Last data update: May 06, 2024. (Total: 46732 publications since 2009)
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Query Trace: Marum L[original query] |
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Improving Sampling Efficiency for Determining Pediatric HIV Prevalence in National Surveys: Evidence From 8 Sub-Saharan African Countries
Reid G , Voetsch AC , Stupp P , McCracken S , Kalton G , Dlamini S , McOllogi Juma J , Kalua T , Kirungi W , Koto M , Mugurungi O , Mulenga L , Mutenda N , Marum L , Saito S . J Acquir Immune Defic Syndr 2021 87 S43-s51 BACKGROUND: Measurement of mother-to-child HIV transmission through population-based surveys requires large sample sizes because of low HIV prevalence among children. We estimate potential improvements in sampling efficiency resulting from a targeted sample design. SETTING: Eight countries in sub-Saharan Africa with completed Population-based HIV Impact Assessment (PHIA) surveys as of 2017. METHODS: The PHIA surveys used a geographically stratified 2-stage sample design with households sampled from randomly selected census enumeration areas. Children (0-14 years of age) were eligible for HIV testing within a random subsample of households (usually 50%). Estimates of child HIV prevalence in each country were calculated using jackknife replicate weights. We compared sample sizes and precision achieved using this design with a 2-phase disproportionate sample design applied to strata defined by maternal HIV status and mortality. RESULTS: HIV prevalence among children ranged from 0.4% (95% confidence interval: 0.2 to 0.6) in Tanzania to 2.8% (95% confidence interval: 2.2 to 3.4) in Eswatini with achieved relative standard errors between 11% and 21%. The expected precision improved in the targeted design in all countries included in the analysis, with proportionate reductions in mean squared error ranging from 27% in Eswatini to 61% in Tanzania, assuming an equal sample size. CONCLUSIONS: Population-based surveys of adult HIV prevalence that also measure child HIV prevalence should consider targeted sampling of children to reduce required sample size, increase precision, and increase the number of positive children tested. The findings from the PHIA surveys can be used as baseline data for informing future sample designs. |
Saving Mothers, Giving Life: It takes a system to save a mother
Conlon CM , Serbanescu F , Marum L , Healey J , LaBrecque J , Hobson R , Levitt M , Kekitiinwa A , Picho B , Soud F , Spigel L , Steffen M , Velasco J , Cohen R , Weiss W . Glob Health Sci Pract 2019 7 S6-s26 BACKGROUND: Ending preventable maternal and newborn deaths remains a global health imperative under United Nations Sustainable Development Goal targets 3.1 and 3.2. Saving Mothers, Giving Life (SMGL) was designed in 2011 within the Global Health Initiative as a public-private partnership between the U.S. government, Merck for Mothers, Every Mother Counts, the American College of Obstetricians and Gynecologists, the government of Norway, and Project C.U.R.E. SMGL's initial aim was to dramatically reduce maternal mortality in low-resource, high-burden sub-Saharan African countries. SMGL used a district health systems strengthening approach combining both supply- and demand-side interventions to address the 3 key delays to accessing effective maternity care in a timely manner: delays in seeking, reaching, and receiving quality obstetric services. IMPLEMENTATION: The SMGL approach was piloted from June 2012 to December 2013 in 8 rural districts (4 each) in Uganda and Zambia with high levels of maternal deaths. Over the next 4 years, SMGL expanded to a total of 13 districts in Uganda and 18 in Zambia. SMGL built on existing host government and private maternal and child health platforms, and was aligned with and guided by Ugandan and Zambian maternal and newborn health policies and programs. A 35% reduction in the maternal mortality ratio (MMR) was achieved in SMGL-designated facilities in both countries during the first 12 months of implementation. RESULTS: Maternal health outcomes achieved after 5 years of implementation in the SMGL-designated pilot districts were substantial: a 44% reduction in both facility and districtwide MMR in Uganda, and a 38% decrease in facility and a 41% decline in districtwide MMR in Zambia. Facility deliveries increased by 47% (from 46% to 67%) in Uganda and by 44% (from 62% to 90%) in Zambia. Cesarean delivery rates also increased: by 71% in Uganda (from 5.3% to 9.0%) and by 79% in Zambia (from 2.7% to 4.8%). The average annual rate of reduction for maternal deaths in the SMGL-supported districts exceeded that found countrywide: 11.5% versus 3.5% in Uganda and 10.5% versus 2.8% in Zambia. The changes in stillbirth rates were significant (-13% in Uganda and -36% in Zambia) but those for pre-discharge neonatal mortality rates were not significant in either Uganda or Zambia. CONCLUSION: A district health systems strengthening approach to addressing the 3 delays to accessing timely, appropriate, high-quality care for pregnant women can save women's lives from preventable causes and reduce stillbirths. The approach appears not to significantly impact pre-discharge neonatal mortality. |
Addressing the second delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Reaching appropriate maternal care in a timely manner
