Transmission Of HIV In Kenya Research Articles

Effect of an opt-out point-of-care HIV-1 nucleic acid testing intervention to detect acute and prevalent HIV infection in symptomatic adult outpatients and reduce HIV transmission in Kenya: a randomized controlled trial.

BackgroundIn sub‐Saharan Africa, adult outpatients with symptoms of acute infectious illness are not routinely tested for prevalent or acute HIV infection (AHI) when seeking healthcare.MethodsAdult symptomatic outpatients aged 18–39 years were evaluated by a consensus AHI risk score. Patients with a risk score ≥ 2 and no previous HIV diagnosis were enrolled in a stepped‐wedge trial of opt‐out delivery of point‐of‐care (POC) HIV‐1 nucleic acid testing (NAAT), compared with standard provider‐initiated HIV testing using rapid tests in the observation period. The primary outcome was the number of new diagnoses in each study period. Generalized estimating equations with a log‐binomial link and robust variance estimates were used to account for clustering by health facility. The trial is registered with ClinicalTrials.gov NCT03508908.ResultsBetween 2017 and 2020, 13 (0.9%) out of 1374 participants in the observation period and 37 (2.5%) out of 1500 participants in the intervention period were diagnosed with HIV infection. Of the 37 newly diagnosed cases in the intervention period, two (5.4%) had AHI. Participants in the opt‐out intervention had a two‐fold greater odds of being diagnosed with HIV (odds ratio = 2.2, 95% confidence interval: 1.39–3.51) after adjustment for factors imbalanced across study periods.ConclusionsAmong symptomatic adults aged 18–39 years targeted by our POC NAAT intervention, we identified one chronic HIV infection for every 40 patients and one AHI patient for every 750 patients tested. Although AHI yield was low in this population, routinely offered opt‐out testing could diagnose twice as many patients as an approach relying on provider discretion.

An Interactive Text Messaging Intervention to Improve Adherence to Option B+ Prevention of Mother-to-Child HIV Transmission in Kenya: Cost Analysis.

BackgroundMobile health (mHealth) approaches offer potentially affordable ways to support the care of HIV-infected patients in overstretched health care systems. However, only few studies have analyzed the costs associated with mHealth solutions for HIV care.ObjectiveThe aim of this study was to estimate the total incremental costs and incremental cost per beneficiary of an interactive SMS text messaging support intervention within a clinical trial.MethodsThe Mobile WAChX trial (NCT02400671) evaluates an interactive semiautomated SMS text messaging intervention to improve adherence to antiretroviral therapy and retention in care among peripartum women infected with HIV in Kenya to reduce the mother-to-child transmission of HIV. Women were randomized to receive one-way versus two-way SMS text messages. Messages were sent weekly, and these messages included motivational and educational content and visit reminders; two-way messaging enabled prompt consultation with the nurse as needed. Microcosting methods were used to collect resource-use data related to implementing the Mobile WAChX SMS text messaging intervention. At 2 sites (Nairobi and Western Kenya), we conducted semistructured interviews with health personnel to identify startup and recurrent activities by obtaining information on the personnel, supplies, and equipment. Data on expenditures and prices from project expense reports, administrative records, and published government salary data were included to estimate the total incremental costs. Using a public provider perspective, we estimated incremental unit costs per beneficiary and per contact during 2017.ResultsThe weighted average annual incremental costs for the two-way SMS text messaging group were US $3725 per facility, US $62 per beneficiary, and US $0.85 per contact to reach 115 beneficiaries. For the one-way SMS text messaging group, the weighted average annual incremental costs were US $2542 per facility, US $41 per beneficiary, and US $0.66 per contact to reach 117 beneficiaries. The largest cost shares were for the personnel: 48.2% (US $1794/US $3725) in two-way and 32.4% (US $825/US $2542) in one-way SMS text messaging groups. Costs associated with software development and communication accounted for 29.9% (US $1872/US $6267) of the costs in both intervention arms (US $1042 vs US $830, respectively).ConclusionsCost information for budgeting and financial planning is relevant for implementing mHealth interventions in national health plans. Given the proportion of costs related to systems development, it is likely that costs per beneficiary will decline with the scale-up of the interventions.

