The UNAIDS 95-95-95 targets are an important metric for guiding national HIV programs and measuring progress towards ending the HIV epidemic as a public health threat by 2030. Nevertheless, as proportional targets, the outcome of reaching the 95-95-95 targets will vary greatly across, and within, countries owing to the geographic diversity of the HIV epidemic. Countries and subnational units with a higher initial prevalence and number of people living with HIV (PLHIV) will remain with a larger number and higher prevalence of virally unsuppressed PLHIV-persons who may experience excess morbidity and mortality and can transmit the virus to others. Reliance on achievement of uniform proportional targets as a measure of program success can potentially mislead resource allocation and progress towards equitable epidemic control. More granular surveillance information on the HIV epidemic is required to effectively calibrate strategies and intensity of HIV programs across geographies and address current and projected health disparities that may undermine efforts to reach and sustain HIV epidemic control even after the 95 targets are achieved.

BACKGROUND: HIV low-level viremia (LLV) (51-999 copies/mL) can progress to treatment failure and increase potential for drug resistance. We analyzed retrospective longitudinal data from people living with HIV (PLHIV) on antiretroviral therapy (ART) in Kenya to understand LLV prevalence and virologic outcomes. METHODS: We calculated rates of virologic suppression (≤50 copies/mL), LLV (51-999 copies/mL), virologic non-suppression (≥1000 copies/mL), and virologic failure (≥2 consecutive virologic non-suppression results) among PLHIV aged 15 years and older who received at least 24 weeks of ART during 2015-2021. We analyzed risk for virologic non-suppression and virologic failure using time-dependent models (each viral load (VL) <1000 copies/mL used to predict the next VL). FINDINGS: Of 793,902 patients with at least one VL, 18.5% had LLV (51-199 cp/mL 11.1%; 200-399 cp/mL 4.0%; and 400-999 cp/mL 3.4%) and 9.2% had virologic non-suppression at initial result. Among all VLs performed, 26.4% were LLV. Among patients with initial LLV, 13.3% and 2.4% progressed to virologic non-suppression and virologic failure, respectively. Compared to virologic suppression (≤50 copies/mL), LLV was associated with increased risk of virologic non-suppression (adjusted relative risk [aRR] 2.43) and virologic failure (aRR 3.86). Risk of virologic failure increased with LLV range (aRR 2.17 with 51-199 copies/mL, aRR 3.98 with 200-399 copies/mL and aRR 7.99 with 400-999 copies/mL). Compared to patients who never received dolutegravir (DTG), patients who initiated DTG had lower risk of virologic non-suppression (aRR 0.60) and virologic failure (aRR 0.51); similarly, patients who transitioned to DTG had lower risk of virologic non-suppression (aRR 0.58) and virologic failure (aRR 0.35) for the same LLV range. INTERPRETATION: Approximately a quarter of patients experienced LLV and had increased risk of virologic non-suppression and failure. Lowering the threshold to define virologic suppression from <1000 to <50 copies/mL to allow for earlier interventions along with universal uptake of DTG may improve individual and program outcomes and progress towards achieving HIV epidemic control. FUNDING: No specific funding was received for the analysis. HIV program support was provided by the President's Emergency Plan for AIDS Relief (PEPFAR) through the United States Centers for Disease Control and Prevention (CDC).

We analyzed data from the 2018 Kenya Population-Based HIV Impact Assessment (KENPHIA), a cross-sectional, nationally representative survey, to estimate the burden and prevalence of pediatric HIV infection, identify associated factors, and describe the clinical cascade among children aged < 15 years in Kenya. Interviewers collected information from caregivers or guardians on child's demographics, HIV testing, and treatment history. Blood specimens were collected for HIV serology and if HIV-positive, the samples were tested for viral load and antiretrovirals (ARV). For participants <18 months TNA PCR is performed. We computed weighted proportions with 95% confidence intervals (CI), accounting for the complex survey design. We used bivariable and multivariable logistic regression to assess factors associated with HIV prevalence. Separate survey weights were developed for interview responses and for biomarker testing to account for the survey design and non-response. HIV burden was estimated by multiplying HIV prevalence by the national population projection by age for 2018. Of 9072 survey participants (< 15 years), 87% (7865) had blood drawn with valid HIV test results. KENPHIA identified 57 HIV-positive children, translating to an HIV prevalence of 0.7%, (95% CI: 0.4%-1.0%) and an estimated 138,900 (95% CI: 84,000-193,800) of HIV among children in Kenya. Specifically, children who were orphaned had about 2 times higher odds of HIV-infection compared to those not orphaned, adjusted Odds Ratio (aOR) 2.2 (95% CI:1.0-4.8). Additionally, children whose caregivers had no knowledge of their HIV status also had 2 times higher odds of HIV-infection compared to whose caregivers had knowledge of their HIV status, aOR 2.4 (95% CI: 1.1-5.4)". From the unconditional analysis; population level estimates, 78.9% of HIV-positive children had known HIV status (95% CI: 67.1%-90.2%), 73.6% (95% CI: 60.9%-86.2%) were receiving ART, and 49% (95% CI: 32.1%-66.7%) were virally suppressed. However, in the clinical cascade for HIV infected children, 92% (95% CI: 84.4%-100%) were receiving ART, and of these, 67.1% (95% CI: 45.1%-89.2%) were virally suppressed. The KENPHIA survey confirms a substantial HIV burden among children in Kenya, especially among orphans.