Ngoma T , Asiimwe AR , Mukasa J , Binzen S , Serbanescu F , Henry EG , Hamer DH , Lori JR , Schmitz MM , Marum L , Picho B , Naggayi A , Musonda G , Conlon CM , Komakech P , Kamara V , Scott NA . Glob Health Sci Pract 2019 7 S68-s84 BACKGROUND: Between June 2011 and December 2016, the Saving Mothers, Giving Life (SMGL) initiative in Uganda and Zambia implemented a comprehensive approach targeting the persistent barriers that impact a woman's decision to seek care (first delay), ability to reach care (second delay), and ability to receive adequate care (third delay). This article addresses how SMGL partners implemented strategies specifically targeting the second delay, including decreasing the distance to facilities capable of managing emergency obstetric and newborn complications, ensuring sufficient numbers of skilled birth attendants, and addressing transportation challenges. METHODS: Both quantitative and qualitative data collected by SMGL implementing partners for the purpose of monitoring and evaluation were used to document the intervention strategies and to describe the change in outputs and outcomes related to the second delay. Quantitative data sources included pregnancy outcome monitoring data in facilities, health facility assessments, and population-based surveys. Qualitative data were derived from population-level verbal autopsy narratives, programmatic reports and SMGL-related publications, and partner-specific evaluations that include focus group discussions and in-depth interviews. RESULTS: The proportion of deliveries in any health facility or hospital increased from 46% to 67% in Uganda and from 63% to 90% in Zambia between baseline and endline. Distance to health facilities was reduced by increasing the number of health facilities capable of providing basic emergency obstetric and newborn care services in both Uganda and Zambia-a 200% and 167% increase, respectively. Access to facilities improved through integrated transportation and communication services efforts. In Uganda there was a 6% increase in the number of health facilities with communication equipment and a 258% increase in facility deliveries supported by transportation vouchers. In Zambia, there was a 31% increase in health facilities with available transportation, and the renovation and construction of maternity waiting homes resulted in a 69% increase in the number of health facilities with associated maternity waiting homes. CONCLUSION: The collective SMGL strategies addressing the second delay resulted in increased access to delivery services as seen by the increase in the proportion of facility deliveries in SMGL districts, improved communication and transportation services, and an increase in the number of facilities with associated maternity waiting homes. Sustaining and improving on these efforts will need to be ongoing to continue to address the second delay in Uganda and Zambia. |
Rapid reduction of maternal mortality in Uganda and Zambia through the Saving Mothers, Giving Life initiative: results of year 1 evaluation
Serbanescu F , Goldberg HI , Danel I , Wuhib T , Marum L , Obiero W , McAuley J , Aceng J , Chomba E , Stupp PW , Conlon CM . BMC Pregnancy Childbirth 2017 17 (1) 42 BACKGROUND: Achieving maternal mortality reduction as a development goal remains a major challenge in most low-resource countries. Saving Mothers, Giving Life (SMGL) is a multi-partner initiative designed to reduce maternal mortality rapidly in high mortality settings through community and facility evidence-based interventions and district-wide health systems strengthening that could reduce delays to appropriate obstetric care. METHODS: An evaluation employing multiple studies and data collection methods was used to compare baseline maternal outcomes to those during Year 1 in SMGL pilot districts in Uganda and Zambia. Studies include health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and population-based investigation of community maternal deaths. Population-based evaluation used standard approaches and comparable indicators to measure outcome and impact, and to allow comparison of the SMGL implementation in unique country contexts. RESULTS: The evaluation found a 30% reduction in the population-based maternal mortality ratio (MMR) in Uganda during Year 1, from 452 to 316 per 100,000 live births. The MMR in health facilities declined by 35% in each country (from 534 to 345 in Uganda and from 310 to 202 in Zambia). The institutional delivery rate increased by 62% in Uganda and 35% in Zambia. The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 25 in Uganda and from 7 to 11 in Zambia. Partial EmONC care became available in many more low and mid-level facilities. Cesarean section rates for all births increased by 23% in Uganda and 15% in Zambia. The proportion of women with childbirth complications delivered in EmONC facilities rose by 25% in Uganda and 23% in Zambia. Facility case fatality rates fell from 2.6 to 2.0% in Uganda and 3.1 to 2.0% in Zambia. CONCLUSIONS: Maternal mortality ratios fell significantly in one year in Uganda and Zambia following the introduction of the SMGL model. This model employed a comprehensive district system strengthening approach. The lessons learned from SMGL can inform policymakers and program managers in other low and middle income settings where similar approaches could be utilized to rapidly reduce preventable maternal deaths. |
HIV testing services in Africa: are they sustainable?
