infected infants and controls were exposed, uninfected infants. Conditional logistic regression analysis was conducted to determine characteristics associated with HIV infection. Forty-five cases and 45 controls were compared. Characteristics associated with HIV-infection included poor PMTCT service uptake such as late infant enrollment (odds ratio [OR]: 7.1, 95% confidence interval [CI]: 2.6–16.7) and poor adherence to infant prophylaxis (OR: 8.3, 95%CI: 3.2–21.4). Maternal characteristics associated with MTCT included lack of awareness of HIV status (OR: 5.6, 95%CI: 2.2–14.5), failure to access antiretroviral prophylaxis (OR: 22.2, 95%CI: 5.8–84.6), and poor adherence (OR: 8.1, 95%CI: 3.7–17.8). Lack of clinic-based HIV education (OR: 7.7, 95%CI: 2.0–25.0) and counseling (OR: 8.3, 95%CI: 2.2–33.3) were reported by mothers of cases. Poor uptake of PMTCT services and a reported absence of HIV education and counseling at the clinic were associated with MTCT. More emphasis on high-quality, comprehensive PMTCT service provision are urgently needed to minimize HIV transmission to children.

The Prevalence of Intimate Partner Violence, Associated Risk Factors, and Other Moderating Effects: Findings From the Kenya National Health Demographic Survey

Intimate partner violence (IPV) is not only a fundamental violation of human rights but also a major public health problem. IPV is the most predominant form of violence committed by men against women. Therefore, our study sought to determine the prevalence of IPV and other moderating factors associated with IPV among these women. This study utilized data from the 2014 Kenya Demographic and Health Survey (KDHS), a nationally representative household-based survey that utilizes a two-stage sampling design. Data was weighted and analyzed using Stata 12 for Windows. A total of 3,028 women were interviewed for the analysis. A majority of the women were aged between 20 and 29 years (1,305; 43.1%), with a greater proportion married (2,329; 76.9%) and identified as Protestant (2,181; 72.1%). On adjusted analysis, factors associated with experiencing IPV included women who: were aged between 40 and 49 years belonging to religions other than Catholic, Protestant, or practiced no religion, resided in urban areas, were currently working, had a poor Wealth Index, were not sexually assertive, had one sexual partner other than their husband/spouse, received money, gifts, or favors in return for sex, had no knowledge on HIV, had husbands/partners aged above 50 years, experienced an early sexual debut of less than 18 years and felt that their partners were justified in beating them. Gender-based violence is complex and multifaceted affecting individuals, families, and society at large and should be addressed from different spectrums of intervention. There is a need for interventions that reduce and prevent IPV through empowering women, creating jobs to accumulate wealth, creating a conducive environment within workplaces for those employed, educating women, and empowering school-aged children to avert IPV.