A Novel HIV-1 RNA Testing Intervention to Detect Acute and Prevalent HIV Infection in Young Adults and Reduce HIV Transmission in Kenya: Protocol for a Randomized Controlled Trial

BackgroundDetection and management of acute HIV infection (AHI) is a clinical and public health priority, and HIV infections diagnosed among young adults aged 18 to 39 years are usually recent. Young adults with recent HIV acquisition frequently seek care for symptoms and could potentially be diagnosed through the health care system. Early recognition of HIV infection provides considerable individual and public health benefits, including linkage to treatment as prevention, access to risk reduction counseling and treatment, and notification of partners in need of HIV testing.ObjectiveThe Tambua Mapema Plus study aims to (1) test 1500 young adults (aged 18-39 years) identified by an AHI screening algorithm for acute and prevalent (ie, seropositive) HIV, linking all newly diagnosed HIV-infected patients to care and offering immediate treatment; (2) offer assisted HIV partner notification services to all patients with HIV, testing partners for acute and prevalent HIV infection and identifying local sexual networks; and (3) model the potential impact of these two interventions on the Kenyan HIV epidemic, estimating incremental costs per HIV infection averted, death averted, and disability-adjusted life year averted using data on study outcomes.MethodsA modified stepped-wedge design is evaluating the yield of this HIV testing intervention at 4 public and 2 private health facilities in coastal Kenya before and after intervention delivery. The intervention uses point-of-care HIV-1 RNA testing combined with standard rapid antibody tests to diagnose AHI and prevalent HIV among young adults presenting for care, employs HIV partner notification services to identify linked acute and prevalent infections, and follows all newly diagnosed patients and their partners for 12 months to ascertain clinical outcomes, including linkage to care, antiretroviral therapy (ART) initiation and virologic suppression in HIV-infected patients, and pre-exposure prophylaxis uptake in uninfected individuals in discordant partnerships.ResultsEnrollment started in December 2017. As of April 2020, 1374 participants have been enrolled in the observation period and 1500 participants have been enrolled in the intervention period, with 13 new diagnoses (0.95%) in the observation period and 37 new diagnoses (2.47%), including 2 AHI diagnoses, in the intervention period. Analysis is ongoing and will include adjusted comparisons of the odds of the following outcomes in the observation and intervention periods: being tested for HIV infection, newly diagnosed with prevalent or acute HIV infection, linked to care, and starting ART by week 6 following HIV diagnosis. Participants newly diagnosed with acute or prevalent HIV infection in the intervention period are being followed for outcomes, including viral suppression by month 6 and month 12 following ART initiation and partner testing outcomes.ConclusionsThe Tambua Mapema Plus study will provide foundational data on the potential of this novel combination HIV prevention intervention to reduce ongoing HIV transmission in Kenya and other high-prevalence African settings.Trial RegistrationClinicalTrials.gov NCT03508908; https://clinicaltrials.gov/ct2/show/NCT03508908International Registered Report Identifier (IRRID)DERR1-10.2196/16198

Postpartum Depression and Prevention of Mother-to-Child Transmission of HIV in Kenya.

Postpartum Depression and Prevention of Mother-to-Child Transmission of HIV in Kenya.