Marum E , Conkling M , Kanyanda J , Gandi SB , Byaruhanga R , Alwano MG . Curr HIV/AIDS Rep 2016 13 (5) 263-8 HIV testing services (HTS) are an essential component of a national response to the HIV epidemic, and in lower and middle income countries, at least 150 million persons are tested annually. HIV testing is necessary to identify persons in need of antiretroviral treatment, which has been documented to be highly effective not only for treatment but also for prevention of HIV transmission to both adults and children. An assessment of the recent literature on sustainability of health and HIV services suggests that organizational performance, flexibility, and integration with other health interventions contribute to sustainability of HIV services and programs. This article describes the experiences of two HIV testing service providers in Uganda and Zambia as well as the track record of services to prevent mother-to-child HIV transmission to illustrate the factors of performance, flexibility, adaptability, and integration which are key to the sustainability of HIV testing services. |
Re-testing and seroconversion among HIV testing and counseling clients in Lesotho
Grabbe KL , Courtenay-Quirk C , Baughman AL , Djomand G , Pedersen B , Lerotholi M , Nkonyana J , Ramphalla-Phatela P , Marum E . AIDS Educ Prev 2015 27 (4) 350-61 HIV testing and counseling (HTC) is an essential component of comprehensive HIV programs. Retrospective HTC program data from 2006 to 2010 were examined to determine patterns of re-testing and seroconversion in Lesotho. Among 104,662 initially negative clients, 6,777 (6.5%) were re-testers. Predictors of re-testing included being male, age ≥ 25 years, divorced/separated, having more than a high school education, being tested as a couple, testing in the year 2006, testing in the capital city, and awareness of partner's recent testing behavior. Among re-testers who seroconverted (N = 259), predictors included being female and having less than a high school education. There is a critical need for more effectively targeting HIV retesting messages to align with WHO (2010) guidelines and identify persons at highest risk for HIV, to increase timely diagnoses and link persons to appropriate HIV prevention, care, and treatment services. |
Expanding HIV testing: back to the future
Branson BM , Viall A , Marum E . J Acquir Immune Defic Syndr 2013 63 Suppl 2 S117-21 The value of HIV testing has grown in parallel with the development of increasingly effective HIV treatment. Evidence for the substantial reductions in transmission when persons receive antiretroviral therapy creates a new impetus to increase testing and early diagnosis. Models of treatment as prevention-dubbed "test and treat"-give reason for optimism that control and elimination of HIV may now be within reach. This will be possible only with widespread testing, prompt and accurate diagnosis, and universal access to immediate antiviral therapy. Many successful approaches for scaling up testing were pioneered in resource-limited countries before they were adopted by countries in the developed world. The future of HIV testing is changing. Lessons learned from other case-finding initiatives can help chart the course for comparable HIV testing endeavors. |
"What took you so long?" The impact of PEPFAR on the expansion of HIV testing and counseling services in Africa
Marum E , Taegtmeyer M , Parekh B , Mugo N , Lembariti S , Phiri M , Moore J , Cheng AS . J Acquir Immune Defic Syndr 2012 60 Suppl 3 S63-9 HIV testing and counseling services in Africa began in the early 1990s, with limited availability and coverage. Fears of stigma and discrimination, complex laboratory systems, and lack of available care and treatment services hampered expansion. Use of rapid point-of-care tests, introduction of services to prevent mother-to-child transmission, and increasing provision of antiretroviral drugs were key events in the late 1990s and early 2000s that facilitated the expansion of HIV testing and counseling services. Innovations in service delivery included providing HIV testing in both clinical and community sites, including mobile and home testing. Promotional campaigns were conducted in many countries, and evolutions in policies and guidance facilitated expansion and uptake. Support from President's Emergency Plan for AIDS Relief and national governments, other donors, and the Global Fund for AIDS, Tuberculosis, and Malaria contributed to significant increases in the numbers of persons tested in many countries. Quality of both testing and counseling, limited number of health care workers, uptake by couples, and effectiveness of linkages and referral systems remain challenges. Expansion of antiretroviral treatment, especially in light of the evidence that treatment contributes to prevention of transmission, will require greater yet strategic coverage of testing services, especially in clinical settings and in combination with other high-impact HIV prevention strategies. Continued support from President's Emergency Plan for AIDS Relief, governments, and other donors is required for the expansion of testing needed to achieve international targets for the scale-up of treatment and universal access to knowledge of HIV status. |