BACKGROUND: In sub-Saharan Africa, HIV prevalence in adolescent girls and young women (AGYW) is 2-fold to 3-fold higher than that in adolescent boys and young men. Understanding AGYW's perception of HIV risk is essential for HIV prevention efforts. METHODS: We analyzed data from a HIV biobehavioral survey conducted in western Kenya in 2018. Data from AGYW aged 15-24 years who had a documented HIV status were included. We calculated weighted prevalence and evaluated factors associated with outcomes of interest (HIV infection and high risk perception) using generalized linear models to calculate prevalence ratios. RESULTS: A total of 3828 AGYW were included; 63% were aged 15-19 years. HIV prevalence was 4.5% and 14.5% of sexually active AGYW had high risk perception. Over 70% of participants had accessed HIV testing and counseling in the past 12 months. Factors associated with both HIV infection and high risk perception included having an HIV-positive partner or partner with unknown status and having a sexually transmitted infection in the past 12 months. Having an older (by ≥10 years) partner was associated with HIV infection, but not high risk perception. Less than 30% of sexually active AGYW with 3 or more HIV risk factors had high perception of HIV risk. CONCLUSION: Gaps in perceived HIV risk persist among AGYW in Kenya. High access to HIV testing and prevention services in this population highlights platforms through which AGYW may be reached with improved risk counseling, and to increase uptake of HIV prevention strategies.

Introduction: Kaposis sarcoma (KS) is the most common HIV-associated malignancy in Sub Saharan Africa. In 2018, it was the 7th most common cancer and the 10th most common cause of cancer death in Kenya. This study aimed to describe the baseline and clinical characteristics and treatment response observed following combined antiretroviral treatment (ART) and chemotherapy in KS patients. Methods: This was a descriptive analysis of patients aged 15 years treated for KS and HIV at 11 treatment hubs in Central Kenya between 2011 and 2014. Data on baseline and clinical characteristics, ART and chemotherapy regimens as well as treatment responses were collected from patient files and KS registers. Results: A total of 95 patients presenting with clinically suspected KS with no history of prior treatment with chemotherapy were reviewed. All had histological diagnostic samples taken with 67 (71%) having confirmed KS. All were on ART, either newly initiated or continuing on ART, and 63 of the 67 (94.0%) confirmed to have KS received chemotherapy. Among the 67 patients with confirmed KS, mean age was 37.2 years ( 13.2) and 40 (59.7%) were male. More than 80% had normal baseline and follow-up BMI, and 34 (50.7%) were on a TDF-based regimen, 52 (77.6%) were treated with the Adriamycin, bleomycin and vinblastine protocol, and 55 (82.1%) had KS diagnosis before HIV diagnosis. All 67 patients had mucocutaneous lesions. Complete, partial response and stable disease occurred in 27 (40.3%), 10 (14.9%) and 7 (10.4%), respectively, 11 (16.4%) defaulted care during treatment, six patients died during treatment, four patients died before treatment while two patients had progressive disease during chemotherapy. Conclusion: The diagnosis of KS preceded HIV in the majority of cases reviewed, with histology helpful to reduce misdiagnosis. Patients generally complied with their chemotherapy, with overall good response rate for this intervention implemented at primary health-care facilities. 2022 McLigeyo et al.

BACKGROUND: Maternal immunization is a key strategy for reducing morbidity and mortality associated with infectious diseases in mothers and their newborns. Recent developments in the science and safety of maternal vaccinations have made possible development of new maternal vaccines ready for introduction in low- and middle-income countries. Decisions at the policy level remain the entry point for maternal immunization programs. We describe the policy and decision-making process in Kenya for the introduction of new vaccines, with particular emphasis on maternal vaccines, and identify opportunities to improve vaccine policy formulation and implementation process. METHODS: We conducted 29 formal interviews with government officials and policy makers, including high-level officials at the Kenya National Immunization Technical Advisory Group, and Ministry of Health officials at national and county levels. All interviews were recorded and transcribed. We analyzed the qualitative data using NVivo 11.0 software. RESULTS: All key informants understood the vaccine policy formulation and implementation processes, although national officials appeared more informed compared to county officials. County officials reported feeling left out of policy development. The recent health system decentralization had both positive and negative impacts on the policy process; however, the negative impacts outweighed the positive impacts. Other factors outside vaccine policy environment such as rumours, sociocultural practices, and anti-vaccine campaigns influenced the policy development and implementation process. CONCLUSIONS: Public policy development process is complex and multifaceted by its nature. As Kenya prepares for introduction of other maternal vaccines, it is important that the identified policy gaps and challenges are addressed.