Association of the US President’s Emergency Plan for AIDS Relief’s Funding With Prevention of Mother-to-Child Transmission of HIV in Kenya

From 2004 to 2014, the US President's Emergency Plan for AIDS Relief (PEPFAR) invested more than $248 000 000 in the prevention of mother-to-child transmission (PMTCT) of HIV in Kenya. Concurrently, child mortality in Kenya decreased by half. To identify the extent to which the decrease in child mortality in Kenya is associated with PEPFAR funding for PMTCT of HIV. This population-based survey study conducted in Kenya estimated the association between annual per capita PEPFAR funding for PMTCT (annual PCF) and cumulative per capita PEPFAR funding for PMTCT (cumulative PCF), extracted using 2004-2014 country operational reports as well as individual-level health outcomes, extracted from the 2003, 2008-2009, and 2014 Kenya Demographic and Health Surveys and the 2007 and 2012 Kenya AIDS Indicator Surveys. The study included children of female respondents to the 2003, 2008-2009, and 2014 Kenya Demographic and Health Surveys who were born 1 to 60 months (for neonatal mortality) or 12 to 60 months (for infant mortality) before the survey, as well as female respondents who had recently given birth and reported on HIV testing during antenatal care (ANC) during the 2007-2014 surveys. Results were adjusted for year, province, and survey respondent characteristics. Statistical analysis was performed from July 8, 2016, to December 10, 2018. Neonatal mortality was defined as death within the first month of life and infant mortality was defined as death within the first year of life. HIV testing during ANC was defined as receiving counseling on PMTCT, undergoing an HIV test, and receiving test results during ANC. The analysis included 33 181 neonates (16 870 boys), 26 876 infants (13 679 boys), and 20 775 mothers (mean [SD] age, 28.0 [6.7] years). PEPFAR funding was not associated with neonatal mortality. A $0.33 increase in annual PCF, corresponding to the difference between the 75th and 25th (interquartile range) percentiles of funding, was significantly associated with a 16% (95% CI, 4%-27%) reduction in infant mortality after a 1-year lag. A 14% to 16% reduction persisted after 2- and 3-year lags, and comparable reductions were observed for unlagged and 1-year lagged cumulative PCF. An increase of 1 interquartile range in cumulative PCF was associated with a 7% (95% CI, 3%-11%) increase in HIV testing during ANC, which intensified with subsequent lags. Between 2004 and 2014, sustained funding levels of $0.33 annual PCF could have averted 118 039 to 273 924 infant deaths. Evidence from publicly available data suggests that PEPFAR's PMTCT funding was associated with a reduction in infant mortality and an increase in HIV testing during ANC in Kenya. The full outcome of funding may not be realized until several years after allocation.

Adapting the HIV Infant Tracking System to Support Prevention of Mother-to-Child Transmission of HIV in Kenya: Protocol for an Intervention Development Pilot Study in Two Hospitals.

BackgroundDespite progress to expand access to HIV testing and treatment during pregnancy in Kenya, gaps still remain in prevention of mother-to-child transmission of HIV (PMTCT) services. This study addresses the need for effective and scalable interventions to support women throughout the continuum of care for PMTCT services in low-resource settings. Our research team has successfully implemented the HIV Infant Tracking System (HITSystem), a Web-based, system-level intervention to improve early infant diagnosis (EID) outcomes.ObjectiveThis study will expand the scope of the HITSystem to address PMTCT services to bridge the gap between maternal and pediatric HIV services and improve outcomes. This paper describes the intervention development protocol to adapt and pilot an HITSystem version 2.0 to assess acceptability, feasibility, and preliminary PMTCT outcomes in Kenya.MethodsThis is a 3-year intervention development study to adapt the current HITSystem intervention to support a range of PMTCT outcomes including appointment attendance, antiretroviral therapy (ART) adherence, hospital deliveries, and integration of maternal and pediatric HIV services in low-resource settings. The study will be conducted in 3 phases. Phase 1 will elicit feedback from intervention users (patients and providers) to guide development and refinement of the new PMTCT components and inform optimal implementation. In Phase 2, we will design and develop the HITSystem 2.0 features to support key PMTCT outcomes guided by clinical content experts and findings from Phase 1. Phase 3 will assess complete PMTCT retention (before, during, and after delivery) using a matched randomized pilot study design in 2 hospitals over 18 months. A total of N=108 HIV-positive pregnant women (n=54 per site) will be enrolled and followed from their first PMTCT appointment until infant HIV DNA Polymerase Chain Reaction testing at the target age of 6 weeks (<7 weeks) postnatal.ResultsFunding for this study was received in August 2015, enrollment in Phase 1 began in March 2016, and completion of data collection is expected by May 2019.ConclusionsThis protocol will extend, adapt, and pilot an HITSystem 2.0 version to improve attendance of PMTCT appointments, increase ART adherence and hospital-based deliveries, and prompt EID by 6 weeks postnatal. The HITSystem 2.0 aims to improve the integration of maternal and pediatric HIV services.Trial RegistrationClinicalTrials.gov NCT02726607; https://clinicaltrials.gov/ct2/show/NCT02726607 (Archived by WebCite at http://www.webcitation.org/78VraLrOb)International Registered Report Identifier (IRRID)DERR1-10.2196/13268