Lack of knowledge of HIV status a major barrier to HIV prevention, care and treatment efforts in Kenya: results from a nationally representative study
Cherutich P , Kaiser R , Galbraith J , Williamson J , Shiraishi RW , Ngare C , Mermin J , Marum E , Bunnell R . PLoS One 2012 7 (5) e36797 BACKGROUND: We analyzed HIV testing rates, prevalence of undiagnosed HIV, and predictors of testing in the Kenya AIDS Indicator Survey (KAIS) 2007. METHODS: KAIS was a nationally representative sero-survey that included demographic and behavioral indicators and testing for HIV, HSV-2, syphilis, and CD4 cell counts in the population aged 15-64 years. We used gender-specific multivariable regression models to identify factors independently associated with HIV testing in sexually active persons. RESULTS: Of 19,840 eligible persons, 80% consented to interviews and blood specimen collection. National HIV prevalence was 7.1% (95% CI 6.5-7.7). Among ever sexually active persons, 27.4% (95% CI 25.6-29.2) of men and 44.2% (95% CI 42.5-46.0) of women reported previous HIV testing. Among HIV-infected persons, 83.6% (95% CI 76.2-91.0) were unaware of their HIV infection. Among sexually active women aged 15-49 years, 48.7% (95% CI 46.8-50.6) had their last HIV test during antenatal care (ANC). In multivariable analyses, the adjusted odds ratio (AOR) for ever HIV testing in women ≥35 versus 15-19 years was 0.2 (95% CI: 0.1-0.3; p<0.0001). Other independent associations with ever HIV testing included urban residence (AOR 1.6, 95% CI: 1.2-2.0; p = 0.0005, women only), highest wealth index versus the four lower quintiles combined (AOR 1.8, 95% CI: 1.3-2.5; p = 0.0006, men only), and an increasing testing trend with higher levels of education. Missed opportunities for testing were identified during general or pregnancy-specific contacts with health facilities; 89% of adults said they would participate in home-based HIV testing. CONCLUSIONS: The vast majority of HIV-infected persons in Kenya are unaware of their HIV status, posing a major barrier to HIV prevention, care and treatment efforts. New approaches to HIV testing provision and education, including home-based testing, may increase coverage. Targeted interventions should involve sexually active men, sexually active women without access to ANC, and rural and disadvantaged populations. |
Comparison of HIV-1 detection in plasma specimens and dried blood spots using the Roche COBAS Ampliscreen HIV-1 test in Kisumu, Kenya
Okonji JA , Basavaraju SV , Mwangi J , Shiraishi RW , Odera M , Ouma K , Pitman JP , Marum LH , Ou CY , Zeh C . J Virol Methods 2012 179 (1) 21-5 The World Health Organization recommends screening donor blood for HIV in centralized laboratories. This recommendation contributes to quality, but presents specimen transport challenges for resource-limited settings which may be relieved by using dried blood spots (DBS). In sub-Saharan Africa, most countries screen donor blood with serologic assays only. Interest in window period reduction has led blood services to consider adding HIV nucleic acid testing (NAT). The U.S. Food and Drug Administration (FDA) mandates that HIV-1 NAT blood screening assays have a 95% detection limit at or below 100copies/ml and 5000copies/ml for pooled and individual donations, respectively. The Roche COBAS Ampliscreen HIV-1 test, version 1.5, used for screening whole blood or components for transfusion, has not been tested with DBS. We compared COBAS Ampliscreen HIV-1 RNA detection limits in DBS and plasma. An AIDS Clinical Trials Group, Viral Quality Assurance laboratory HIV-1 standard with a known viral load was used to create paired plasma and DBS standard nine member dilution series. Each was tested in 24 replicates with the COBAS Ampliscreen. A probit analysis was conducted to calculate 95% detection limits for plasma and DBS, which were 23.8copies/ml (95% CI 15.1-51.0) for plasma and 106.7copies/ml (95% CI 73.8-207.9) for DBS. The COBAS Ampliscreen detection threshold with DBS suggests acceptability for individual donations, but optimization may be required for pooled specimens. |
Correlates of HIV infection among sexually active adults in Kenya: a national population-based survey
Oluoch T , Mohammed I , Bunnell R , Kaiser R , Kim AA , Gichangi A , Mwangi M , Dadabhai S , Marum L , Orago A , Mermin J . Open AIDS J 2011 5 125-34 OBJECTIVE: To identify factors associated with prevalent HIV in a national HIV survey in Kenya. METHODS: The Kenya AIDS Indicator Survey was a nationally representative population-based sero-survey that examined demographic and behavioral factors and serologic testing for HIV, HSV-2 and syphilis in adults aged 15-64 years. We analyzed questionnaire and blood testing data to identify significant correlates of HIV infection among sexually active adults. RESULTS: Of 10,957 eligible women and 8,883 men, we interviewed 10,239 (93%) women and 7,731 (87%) men. We collected blood specimens from 9,049 women and 6,804 men of which 6,447 women and 5,112 men were sexually active during the 12 months prior to the survey. HIV prevalence among sexually active adults was 7.4%. Factors independently associated with HIV among women were region (Nyanza vs Nairobi: adjusted OR [AOR] 1.6, 95%CI 1.1-2.3), number of lifetime sex partners (6-9 vs 0-1 partners: AOR 3.0, 95%CI 1.6-5.9), HSV-2 (AOR 6.5, 95%CI 4.9-8.8), marital status (widowed vs never married: AOR 2.7, 95%CI 1.5-4.8) and consistent condom use with last sex partner (AOR 2.3, 95%CI 1.6-3.4). Among men, correlates of HIV infection were 30-to-39-year-old age group (AOR 5.2, 95%CI 2.6-10.5), number of lifetime sex partners (10+ vs 0-1 partners, AOR 3.5, 95%CI 1.4-9.0), HSV-2 (AOR 4.7, 95%CI 3.2-6.8), syphilis (AOR 2.4, 95%CI 1.4-4.0), consistent condom use with last sex partner (AOR 2.1, 95% CI 1.5-3.1) and lack of circumcision (AOR 4.0, 95%CI 2.8 - 5.5). CONCLUSION: Kenya's heterogeneous epidemic will require regional and gender-specific prevention approaches. |