To inform targeted HIV testing, we developed and externally validated a risk-score algorithm that incorporated behavioral characteristics. Outpatient data from five health facilities in western Kenya, comprising 19,458 adults >/= 15 years tested for HIV from September 2017 to May 2018, were included in univariable and multivariable analyses used for algorithm development. Data for 11,330 adults attending one high-volume facility were used for validation. Using the final algorithm, patients were grouped into four risk-score categories: </= 9, 10-15, 16-29 and >/= 30, with increasing HIV prevalence of 0.6% [95% confidence interval (CI) 0.46-0.75], 1.35% (95% CI 0.85-1.84), 2.65% (95% CI 1.8-3.51), and 15.15% (95% CI 9.03-21.27), respectively. The algorithm's discrimination performance was modest, with an area under the receiver-operating-curve of 0.69 (95% CI 0.53-0.84). In settings where universal testing is not feasible, a risk-score algorithm can identify sub-populations with higher HIV-risk to be prioritized for HIV testing.

BACKGROUND: The scale-up of HIV treatment programs has resulted in a reduction in HIV-related morbidity and mortality. However, retention of patients in these programs remains a challenge in sub-Saharan Africa. Understanding factors associated with loss to follow-up (LTFU) and mortality outcomes is therefore important to inform targeted program interventions. METHODS: A retrospective multi-cohort analysis of 23,890 adult patients on ART over 36 months of follow-up in Kenya was done. Multivariate logistic regression analysis was done to assess for factors associated with LTFU and mortality at 6, 12, 24, and 36 months of follow-up. RESULTS: Majority, 67.7%, were female. At 36 months, 27.2% were LTFU and 13.5% had died. Factors associated with mortality at 36 months included older age (51 years and above) using 20-35 years as reference [(adjusted odds ratio [aOR], 1.51, 95% confidence interval (CI) 1.23-1.86, p < 0.001], being male (aOR, 1.59, 95% CI 1.39-1.83, p < 0.001), divorced using married as reference (aOR, 1.86, 95% CI 1.56-2.22, p < 0.001), having a body mass index (BMI) score of less than 18.5 kg/m(2) using 18.5-24.9 kg/m(2) as reference (aOR = 1.79, 95% CI 1.52-2.11, p < 0.001), and, World Health Organization stage III and IV using stage I as the reference (aOR, 1.94, 95% CI 1.43-2.63 and aOR, 4.24, 95% CI 3.06-5.87, p < 0.001 respectively). Factors associated with LTFU at 36 months included being young between 20 and 35 years (aOR, 1.49, 95% CI 1.40-1.59, p < 0.001) using 36-50 years as reference, being male (aOR, 1.19, 95% CI 1.12-1.27, p < 0.001), and being single or divorced using married as reference (aOR, 1.34, 95% CI 1.23-1.45 and aOR, 1.25, 95% CI 1.15-1.36, p < 0.001 respectively). Patients with baseline BMI of less than 18.5 kg/m(2) using normal BMI as reference (aOR, 1.68, 95% CI 1.39-2.02, p < 0.001) were also likely to be LTFU. CONCLUSIONS: Factors associated with LTFU and mortality were generally similar over time. Implementation of programs in similar settings should be tailored to gender, age profiles, nutritional, and, marital status of patients to address LTFU. In addition, programs should focus on the care of older patients to reduce the risk of mortality.

Homa Bay, Siaya, and Kisumu counties in western Kenya have the highest estimated HIV prevalence (16.3-21.0%) in the country, and struggle to meet program targets for HIV testing services (HTS). The Kenya Ministry of Health (MOH) recommends annual HIV testing for the general population. We assessed the degree to which reducing the interval for retesting to less than 12 months increased diagnosis of HIV in outpatient departments (OPD) in western Kenya. We conducted a retrospective analysis of routinely collected program data from seven high-volume (>800 monthlyOPD visits) health facilities in March-December, 2017. Data from persons >/=15 years of age seeking medical care (patients) in the OPD and non-care-seekers (non-patients) accompanying patients to the OPD were included. Outcomes were meeting MOH (routine) criteria versus criteria for a reduced retesting interval (RRI) of <12 months, and HIV test result. STATA version 14.2 was used to calculate frequencies and proportions, and to test for differences using bivariate analysis. During the 9-month period, 119,950 clients were screened for HIV testing eligibility, of whom 79% (94,766) were eligible and 97% (92,153) received a test. Among 92,153 clients tested, the median age was 28 years, 57% were female and 40% (36,728) were non-patients. Overall, 20% (18,120) of clients tested met routine eligibility criteria: 4% (3,972) had never been tested, 10% (9,316) reported a negative HIV test in the past >12 months, and 5% (4,832) met other criteria. The remaining 80% (74,033) met criteria for a RRI of < 12 months. In total 1.3% (1,185) of clients had a positive test. Although the percent yield was over 2-fold higher among those meeting routine criteria (2.4% vs. 1.0%; p<0.001), 63% (750) of all HIV infections were found among clients tested less than 12 months ago, the majority (81%) of whom reported having a negative test in the past 3-12 months. Non-patients accounted for 45% (539) of all HIV-positive persons identified. Percent yield was higher among non-patients as compared to patients (1.5% vs. 1.2%; p-value = <0.001) overall and across eligibility criteria and age categories. The majority of HIV diagnoses in the OPD occurred among clients reporting a negative HIV test in the past 12 months, clients ineligible for testing under the current MOH guidelines. Nearly half of all HIV-positive individuals identified in the OPD were non-patients. Our findings suggest that in the setting of a generalized HIV epidemic, retesting persons reporting an HIV-negative test in the past 3-12 months, and routine testing of non-patients accessing the OPD are key strategies for timely diagnosis of persons living with HIV.