Development of a Novel Scale to Measure Male Partner Involvement in the Prevention of Mother-to-Child Transmission of HIV in Kenya.

Male partner involvement is an important factor in prevention of mother-to-child transmission (PMTCT). Yet, poor conceptualization has hindered optimal assessment of male involvement. We created and evaluated a brief 10-item male partner involvement scale using principal components analysis and scree plots, Cronbach's alpha, and linear regression with survey data from postpartum women with HIV (n = 200) in Kenya. The scale had a two-factor structure: male encouragement/reminders and active participation. The overall scale and the encouragement/reminders sub-scale displayed strong internal reliability. In the multivariable models, the scales were positively associated with constructive relationship dynamics, HIV status disclosure, and couple HIV testing and counseling, and negatively associated with internalized HIV stigma. The encouragements/reminders sub-scale was also negatively associated with a new HIV diagnosis during pregnancy. This work furthers the conceptualization of male partner involvement in PMTCT and provides a valid measure to assess male involvement as a pathway to better PMTCT outcomes.

The Enhanced Mentor Mother ProgrAm (EMMA) for the prevention of mother-to-child transmission of HIV in Kenya: study protocol for a cluster randomized controlled trial

BackgroundAs of September 2014, Kenya implemented the WHO recommended Option B+ guidelines in which all newly diagnosed HIV-infected pregnant women are immediately eligible for triple antiretroviral therapy (ART) for life regardless of CD4 count. In addition, Kenya previously established the Kenya Mentor Mother Program (KMMP) in 2012 to improve peer education and psychosocial support services within the national prevention of mother-to-child transmission (PMTCT) program. The primary objectives of the study described in the current protocol are: (1) to evaluate implementation of these new guidelines (Option B+ with Mentor Mothers) as part of routine service delivery; and (2) to evaluate potential benefits of a package of services within the KMMP (called EMMA) to improve PMTCT service delivery.MethodsWe will conduct a cluster randomized controlled trial in western Kenya. We will allocate 12 clinics providing PMTCT services including ART to two study arms using pair matching: the standard of care (SOC) arm, which includes the KMMP as implemented by the clinics; and the intervention arm, which is the SOC (including KMMP) with the EMMA package of services (a targeted exit interview, visit reminders, and targeted follow-up). At the intervention clinics, the EMMA package of services is implemented as part of routine service delivery. A total of 360 (180 in each arm) pregnant women will be enrolled in the study at or near their first visit for antenatal care for prospective records review through 72 weeks post-partum. The primary and secondary outcomes are uninterrupted supplies of ART medications throughout the PMTCT cascade of care as well as infants completing HIV testing on schedule.DiscussionThe EMMA package of services provides specific structure to the use of Mentor Mothers within PMTCT programs. This strategy was developed in collaboration with local health facility and PMTCT program staff based on their experience providing PMTCT services within the integrated ART-MCH facilities. If successful, this approach has the potential to improve dramatically PMTCT service delivery with minor additional costs beyond the basic mother–mentor program and support global goals to eliminate mother-to-child transmission.Trial registrationClinicalTrials.gov, NCT02848235. Registered on 19 July 2016.