Unsafe sex among HIV-infected adults in Kenya: results of a nationally representative survey
Mwangi M , Bunnell R , Nyoka R , Gichangi A , Makokha E , Kim A , Kichamu G , Marum L , Ichwara J , Mermin J . J Acquir Immune Defic Syndr 2011 58 (1) 80-8 OBJECTIVE: Assess factors associated with knowledge of HIV status, sexual activity, and unprotected sex with a partner of unknown or negative HIV status (unsafe sex) among HIV-infected adults in Kenya. DESIGN: Nationally representative Kenya AIDS Indicator Survey among adults aged 15-64 years in 2007. METHODS: A standardized questionnaire was administered and blood samples tested for HIV. We assessed factors associated with knowledge of HIV infection, sexual activity, and unsafe sex. Analyses took into account stratification and clustering in the survey design and estimates were weighted to account for sampling probability. RESULTS: Of 15,853 participants with blood samples, 1104 (6.9%) were HIV infected. Of these, 83.8% did not know their HIV status (56% had never tested; 27.8% reported their last HIV test was negative), and 80.4% were sexually active. Of 861 sexually active adults, 76.9% reported unsafe sex in the past year. Adults who did not know their HIV status were more likely to be sexually active [never tested adjusted odds ratio (AOR): 5.5, 95% confidence interval (CI): 2.8 to 10.7; ever tested, incorrect knowledge AOR: 6.5, CI: 2.1 to 19.6) and to report unsafe sex (never tested AOR: 51.7, CI: 27.3 to 97.6; ever tested, incorrect knowledge of status AOR: 18.6, CI: 8.6 to 40.5) than those who knew their status. CONCLUSIONS: The majority of adults did not know they were infected and engaged in unsafe sex. Adults who knew their HIV status were less likely to be sexually active and report unsafe sex compared with those unaware of their infection. HIV prevention interventions that target HIV-infected adults are urgently needed. |
The contribution of HIV-discordant relationships to new HIV infections in Rakai, Uganda
Grabbe KL , Medley A , Bachanas P , Bock N , Marum E . AIDS 2011 25 (15) 1931-2 In their recent research letter entitled ‘The contribution of HIV-discordant relationships to new HIV infections in Rakai, Uganda’, Gray et al. [1] argue that targeting HIV testing and counseling efforts to HIV serodiscordant couples will have limited impact for HIV prevention. We disagree with this argument for several reasons. | Gray et al. [1] underestimate the true contribution to overall HIV incidence from serodiscordant couples in two ways. First, they focus only on study participants identified as both married and serodiscordant. Yet approximately one-third of married couples had a partner of unknown HIV status (36 and 33% in the pre- and post-antiretroviral therapy (ART) intervals, respectively). It is likely that some of these couples were in fact HIV serodiscordant. Likewise, among those who were not currently married, some were likely in long-term serodiscordant relationships. Thus, the number of infections that occurred among serodiscordant couples is unknown but likely higher than could be reported with the available data. | Second, although the authors state that acceptance of couples counseling has been low in their cohort, it is unclear from the letter what proportion of the couples identified as serodiscordant in the database were actually aware of their serodiscordant status or had received couples HIV testing and counseling (CHTC). Thus, the contribution of serodiscordant couples to new HIV infections may have been low because of mutual disclosure of HIV status or other effective interventions that reduce sexual risk behaviors and transmission [2–7]. |
Evaluating the BED capture enzyme immunoassay to estimate HIV incidence among adults in three countries in Sub-Saharan Africa