BACKGROUND: Pregnant women and newborns are at high risk for infectious diseases. Altered immunity status during pregnancy and challenges fully vaccinating newborns contribute to this medical reality. Maternal immunization is a strategy to protect pregnant women and their newborns. This study aimed to find out how patient-provider relationships affect maternal vaccine uptake, particularly in the context of a lower middle- income country where limited research in this area exists. METHODS: We conducted semi-structured, in-depth narrative interviews of both providers and pregnant women from four sites in Kenya: Siaya, Nairobi, Mombasa, and Marsabit. Interviews were conducted in either English or one of the local regional languages. RESULTS: We found that patient trust in health care providers (HCPs) is integral to vaccine acceptance among pregnant women in Kenya. The HCP-patient relationship is a fiduciary one, whereby the patients' trusts is primarily rooted in the provider's social position as a person who is highly educated in matters of health. Furthermore, patient health education and provider attitudes are crucial for reinstating and fostering that trust, especially in cases where trust was impeded by rumors, community myths and misperceptions, and religious and cultural factors. CONCLUSION: Patient trust in providers is a strong facilitator contributing to vaccine acceptance among pregnant women in Kenya. To maintain and increase immunization trust, providers have a critical role in cultivating a positive environment that allows for favorable interactions and patient health education. This includes educating providers on maternal immunizations and enhancing knowledge of effective risk communication tactics in clinical encounters.

Background . Expansion of maternal immunization, which offers some of the most effective protection against morbidity and mortality in pregnant women and neonates, requires broad acceptance by healthcare providers and their patients. We aimed to describe issues surrounding acceptance and demand creation for maternal vaccines in Kenya from a provider perspective. Methods . Nurses and clinical officers were recruited for semi-structured interviews covering resources for vaccine delivery, patient education, knowledge and attitudes surrounding maternal vaccines, and opportunities for demand creation for new vaccines. Interviews were conducted in English and Swahili, transcribed verbatim from audio recordings, and analyzed using codes developed from interview guide questions and emergent themes. Results . Providers expressed favorable attitudes about currently available maternal immunizations and introduction of additional vaccines, viewing themselves as primarily responsible for vaccine promotion and patient education. The importance of educational resources for both patients and providers to maintain high levels of maternal immunization coverage was a common theme. Most identified barriers to vaccine acceptance and delivery were cultural and systematic in nature. Suggestions for improvement included improved patient and provider education, including material resources, and community engagement through religious and cultural leaders. Conclusions . The distribution of standardized, evidence-based print materials for patient education may reduce provider overwork and facilitate in-clinic efforts to inform women about maternal vaccines. Continuing education for providers should address communication surrounding current vaccines and those under consideration for introduction into routine schedules. Engagement of religious and community leaders, as well as male decision-makers in the household, will enhance future acceptance of maternal vaccines.

Purpose: Informing adolescents of their own HIV infection is critical as the number of adolescents living with HIV increases. We assessed the association between HIV disclosure and retention in care and mortality among adolescents aged 10-14 years in Kenya's national program. Methods: We abstracted routinely collected patient-level data for adolescents enrolled into HIV care in 50 health facilities from November 1, 2004, through March 31, 2010. We defined disclosure as any documentation that the adolescent had been fully or partially made aware of his or her HIV status. We compared weighted proportions for categorical variables using chi2 and weighted logistic regression to identify predictors of HIV disclosure; we estimated the probability of LTFU using Kaplan-Meier methods and dying using Cox regression-based test for equality of survival curves. Results: Of the 710 adolescents aged 10-14 years analyzed; 51.3% had severe immunosuppression, 60.3% were in WHO stage 3 or 4, and 36.6% were aware of their HIV status. Adolescents with HIV-infected parents, histories of opportunistic infections (OIs), and enrolled in support groups were more likely to be disclosed to. At 36 months, disclosure was associated with lower mortality [1.5% (95% CI.6%-4.1%) versus 5.4% (95% CI 3.6.6%-8.0%, p <.001)] and lower LTFU [6.2% (95% CI 3.0%-12.6%) versus 33.9% (95% CI 27.3%-41.1%) p <.001]. Conclusions: Only one third of HIV-infected Kenyan adolescents in treatment programs had been told they were infected, and knowing their HIV status was associated with reduced LTFU and mortality. The disclosure process should be systematically encouraged and organized for HIV-infected adolescents.