Frontloading HIV financing maximizes the achievable impact of HIV prevention.

IntroductionDue to the nature of funding, national planners and international donors typically balance budgets over short time periods when designing HIV programmes (˜5‐year funding cycles). We aim to explicitly quantify the cost of short‐term funding arrangements on the success of future HIV prevention programmes.MethodsUsing mathematical models of HIV transmission in Kenya, we compare the impact of optimized combination prevention strategies under different constraints on investment over time. Each scenario has the same total budget for the 30‐year intervention period but the pattern of spending over time is allowed to vary. We look at the impact of programmes with decreasing, increasing or constant spending across 5‐year funding cycles for a 30‐year period. Interventions are optimized within each funding cycle such that strategies take a short‐term view of the epidemic. We compare these with two strategies with no spending pattern constraints: one with static intervention choices and another flexible strategy with interventions changed in year ten.Results and DiscussionFor the same total 30‐year budget, greatest impact is achieved if larger initial prevention spending is offset by later treatment savings which leads to accumulating benefits in reduced infections. The impact under funding cycle constraints is determined by the extent to which greater initial spending is permitted. Short‐term funding constraints and funds held back to later years may reduce impact by up to 18% relative to the flexible long‐term strategy.ConclusionsEnsuring that funding arrangements are in place to support long‐term prevention strategies will make spending most impactful. Greater prevention spending now will bring considerable returns through reductions in new infections, greater population health and reductions in the burden on health services in the future.

Mathematical modelling of the impact of testing, treatment and control of HIV transmission in Kenya

The control of spread of HIV to reduce its effects on a population is an important role of public health. HIV testing and counselling (HTC) and eventual enrolment of infected individuals on anti re...

Mother-to-child transmission of HIV in Kenya: A cross-sectional analysis of the national database over nine years.

ObjectiveTo describe factors associated with mother-to-child HIV transmission (MTCT) in Kenya and identify opportunities to increase testing/care coverage.DesignCross-sectional analysis of national early infant diagnosis (EID) database.Methods365,841 Kenyan infants were tested for HIV from January 2007-July 2015 and results, demographics, and treatment information were entered into a national database. HIV risk factors were assessed using multivariable logistic regression.Results11.1% of infants tested HIV positive in 2007–2010 and 6.9% in 2014–2015. Greater odds of infection were observed in females (OR: 1.08; 95% CI:1.05–1.11), older children (18–24 months vs. 6 weeks-2 months: 4.26; 95% CI:3.87–4.69), infants whose mothers received no PMTCT intervention (vs. HAART OR: 1.92; 95% CI:1.79–2.06), infants receiving no prophylaxis (vs. nevirapine for 6 weeks OR: 2.76; 95% CI:2.51–3.05), and infants mixed breastfed (vs. exclusive breastfeeding OR: 1.39; 95% CI:1.30–1.49). In 2014–2015, 9.1% of infants had mothers who were not on treatment during pregnancy, 9.8% were not on prophylaxis, and 7.0% were mixed breastfed. Infants exposed to all three risky practices had a seven-fold higher odds of HIV infection compared to those exposed to recommended practices. The highest yield of HIV-positive infants were found through targeted testing of symptomatic infants in pediatric/outpatient departments (>15%); still, most infected infants were identified through PMTCT programs.ConclusionDespite impressive gains in Kenya’s PMTCT program, some HIV-infected infants present late and are not benefitting from PMTCT best practices. Efforts to identify these early and enforce evidence-based practice for PMTCT should be scaled up. Infant testing should be expanded in pediatric/outpatient departments, given high yields in these portals.

Progress toward elimination of perinatal HIV transmission in Kenya: Analysis of early infant diagnosis data.