Kim AA , McDougal JS , Hargrove J , Rehle T , Pillay-Van Wyk V , Puren A , Ekra A , Borget-Alloue MY , Adje-Toure C , Abdullahi AS , Odawo L , Marum L , Parekh BS . AIDS Res Hum Retroviruses 2010 26 (10) 1051-61 Serological assays for estimating HIV-1 incidence are prone to misclassification, limiting the accuracy of the incidence estimate. Adjustment factors have been developed and recommended for estimating assay-based HIV-1 incidence in cross-sectional settings. We evaluated the performance of the recommended adjustment factors for estimating incidence in national HIV surveys in three countries in sub-Saharan Africa. The BED-capture enzyme immunoassay was applied to stored blood specimens from (1) pregnant women aged 15-49 years attending antenatal clinics in Cote d'Ivoire (1998-2004), (2) adults aged 15-49 years participating in a demographic health survey in Kenya (2003), and (3) adults aged 15-49 years participating in a national household serosurvey in South Africa (2005). Assay-derived incidence estimates were corrected for misclassification using recommended adjustment factors and, where possible, were compared to mathematically modeled incidence in the same populations. Trends in HIV prevalence were compared to trends in assay-derived incidence to assess plausibility in the assay-derived trends. Unadjusted incidence was 3.8% [95% confidence interval (CI) 3.3-4.5] in Cote d'Ivoire, 3.5% (2.7-4.3) in Kenya, and 4.4% (CI 2.3-6.5]) in South Africa. Adjusted incidence was 2.9% (CI 2.1-3.7) in Cote d'Ivoire, 2.6% (CI 2.0-3.2) in Kenya, and 2.4% (CI 1.7-3.1) in South Africa. After adjustment, peak incidence shifted from older to younger age groups in Cote d'Ivoire and South Africa. Modeled HIV incidence was 1.0% (CI 1.02-1.08) in Kenya and 2.0% (CI 1.7-2.4) in South Africa. After applying the recommended adjustments factors, adjusted assay-derived estimates remained implausibly high in two of three populations evaluated. For more accurate measures of assay-derived population incidence, adjustment factors must be locally derived and validated. Until improved assays are available, caution should be applied in the use and interpretation of data from incidence assays. |
Blood donors in Kenya: a comparison of voluntary and family replacement donors based on a population-based survey
Kimani D , Mwangi J , Mwangi M , Bunnell R , Kellogg TA , Oluoch T , Gichangi A , Kaiser R , Mugo N , Odongo T , Oduor M , Marum L . Vox Sang 2010 100 (2) 212-8 BACKGROUND AND OBJECTIVES: Blood safety and sufficiency are major challenges in Kenya and other sub-Saharan African countries forcing many countries to rely on family replacement donors (FRD). We analysed data from a national AIDS indicator survey to describe blood donors in Kenya and potential risks of transfusion transmissible infections (TTI) comparing voluntary donors and FRD. MATERIALS AND METHODS: A population-based, cross-sectional survey was conducted in 2007 among 15- to 64- year-olds. Consenting participants were interviewed about blood donation history and were tested for HIV, HSV-2 and syphilis. RESULTS: Of the 17 940 people surveyed, 445 (2.3%) reported donating blood in the prior 12 months. Sixty-four per cent were voluntary donors, and the rest were FRD. Compared to FRD, the majority of voluntary donors were < 25 years old (59% versus 18%), from the highest wealth quintile (57% versus 42%) and single (64% versus 23%). In addition, voluntary donors were less likely to have been sexually active than replacement donors (43% versus 13%). HIV prevalence was lower among voluntary donors than among FRD (2.6% versus 7.4%, P-value = 0.07). CONCLUSIONS: The majority of blood donors in Kenya are voluntary with lower potential risk of TTI. |
Quantification of print, radio and television exposure among previous blood donors in Kenya: an opportunity for encouraging repeat donation in a resource-limited setting?
Basavaraju SV , Mwangi J , Kellogg TA , Odawo L , Marum LH , 2007 Kenya AIDS Indicator Survey Group . Vox Sang 2010 99 (3) 274-7 Blood services in sub-Saharan Africa experience blood shortages and low retention of voluntary, non-remunerated donors. To boost collections by encouraging repeat donations, the Kenya National Blood Transfusion Service is exploring the likelihood of reaching previous donors through targeted print, radio and television advertising. We analysed data from a national AIDS Indicator Survey to determine whether previous donors have significant exposure to media. Respondents reporting history of blood donation had significantly higher exposure to print, radio and television media than those without history of blood donation. Targeted media campaigns encouraging repeat donation are likely to reach previous donors even in resource-limited settings. |
Reduced risk of transfusion-transmitted HIV in Kenya through centrally co-ordinated blood centres, stringent donor selection and effective p24 antigen-HIV antibody screening
Basavaraju SV , Mwangi J , Nyamongo J , Zeh C , Kimani D , Shiraishi RW , Madoda R , Okonji JA , Sugut W , Ongwae S , Pitman JP , Marum LH . Vox Sang 2010 99 (3) 212-9 BACKGROUND: Following a 1994 study showing a high rate of transfusion-associated HIV, Kenya implemented WHO blood safety recommendations including: organizing the Kenya National Blood Transfusion Service (NBTS), stringent blood donor selection, and universal screening with fourth-generation p24 antigen and HIV antibody assays. Here, we estimate the risk of transfusion-associated HIV transmission in Kenya resulting from NBTS laboratory error and consider the potential safety benefit of instituting pooled nucleic acid testing (NAT) to reduce window period transmission. METHODS: From November to December 2008 in one NBTS regional centre, and from March to June 2009 in all six NBTS regional centres, every third unit of blood screened negative for HIV by the national algorithm was selected. Dried blood spots were prepared and sent to a reference laboratory for further testing, including NAT. Test