Antenatal register data from 62 clinics in 5 regions of Kenya were used to estimate women with HIV risk (partner HIV status, syphilis). With individual risk-guided PrEP offer in all regions, 39% of pregnant women nationally would be offered PrEP. PrEP offer to all women in high prevalence regions would result in 26%.

Background: Understanding trends in patient profiles and identifying predictors for adverse outcomes are key to improving the effectiveness of HIV care and treatment programs. Previous work in Kenya has documented findings from a rural setting. This paper describes trends in demographic and clinical characteristics of antiretroviral therapy (ART) treatment cohorts at a large urban, referral HIV clinic and explores treatment outcomes and factors associated with attrition during 12 years of follow-up. Methods: This was a retrospective cohort analysis of HIV-infected adults who started ART between January 1, 2004, and September 30, 2015. ART-experienced patients and those with missing data were excluded. The Cochran-Armitage test was used to determine trends in baseline characteristics over time. Cox proportional hazards models were used to determine the effect of baseline characteristics on attrition. Results: ART uptake among older adolescents (15-19 years), youth, and young adults increased over time (p=0.0001). Independent predictors for attrition included (adjusted hazard ratio [95% CI]) male sex: 1.30 (1.16-1.45), p=0.0001; age: 15-19 years: 1.83 (1.26-2.66), p=0.0014; 20-24 years: 1.93 (1.52-2.44), p=0.0001; and 25-29 years: 1.31 (1.11-1.54), p=0.0012; marital status - single: 1.27 (1.11-1.44), p=0.0005; and divorced/separated: 1.56 (1.30-1.87), p=0.0001; urban residence: 1.40 (1.20-1.64), p=0.0001; entry into HIV care following hospitalization: 1.31 (1.10-1.57), p=0.0026, or transfer from another facility: 1.60 (1.26-2.04), p=0.0001; initiation of ART more than 12 months after the date of HIV diagnosis: 1.36 (1.19-1.55), p=0.0001, and history of a current or past opportunistic infection (OI): 1.15 (1.02-1.30), p=0.0284. Conclusion: Although ART uptake among adolescents and young people increased over time, this group was at increased risk for attrition. Single marital status, urban residence, history of hospitalization or OI, and delayed initiation of ART also predicted attrition. This calls for focused evidence-informed strategies to address attrition and improve outcomes.

Introduction: Home Based Testing and Counselling (HBTC) aims at reaching individuals who have low HIV risk perception and experience barriers which prevent them from seeking HIV testing and counseling (HTC) services. Saturating the community with HTC is needed to achieve the ambitious 90-90-90 targets of knowledge of HIV status, ARV treatment and viral suppression. This paper describes the use of health belief model and community participation principles in HBTC to achieve increased household coverage and HTC uptake. Methods: This cross sectional survey was done between August 2009 and April 2011 in Kibera slums, Nairobi city. Using three community participation principles; defining and mobilizing the community, involving the community, overcoming barriers and respect to cultural differences and four constructs of the health belief model; risk perception, perceived severity, perceived benefits of changed behavior and perceived barriers; we offered HTC services to the participants. Descriptive statistics were used to describe socio-demographic characteristics, calculate uptake and HIV prevalence. Results: There were 72,577 individuals enumerated at the start of the program; 75,141 residents were found during service delivery. Of those, 71,925 (95.7%) consented to participate, out of which 71,720 (99.7%) took the HIV test. First time testers were (39%). The HIV prevalence was higher (6.4%) among repeat testers than first time testers (4.0%) with more women (7.4%) testing positive than men (3.6%) and an overall 5.5% slum prevalence. Conclusion: This methodology demonstrates that the use of community participation principles combined with a psychosocial model achieved high HTC uptake, coverage and diagnosed HIV in individuals who believed they are HIV free. This novel approach provides baseline for measuring HTC coverage in a community.

A survey of 461 HIV-infected Kenyan children receiving antiretroviral therapy found 143 (31%) failing virologically. Drug resistance mutations were found in 121; 37 had L74V/I mutations, with 95% receiving abacavir-containing regimens. L74V/I was associated with current abacavir usage (p=0.0001). L74V/I may be more prevalent than previously realized in children failing abacavir-containing regimens, even when time on treatment has been short. Ongoing rigorous pediatric drug resistance surveillance is needed.

