Zachary Kwena

Association of Attitudes and Beliefs towards Antiretroviral Therapy with HIV-Seroprevalence in the General Population of Kisumu, Kenya

Background Since antiretroviral therapy (ART) became available in the developed world, the prevalence of unprotected sex and the incidence of sexually transmitted infections (STIs) and HIV have increased. We hypothesized that a similar phenomenon may be occurring in sub-Saharan Africa concomitant with the scale-up of HIV treatment. Methods We conducted a general population-based survey in Kisumu, Kenya. Participants completed an interview that included demographics as well as ART-related attitudes and beliefs (AB) and then underwent HIV serological testing. Exploratory and confirmatory factor analyses of AB about ART indicated two factors: 1) ART-related risk compensation (increased sexual risk taking now that ART is available); and 2) a perception that HIV is more controllable now that ART is available. Logistic regression was used to determine associations of these factors with HIV-seroprevalence after controlling for age. Findings 1,655 (90%) of 1,844 people aged 15–49 contacted, including 749 men and 906 women, consented to participate in the study. Most participants (n = 1164; 71%) had heard of ART. Of those who had heard of ART, 23% believed ART was a cure for HIV. ART-related risk compensation (Adjusted (A)OR = 1.45, 95% CI 1.16–1.81), and a belief that ART cures HIV (AOR = 2.14, 95% CI 1.22–3.76) were associated with an increased HIV seroprevalence in men but not women after controlling for age. In particular, ART-related risk compensation was associated with an increased HIV-seroprevalence in young (aged 15–24 years) men (OR = 1.56; 95% CI 1.12–2.19). Conclusions ART-related risk compensation and a belief that ART cures HIV were associated with an increased HIV seroprevalence among men but not women. HIV prevention programs in sub-Saharan Africa that target the general population should include educational messages about ART and address the changing beliefs about HIV in the era of greater ART availability.

Epidemiology of human papillomavirus infection among fishermen along Lake Victoria Shore in the Kisumu District, Kenya.

Objectives: The epidemiology of human papillomavirus (HPV) infection in men in Kenya is largely uncharacterised. We set out to determine the prevalence and determinants of HPV infection among sexually active fishermen along Lake Victoria in the Kisumu district of Kenya. Methods: Genital swabs were obtained from 250 consenting fishermen from 18 beaches and a detailed sociodemographic questionnaire was administered. HPV positivity was determined by polymerase chain reaction amplification and detected by dot blot hybridisation with generic HPV and β-globin probes. HPV positive samples were genotyped using the Roche Linear array assay. Results: Overall, 144 (57.6%) fishermen had detectable HPV DNA, 106 (42.4%) were infected with oncogenic HPV types, with HPV-16 being the most frequent type (12.4%). Among HPV positive men, 105 (72.9%) were infected with more than one HPV type and 20 (13.9%) were infected with more than six different types. HIV seropositive men (PR 1.49, 95% CI 1.19 to 1.86) and those divorced or separated (PR 1.62, 95% CI 1.13 to 2.33) were more likely to be infected with HPV. HIV infection (PR 1.22, 95% CI 1.01 to 1.47) was the only factor independently associated with infection with multiple types of HPV. Conclusion: The prevalence of oncogenic HPV infection is high among this population and is associated with HIV serostatus and marital status. This community could benefit from enhanced sexually transmitted infection and HIV prevention interventions.

Short-Term Mobility and the Risk of HIV Infection among Married Couples in the Fishing Communities along Lake Victoria, Kenya

Objective Mobility has long been associated with high HIV prevalence. We sought to assess sex differences in the relationship between mobility and risk for HIV infection among married couples in the fishing communities. Methods We conducted 1090 gender-matched interviews and rapid HIV testing with 545 couples proportionally representing all the different sizes of the fish-landing beaches in Kisumu County. We contacted a random sample of fishermen as our index participants and asked them to enrol in the study together with their spouses. The consenting couples were separated into different private rooms for concurrent interviews and thereafter reunited for couple rapid HIV counselling and testing. In addition to socio-economic and behavioural data, we collected information on overnight travels and divided couples in 4 groups as follows both partners not mobile, both partners mobile, only woman mobile, and only man mobile. Other than descriptive statistics, we used X2 and U tests to compare groups of variables and multivariate logistic regression to measure association between mobility and HIV infection. Results We found significant differences in the number of trips women travelled in the preceding month (mean 4.6, SD 7.1) compared to men (mean 3.3, SD 4.9; p<0.01) and when the women did travel, they were more likely to spend more days away from home than their male partners (mean 5.2 [SD 7.2] versus 3.4 SD 5.6; p = 0.01). With an HIV prevalence of 22.7% in women compared to 20.9% among men, mobile women who had non-mobile spouses had 2.1 times the likelihood of HIV infection compared to individuals in couples where both partners were non-mobile. Conclusion The mobility of fishermen’s spouses is associated with HIV infection that is not evident among fishermen themselves. Therefore, interventions in this community could be a combination of sex-specific programming that targets women and combined programming for couples.