results from the reference laboratory and NBTS were compared. Risk of transfusion-associated HIV transmission owing to laboratory error and the estimated yield of implementing NAT were calculated. FINDINGS: No cases of laboratory error were detected in 12 435 units tested. We estimate that during the study period, the percentage of units reactive for HIV by NAT but non-reactive by the national algorithm was 0.0% (95% exact binomial confidence interval, 0.00-0.024%). INTERPRETATION: By adopting WHO blood safety strategies for resource-limited settings, Kenya has substantially reduced the risk of transfusion-associated HIV infection. As the national testing and donor selection algorithm is effective, implementing NAT is unlikely to add a significant safety benefit. These findings should encourage other countries in the region to fully adopt the WHO strategies. |
Increasing access to HIV counseling and testing through mobile services in Kenya: strategies, utilization, and cost-effectiveness
Grabbe KL , Menzies N , Taegtmeyer M , Emukule G , Angala P , Mwega I , Musango G , Marum E . J Acquir Immune Defic Syndr 2010 54 (3) 317-23 INTRODUCTION: This study compares client volume, demographics, testing results, and costs of 3 "mobile" HIV counseling and testing (HCT) approaches with existing "stand-alone" HCT in Kenya. A retrospective cohort of 62,173 individuals receiving HCT between May 2005 and April 2006 was analyzed. Mobile HCT approaches assessed were community-site mobile HCT, semimobile container HCT, and fully mobile truck HCT. Data were obtained from project monitoring data, project accounts, and personnel interviews. RESULTS: Mobile HCT reported a higher proportion of clients with no prior HIV test than stand-alone (88% vs. 58%). Stand-alone HCT reported a higher proportion of couples than mobile HCT (18% vs. 2%) and a higher proportion of discordant couples (12% vs. 4%). The incremental cost-effectiveness of adding mobile HCT to stand-alone services was $14.91 per client tested (vs. $26.75 for stand-alone HCT); $16.58 per previously untested client (vs. $43.69 for stand-alone HCT); and $157.21 per HIV-positive individual identified (vs. $189.14 for stand-alone HCT). CONCLUSIONS: Adding mobile HCT to existing stand-alone HCT seems to be a cost-effective approach for expanding HCT coverage for reaching different target populations, including women and young people, and for identifying persons with newly diagnosed HIV infection for referral to treatment and care. |
The need for computerized tracking systems for resource-limited settings: the example of Georgetown, Guyana
Basavaraju SV , Pitman JP , Henry N , McEwan C , Harry C , Hasbrouck L , Marum L . Transfus Med 2009 19 (3) 149-51 Blood services in industrialized countries routinely use computerized tracking systems, the merits of which are described extensively in the literature. Such systems ease blood utilization review, enhance safety and improve tracking (Dohnalek et al., 2004; Davies et al., 2006; Dzik, 2007). Computerized blood-use modelling and prediction systems are typically used in developed nations to forecast demand (Katz et al., 1983; Sirelson & Brodheim, 1991; Nightingale et al., 2003). Because of financial and logistical challenges, such systems are uncommon in resource-limited settings, where blood services rely on manual, paper-based methods, or simple electronic tools (e.g., Microsoft Excel). Here we highlight the specific challenges faced by a blood service in a resource-limited setting and describe future options for low-cost, scalable computerized systems for developing countries. | In Guyana, blood is collected, screened and distributed by the National Blood Transfusion Service (NBTS), a branch of the Guyana Ministry of Health. Approximately 80% of all blood collected by NBTS is distributed to the Georgetown Public Hospital Corporation (GPHC), Guyana's only tertiary-care referral centre. For record keeping, NBTS collects daily information on blood (whole blood and blood products) units requested, cross-matched units issued and units returned unused in three paper-based registers. In October 2007, NBTS instituted an expanded paper-based Blood Request Form (BRF), which, for the first time, allowed NBTS to match patient data from the wards with blood centre data from the three registers. Properly completed BRFs, which are submitted by physicians, are now required for NBTS to dispense blood. NBTS files BRFs in three folders labelled as follows: (1) cancelled before preparation by NBTS; (2) prepared and retrieved by ward and (3) prepared but not retrieved by ward. In December 2007, NBTS conducted a preliminary internal review of November 2007 (the first complete month in which BRFs were used) records. This review suggested that nearly 60% of all blood units requested by GPHC were not delivered by NBTS. In January 2008, NBTS requested technical assistance from the U.S. Centers for Disease Control and Prevention (CDC) to conduct a rapid and focused assessment to investigate the extent of this apparent blood shortage. The investigation focused on the blood-ordering process at GPHC, the NBTS system to track GPHC requests and the distribution and flow of blood units. In conjunction with NBTS, CDC conducted a retrospective review and descriptive analysis of NBTS records for November 2007. The review tracked blood request information through the paper-based system of registers and folders. Data were extracted from the sources described above: BRFs filed in the three folders and entries in the three data registers. |