BACKGROUND: Tuberculosis (TB) screening in Prevention of Mother-To-Child Transmission (PMTCT) programs is important to improve TB detection, prevention and treatment. METHODS: As part of a national PMTCT program evaluation, mother-infant pairs attending 6-week and 9-month immunization visits were enrolled at 141 maternal and child health clinics throughout Kenya. Clinics were selected using population-proportion-to-size sampling with oversampling in a high human immunodeficiency virus (HIV) prevalence region. The World Health Organization (WHO) TB symptom screen was administered to HIV-infected mothers, and associations with infant cofactors were determined. RESULTS: Among 498 HIV-infected mothers, 165 (33%) had a positive TB symptom screen. Positive maternal TB symptom screen was associated with prior TB (P = 0.04). Women with a positive TB symptom screen were more likely to have an infant with HIV infection (P = 0.02) and non-specific TB symptoms, including cough (P = 0.003), fever (P = 0.05), and difficulty breathing (P = 0.01). TB exposure was reported by 11% of the women, and 15% of the TB-exposed women received isoniazid preventive therapy. CONCLUSIONS: Postpartum HIV-infected mothers frequently had a positive TB symptom screen. Mothers with a positive TB symptom screen were more likely to have infants with HIV or non-specific TB symptoms. Integration of maternal TB screening and prevention into PMTCT programs may improve maternal and infant outcomes.

BACKGROUND: The success of antiretroviral therapy in resource-scarce settings is an illustration that complex healthcare interventions can be successfully delivered even in fragile health systems. Documenting the success factors in the scale-up of HIV care and treatment in resource constrained settings will enable health systems to prepare for changing population health needs. This study describes changing demographic and clinical characteristics of adult pre-ART cohorts, and identifies predictors of pre-ART attrition at a large urban HIV clinic in Nairobi, Kenya. METHODS: We conducted a retrospective cohort analysis of data on HIV infected adults (≥15 years) enrolling in pre-ART care between January 2004 and September 2015. Attrition (loss to program) was defined as those who died or were lost to follow-up (having no contact with the facility for at least 6 months). We used Kaplan-Meier survival analysis to determine time to event for the different modes of transition, and Cox proportional hazards models to determine predictors of pre-ART attrition. RESULTS: Over the 12 years of observation, there were increases in the proportions of young people (age 15 to 24 years); and patients presenting with early disease (by WHO clinical stage and higher median CD4 cell counts), p = 0.0001 for trend. Independent predictors of attrition included: aHR (95% CI): male gender 1.98 (1.69-2.33), p = 0.0001; age 20-24 years 1.80 (1.37-2.37), p = 0.0001), or 25-34 years 1.22 (1.01-1.47), p = 0.0364; marital status single 1.55 (1.29-1.86), p = 0.0001) or divorced 1.41(1.02-1.95), p = 0.0370; urban residency 1.83 (1.40-2.38), p = 0.0001; CD4 count of 0-100 cells/µl 1.63 (1.003-2.658), p = 0.0486 or CD4 count >500 cells/µl 2.14(1.46-3.14), p = 0.0001. CONCLUSIONS: In order to optimize the impact of HIV prevention, care and treatment in resource scarce settings, there is an urgent need to implement prevention and treatment interventions targeting young people and patients entering care with severe immunosuppression (CD4 cell counts <100 cells/µl). Additionally, care and treatment programmes should strengthen inter-facility referrals and linkages to improve care coordination and prevent leakages in the HIV care continuum.

BACKGROUND: Tenofovir disoproxil fumarate (TDF) is commonly used in antiretroviral treatment (ART) and preexposure prophylaxis regimens. We evaluated the relationship of prenatal TDF use and growth outcomes among Kenyan HIV-exposed uninfected (HEU) infants. Materials and Methods: We included PCR-confirmed HEU infants enrolled in a cross-sectional survey of mother-infant pairs conducted between July and December 2013 in Kenya. Maternal ART regimen during pregnancy was determined by self-report and clinic records. Six-week and 9-month z-scores for weight-for-age (WAZ), weight-for-length (WLZ), length-for-age (LAZ), and head circumference-for-age (HCAZ) were compared among HEU infants with and without TDF exposure using t-tests and multivariate linear regression models. RESULTS: 277 mothers who received ART during pregnancy, 63% initiated ART before pregnancy, of which 89 (32%) used TDF. No differences in birth weight (3.0 kg versus 3.1 kg, p = 0.21) or gestational age (38 weeks versus 38 weeks, p = 0.16) were detected between TDF-exposed and TDF-unexposed infants. At 6 weeks, unadjusted mean WAZ was lower among TDF-exposed infants (-0.8 versus -0.4, p = 0.03), with a trend towards association in adjusted analyses (p = 0.06). There were no associations between prenatal TDF use and WLZ, LAZ, and HCAZ in 6-week or 9-month infant cohorts. CONCLUSION: Maternal TDF use did not adversely affect infant growth compared to other regimens.