Prevalence and risk factors for sexually transmitted infections in a high-risk occupational group: the case of fishermen along Lake Victoria in Kisumu, Kenya.

The aim of this study was to assess prevalence and risk factors for sexually transmitted infections (STIs) among fishermen along Lake Victoria, Kenya. This cross-sectional study surveyed 250 fishermen from beaches in Kisumu District using proportional-to-size sampling based on the number of registered boats per beach. Participants provided demographic and sexual behaviour information, blood for HIV-1 herpes simplex virus type 2 (HSV-2) and syphilis serological tests urine for transcription-mediated amplification assays for Neisseria gonorrhoeae and Chlamydia trachomatis and penile and scrotal swabs for human papillomavirus (HPV) DNA assay. Consistent condom use with the three most recent sexual partners was reported by 30%; 38% reported concurrent sexual partnerships and 65% reported ever having transactional sex. HIV seroprevalence was 26%, HSV-2 seroprevalence by Western blot assay was 58% and 9.5% were rapid plasma reagin and Treponema pallidum particle agglutination assay positive. Genital HPV DNA of any type was detected in 57.2% with 74% of these having two or more HPV types. C. trachomatis and N. gonorrhoeae were detected in 3.2% and 1.2% respectively. Risk factors for syphilis seropositivity included working on multiple beaches during the past year (adjusted odds ratio [AOR] 3.81; 95% confidence interval [CI] 1.29–11.28). HPV infection was associated with owning a radio which is a marker for higher socioeconomic status (AOR 6.33; 95% CI 2.94–7.14) and reporting transactional sex with the most recent sexual partner (AOR 3.03; 95% CI 1.23–7.69). In conclusion, 90% of fishermen had evidence of one or more STIs. This exceptionally high-risk occupational group represents a high priority for preventive interventions.

Sexual identity and risk of HIV/STI among men who have sex with men in Nairobi

Although there is great regional variation a significant proportion of those with human immunodeficiency virus (HIV/ AIDS) globally are men who have sex with men (MSM) due to the high efficiency of transmission via anal intercourse. This relatively small number of individuals may be disproportionately at risk of HIV transmission vis-a-vis the wider population particularly in countries where social or legal retribution accompanies public disclosure. Recent short-term estimates suggest that of the approximately 82300 new HIV infections in Kenya in 2005 4.5% were in MSM. The incidence among these men may be even higher as the models assumed that only 1% of the male population had sex with men and did not account for male sex workers in this population. The success of HIV/sexually transmitted infections (STI) education prevention and treatment programs for MSM will depend on understanding the diversity of identities roles and situations in this subpopulation. By the late 1990s a growing body of scientific literature revealed that some men in Africa had sexual intercourse with men that some of these men also had sex with women and that these men were at significant risk for HIV/ STI. In Kenya researchers lamented the lack of data on MSM and suggested that in the absence of social sanction or legal rights MSM in Kenya would deny having male sexual partners engage in clandestine sex and take social cover in marriage. (excerpt)

A brief, standardized tool for measuring HIV-related stigma among health facility staff: results of field testing in China, Dominica, Egypt, Kenya, Puerto Rico and St. Christopher & Nevis

Within healthcare settings, HIV‐related stigma is a recognized barrier to access of HIV prevention and treatment services and yet, few efforts have been made to scale‐up stigma reduction programs in service delivery. This is in part due to the lack of a brief, simple, standardized tool for measuring stigma among all levels of health facility staff that works across diverse HIV prevalence, language and healthcare settings. In response, an international consortium led by the Health Policy Project, has developed and field tested a stigma measurement tool for use with health facility staff.