Site factors may be more important than participant factors in explaining HIV test acceptance in the prevention of mother-to-child HIV transmission programme in Kenya, 2005
Anand A , Shiraishi RW , Sheikh AA , Marum LH , Bolu O , Mutsotso W , Sabin K , Ayisi R , Diaz T . Trop Med Int Health 2009 14 (10) 1215-9 OBJECTIVE: To determine the role of participant factors on the acceptance of a Prevention-of-Mother-to-Child (PMTCT) HIV test programme in a situation with an opt-out testing strategy. METHODS: We analysed antenatal clinic (ANC) HIV sentinel surveillance data. All 43 sites in the 2005 round of Kenya's ANC surveillance offered opt-out PMTCT services and recorded if women were offered PMTCT HIV testing and whether they accepted or refused. Logistic regression was used to determine the role of participant-level factors on PMTCT acceptance. RESULTS: During the period of sentinel surveillance, 13 026 women attended ANC and testing was offered to 12 030 women. Of those offered testing, 9690 (80.5%) accepted, with a large variation in the percent of acceptors by site. Age, residence and educational status were significant determinants of PMTCT acceptance. However, after adjusting for site none of the participant-level factors were significant determinants of PMTCT acceptance. CONCLUSIONS: Participant level factors were not significant determinants of PMTCT HIV test acceptance after adjusting for sites. PMTCT programmes should collect and evaluate the role of site-level (provider and testing service) factors on PMTCT acceptance. Improvement of site-level factors could improve PMTCT uptake. |
Knowledge of HIV status, sexual risk behaviors and contraceptive need among people living with HIV in Kenya and Malawi
Anand A , Shiraishi RW , Bunnell RE , Jacobs K , Solehdin N , Abdul-Quader AS , Marum LH , Muttunga JN , Kamoto K , Aberle-Grasse JM , Diaz T . AIDS 2009 23 (12) 1565-73 BACKGROUND: Several studies support the need for effective interventions to reduce HIV transmission risk behaviors among people living with HIV/AIDS (PLWHAs). DESIGN: Cross-sectional nationally representative demographic health survey of Kenya (2003) and Malawi (2004-2005) that included HIV testing for consenting adults. METHODS: We analyzed demographic health survey data for awareness of HIV status and sexual behaviors of PLWHAs (Kenya: 412; Malawi: 664). The analysis was adjusted (weighted) for the design of the survey and the results are nationally representative. FINDINGS: Eighty-four percent of PLWHAs in Kenya and 86% in Malawi had sex in the past 12 months and in each country, 10% reported using condoms at last intercourse. Among sexually active PLWHAs, 86% in Kenya and 96% in Malawi reported their spouse or cohabiting partner as their most recent partner. In multivariate logistic regression models, married or cohabiting PLWHAs were significantly more likely to be sexually active and less likely to use condoms. Over 80% of PLWHAs were unaware of their HIV status. Of HIV-infected women, nearly three-quarters did not want more children either within the next 2 years or ever, but 32% in Kenya and 20% in Malawi were using contraception. INTERPRETATION: In 2003-2005, majority of PLWHAs in Kenya and Malawi were unaware of their HIV status and were sexually active, especially married or cohabiting PLWHAs. Of HIV-infected women not wanting more children, few used contraception. HIV testing should be expanded, prevention programs should target married or cohabiting couples and family planning services should be integrated with HIV services. |
A peer-led HIV counselling and testing programme for the deaf in Kenya
Taegtmeyer M , Hightower A , Opiyo W , Mwachiro L , Henderson K , Angala P , Ngare C , Marum E . Disabil Rehabil 2009 31 (6) 508-14 PURPOSE: To describe and evaluate the establishment of the first VCT services for the Deaf in Africa. METHOD: Operational research methods were used to document programme establishment. The demographics of deaf VCT clients were compared with hearing clients at the same sites as well as where clients had learned of the service, HIV risks, and HIV test results. Univariate and multivariate analyses were used. RESULTS: During the two year period (January 2004 to December 2005) 1709 Deaf and 1649 hearing clients were seen at three Deaf VCT sites. The majority of Deaf clients in this sample learned of the services through the peer education programme. Data indicate that Deaf VCT clients are as much at risk of HIV from sexual transmission as their hearing counterparts and that Deaf persons seeking VCT services have an HIV prevalence of 7%, similar to the national rate of 6.7%. CONCLUSIONS: The Deaf in Kenya are at risk of HIV and there is an urgent need for Deaf-friendly HIV services, supplemented by peer education programmes. This is the first published report describing HIV services run by the Deaf for the Deaf in the developing world. |
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