Under Kenyan guidelines, HIV-exposed infants should be tested for HIV DNA at 6 weeks or at first clinical contact thereafter, as infants come for immunization. Following the introduction of early infant diagnoses programmes, however, many infants were not being tested and linked to care and treatment. We developed the Mother & Child Health Booklet to help relate mothers' obstetrical history to infants' healthcare providers to facilitate follow-up and timely management. The booklet contains information on the mother's pregnancy, delivery and postpartum course and her child's growth and development, immunization, nutrition and other data need to monitor the child to 5 years of age. It replaced three separate record clinical cards. In a 1 year pilot evaluation of the booklet in Nyanza province in 2007-08, the number of HIV DNA tests on infants increased by 34% from 9966 to 13 379. The booklet was subsequently distributed nationwide in 2009. Overall, the numbers of infants tested for HIV DNA rose from 27 000 in 2007 to 60 000 in 2012, which represents approximately 60% of the estimated HIV-exposed infants in Kenya. We believe that the booklet is an important strategy for identifying and treating infected infants and, thus, in progress toward Millennium Development Goal 4.

Brucellosis is a common bacterial zoonotic infection but data on the prevalence among humans and animals is limited in Kenya. A cross-sectional survey was conducted in three counties practicing different livestock production systems to simultaneously assess the seroprevalence of, and risk factors for brucellosis among humans and their livestock (cattle, sheep, camels, and goats). A two-stage cluster sampling method with random selection of sublocations and households. Blood samples were collected from humans and animals and tested for Brucella immunoglobulin G (IgG) antibodies. Human and animal individual seroprevalence was 16% and 8%, respectively. Household and herd seroprevalence ranged from 5% to 73% and 6% to 68%, respectively. There was a 6-fold odds of human seropositivity in households with a seropositive animal compared with those without. Risk factors for human seropositivity included regular ingestion of raw milk (adjusted odds ratio [aOR] = 3.5, 95% confidence interval [CI] = 2.8-4.4), exposure to goats (herding, milking, and feeding) (aOR = 3.1, 95% CI = 2.5-3.8), and handling of animal hides (aOR = 1.8, 95% CI = 1.5-2.2). Attaining at least high school education and above was a protective factor for human seropositivity (aOR = 0.3, 95% CI = 0.3-0.4). This linked study provides evidence of a strong association between human and animal seropositivity at the household level.

BACKGROUND: Although health care-associated infections are an important cause of morbidity and mortality worldwide, the epidemiology and etiology of respiratory health care-associated infections (rHAIs) have not been documented in Kenya. In 2010, the Ministry of Health, Kenya Medical Research Institute, and Centers for Disease Control and Prevention initiated surveillance for rHAIs at 3 hospitals. METHODS: At each hospital, we surveyed intensive care units (ICUs), pediatric wards, and medical wards to identify patients with rHAIs, defined as any hospital-onset (≥3 days after admission) fever (≥38 degrees C) or hypothermia (<35 degrees C) with concurrent signs or symptoms of acute respiratory infection. Nasopharyngeal and oropharyngeal specimens were collected from these patients and tested by real-time reverse transcription polymerase chain reaction for influenza and 7 other viruses. RESULTS: From April 2010-September 2012, of the 379 rHAI cases, 60.7% were men and 57.3% were children <18 years old. The overall incidence of rHAIs was 9.2 per 10,000 patient days, with the highest incidence in the ICUs. Of all specimens analyzed, 45.7% had at least 1 respiratory virus detected; 92.2% of all positive viral specimens were identified in patients <18 years old. CONCLUSION: We identified rHAIs in all ward types under surveillance in Kenyan hospitals. Viruses may have a substantial role in these infections, particularly among pediatric populations. Further research is needed to refine case definitions and understand rHAIs in ICUs.

Health care workers (HCWs) in sub-Saharan Africa are at a high risk of HIV infection from both sexual and occupational exposures. However, many do not seek HIV testing. This paper examines the acceptability of an unsupervised facility-based HIV self-testing (HIVST) intervention among HCWs and their partners and factors associated with uptake of HIVST among HCWs. HCWs in seven large Kenyan hospitals were invited to participate in pre-HIVST information sessions during which they were offered HIVST kits to take home for self-testing. A post-intervention survey was conducted among 765 HCWs. Forty-one percent attended the information session; of those, 89 % took the HIVST kits and of those, 85 % self-tested. Thirty-four percent of surveyed HCWs used the HIVST to test themselves. Of those who took the HIVST kit and had partners, 73 % gave the kit to their partner and 86 % of them indicated their partner self-tested. Factors positively associated with use of the HIVST on self were being female, being single, and being a HCW from Homa Bay Hospital (located in a high HIV prevalence area). HIVST is acceptable to HCWs and their partners. However, strategies are needed to increase HCWs attendance at pre-implementation information sessions.