Male circumcision in the general population of Kisumu, Kenya: beliefs about protection, risk behaviors, HIV, and STIs.

Using a population-based survey we examined the behaviors, beliefs, and HIV/HSV-2 serostatus of men and women in the traditionally non-circumcising community of Kisumu, Kenya prior to establishment of voluntary medical male circumcision services. A total of 749 men and 906 women participated. Circumcision status was not associated with HIV/HSV-2 infection nor increased high risk sexual behaviors. In males, preference for being or becoming circumcised was associated with inconsistent condom use and increased lifetime number of sexual partners. Preference for circumcision was increased with understanding that circumcised men are less likely to become infected with HIV.

Facilitating HIV status disclosure for pregnant women and partners in rural Kenya: a qualitative study.

BackgroundWomen’s ability to safely disclose their HIV-positive status to male partners is essential for uptake and continued use of prevention of mother-to-child transmission (PMTCT) services. However, little is known about the acceptability of potential approaches for facilitating partner disclosure. To lay the groundwork for developing an intervention, we conducted formative qualitative research to elicit feedback on three approaches for safe HIV disclosure for pregnant women and male partners in rural Kenya.MethodsThis qualitative acceptability research included in-depth interviews with HIV-infected pregnant women (n = 20) and male partners of HIV-infected women (n = 20) as well as two focus groups with service providers (n = 16). The participants were recruited at health care facilities in two communities in rural Nyanza Province, Kenya, during the period June to November 2011. Data were managed in NVivo 9 and analyzed using a framework approach, drawing on grounded theory.ResultsWe found that facilitating HIV disclosure is acceptable in this context, but that individual participants have varying expectations depending on their personal situation. Many participants displayed a strong preference for couples HIV counseling and testing (CHCT) with mutual disclosure facilitated by a trained health worker. Home-based approaches and programs in which pregnant women are asked to bring their partners to the healthcare facility were equally favored. Participants felt that home-based CHCT would be acceptable for this rural setting, but special attention must be paid to how this service is introduced in the community, training of the health workers who will conduct the home visits, and confidentiality.ConclusionPregnant couples should be given different options for assistance with HIV disclosure. Home-based CHCT could serve as an acceptable method to assist women and men with safe disclosure of HIV status. These findings can inform the design and implementation of programs geared at promoting HIV disclosure among pregnant women and partners, especially in the home-setting.

Transactional sex in the fishing communities along Lake Victoria, Kenya: a catalyst for the spread of HIV

The study describes the nature, context and implications of a unique form of transactional sexual relationships in the fishing communities along Lake Victoria in Kisumu County, Kenya. We conducted 12 focus group discussions and 17 key informant interviews among fishermen, fishmongers and fish transporters in Kisumu. Women fishmongers in the fishing communities commonly form relationships with fishermen, which are often sexual, as part of the jaboya system, wherein women who wish to sell fish in the market secure the rights to purchase the fish caught by the fishermen. Due to the nature and context of the sexual intercourse, sex typically occurs in a hurried manner, often without preparation or protection. Thus, by engaging in a web of these relationships, conducted in contexts that compromise their ability to practice safer sex, men and women in these fishing communities are at increased risk of HIV.

Gendered power dynamics and women's negotiation of family planning in a high HIV prevalence setting: a qualitative study of couples in western Kenya.

Abstract In sub-Saharan Africa, high burdens of HIV and unmet need for contraception often coexist. Research emphasises the need to engage men and couples in reproductive health, yet couples’ negotiations around fertility and family planning in the context of HIV have been sparsely studied. This study examined the gendered power dynamics that frame women’s and couples’ negotiations of contraceptive use in western Kenya. We conducted 76 in-depth interviews with 38 couples, of whom 22 couples were concordant HIV-positive. Qualitative data were analysed using a grounded theory approach. Direct communication around contraception with men was often challenging due to perceived or expressed male resistance. A substantial minority of women avoided male reproductive decision-making authority through covert contraceptive use, with concern for severe consequences when contraceptive use was discovered. Many men assumed that family planning use signified female promiscuity and that infidelity motivated covert use. Men were more willing to use condoms to avoid HIV re-infection or on the recommendation of HIV care providers, which allowed some women leverage to insist on condom use. Our findings highlight the tension between male dominated reproductive decision making and women’s agency and point to the need for gender transformative approaches seeking to challenge masculinities that negatively impact health.