BACKGROUND: In Kenya, the comparative incidences of tuberculosis among persons with and without HIV have not been described, and the differential impact of public health interventions on tuberculosis incidence in the two groups is unknown. METHODS: We estimated annual tuberculosis incidence stratified by HIV status during 2006-2012 based on the numbers of reported tuberculosis patients with and without HIV infection, the prevalence of HIV infection in the general population, and the total population. We also made crude estimates of annual tuberculosis incidence stratified by HIV status during 1998-2012 by assuming a constant ratio of HIV prevalence among tuberculosis patients compared to the general population. RESULTS: Tuberculosis incidence among both adults with HIV and adults without HIV increased during 1998-2004 then remained relatively stable until 2007. During 2007-2012, tuberculosis incidence declined by 28-44% among adults with HIV and by 11-26% among adults without HIV, concurrent with an increase in antiretroviral therapy uptake. In 2012, tuberculosis incidence among adults with HIV (1,839-1,936 cases/100,000 population) was still eight times as high as among adults without HIV (231-238 cases/100,000 population), and approximately one third of tuberculosis cases were attributable to HIV. CONCLUSIONS: Although tuberculosis incidence has declined among adults with and without HIV, the persistent high incidence of tuberculosis among those with HIV and the disparity between the two groups are concerning. Early diagnosis of HIV, early initiation of antiretroviral therapy, regular screening for tuberculosis, and isoniazid preventive therapy among persons with HIV, as well as tuberculosis control in the general population, are required to address these issues.

BACKGROUND: Enhanced HIV surveillance using demographic, behavioral, and biologic data from national surveys can provide information to evaluate and respond to HIV epidemics efficiently. METHODS: From October 2012 to February 2013, we conducted a two-stage cluster sampling survey of persons aged 18 months to 64 years in 9 geographic regions in Kenya. Participants answered questionnaires and provided blood for HIV testing. We estimate HIV prevalence, HIV incidence, describe trends in HIV prevalence over the past five years, and identify factors associated with HIV infection. This analysis is restricted to persons aged 15 to 64 years. RESULTS: HIV prevalence was 5.6% (95% CI 4.9-6.3%) in 2012, a significant decrease from 2007, when HIV prevalence, excluding the North Eastern region, was 7.2% (95% CI 6.6-7.9%). HIV incidence was 0.4% (95% CI 0.2-0.6) in 2012. Among women, factors associated with undiagnosed HIV infection included being aged 35-39 years, divorced or separated, being from urban residences and Nyanza region, self-perceiving a moderate risk of HIV infection, condom use with the last partner, and reporting four or more lifetime number of partners. Among men, widowhood, condom use with the last partner, and lack of circumcision were associated with undiagnosed HIV infection. CONCLUSION: HIV prevalence has declined in Kenya since 2007. With improved access to treatment, HIV prevalence has become more challenging to interpret without data on new infections or mortality. Correlates of undiagnosed HIV infection provide important information on where to prioritize prevention interventions to reduce transmission of HIV in the broader population.

BACKGROUND: Prevention of unplanned pregnancies is a critical element in the prevention of mother-to-child-transmission (PMTCT) of HIV, but its potential has not been fully realized. We assessed the utilization of family planning (FP) and fertility desires among women of reproductive age by HIV status. METHODS: We selected a nationally representative sample of households using a stratified two-stage cluster design and surveyed women aged 15-49 years. We administered questionnaires and examined predictors of current use of FP methods and desire for children among sexually active women with known HIV infection and women who were HIV-uninfected. RESULTS: Of 3,583 respondents, 68.2% were currently using FP and 57.7% did not desire children in the future. Among women who did not desire children in the future, 70.9% reported that they were using FP, including 68.7% of women with known HIV infection and 71.0% of women who were HIV-uninfected. Women with known HIV infection had similar odds of using FP as women with no HIV infection (odds ratio [OR] 1.12, 95% confidence interval [CI] 0.81-1.54). Women with no HIV infection had significantly higher adjusted odds of desiring future children (adjusted OR [aOR] 2.27, 95% CI 1.31 - 3.93) than women with known HIV infection. CONCLUSIONS: There is unmet need for FP for HIV-infected women, underscoring a gap in the national PMTCT strategy. Efforts to empower HIV-infected women to prevent unintended pregnancies should lead to expanded access to contraceptive methods and take into account women's reproductive intentions.

BACKGROUND: During the Rift Valley fever (RVF) epidemic of 2006-2007 in eastern Africa, spatial mapping of the outbreaks across Kenya, Somalia, and Tanzania was performed and the RVF viruses were isolated and genetically characterized. METHODS: Following confirmation of the RVF epidemic in Kenya on 19 December 2006 and in Tanzania on 2 February 2007, teams were sent to the field for case finding. Human, livestock, and mosquito specimens were collected and viruses isolated. The World Health Organization response team in Kenya worked with the WHO's polio surveillance team inside Somalia to collect information and specimens from Somalia. RESULTS: Seven geographical foci that reported hundreds of livestock and >25 cases in humans between December 2006 and June 2007 were identified. The onset of RVF cases in each epidemic focus was preceded by heavy rainfall and flooding for at least 10 days. Full-length genome analysis of 16 RVF virus isolates recovered from humans, livestock, and mosquitoes in 5 of the 7 outbreak foci revealed 3 distinct lineages of the viruses within and across outbreak foci. CONCLUSION: The findings indicate that the sequential RVF epidemics in the region were caused by multiple lineages of the RVF virus, sometimes independently activated or introduced in distinct outbreak foci.