Interrupting vertical transmission of HIV from mothers to infants provides opportunity to transform the HIV/AIDS epidemic by eliminating new infections among children. We estimate mother-to-child transmission rates of infants born to known HIV-positive mothers offered prevention of mother-to-child transmission interventions and provide an indication of Kenya's progress toward elimination of perinatal transmission. We obtained from the Kenya National Early Infant Diagnosis (EID) database, all 131,451 DNA polymerase chain reaction test results of HIV-exposed infants aged 0-18 months who had dried blood spot samples taken between January 2008 and October 2013. The majority of samples were from infants aged 0-6 months (81.0%). Infants aged 6-12 months comprised 15.5%, while those aged 12-18 months were 3.5%. Overall, 11,439 (8.7%) were HIV-positive. Positivity rates were higher among older age groups: 6.8, 14.6, and 27.5% in age groups 0-6 months, 6-12 months, and 12-18 months old, respectively. In Kenya, scale-up and decentralization to primary health centers of EID services has been remarkable. Both increasing HIV-positivity trends in age groups 12-18 months and differences between provinces require further interrogation. Although significant, declining HIV-positivity trends in age groups 0-6 months and 6-12 months old observed between 2008 and 2013 is insufficient to achieve the elimination agenda.

The Impact of Human Mobility on HIV Transmission in Kenya.

Disease spreads as a result of people moving and coming in contact with each other. Thus the mobility patterns of individuals are crucial in understanding disease dynamics. Here we study the impact of human mobility on HIV transmission in different parts of Kenya. We build an SIR metapopulation model that incorporates the different regions within the country. We parameterise the model using census data, HIV data and mobile phone data adopted to track human mobility. We found that movement between different regions appears to have a relatively small overall effect on the total increase in HIV cases in Kenya. However, the most important consequence of movement patterns was transmission of the disease from high infection to low prevalence areas. Mobility slightly increases HIV incidence rates in regions with initially low HIV prevalences and slightly decreases incidences in regions with initially high HIV prevalence. We discuss how regional HIV models could be used in public-health planning. This paper is a first attempt to model spread of HIV using mobile phone data, and we also discuss limitations to the approach.

Mother-to-child transmission of HIV in Kenya: results from a nationally representative study.

Kenya has an estimated 13,000 new infant HIV infections that occur annually. We measured the burden of HIV infection among women of childbearing age and assessed access to and coverage of key prevention of mother-to-child transmission interventions. The second Kenya AIDS Indicator Survey was a nationally representative 2-stage cluster sample of households. We analyzed data from women aged 15-54 years who had delivered a newborn within the preceding 5 years and from whom we obtained samples for HIV testing. Of 3310 women who had ≥1 live birth in the preceding 5 years, 2862 (86.5%) consented to HIV testing in the survey, and 171 (6.1%) were found to be infected. Ninety-five percent received prenatal care, 93.1% were screened for HIV during prenatal care, and of those screened, 97.8% received their test results. Seventy-six women were known to be infected in their last pregnancy. Of these, 54 (72.3%) received antepartum antiretroviral prophylaxis, and 51 (69.1%) received intrapartum prophylaxis; 56 (75.3%) reported their newborns received postpartum prophylaxis. Of the 76 children born to these mothers, 63 (82.5%) were tested for HIV at the first immunization visit or thereafter, and 8 (15.1%) were HIV infected. We found a substantial burden of HIV in Kenyan women of childbearing age and a cumulative 5-year mother-to-child transmission rate of 15%. Although screening has improved over the past 5 years, fewer than three-quarters of infected pregnant women are receiving antiretroviral prophylaxis. Universal antiretroviral therapy for HIV-infected pregnant women will be essential in achieving Kenyan's target to eliminate mother-to-child transmission to <5% by 2015.

Medical Injection Use Among Adults and Adolescents Aged 15 to 64 Years in Kenya

Unsafe medical injections remain a potential route of HIV transmission in Kenya. We used data from a national survey in Kenya to study the magnitude of medical injection use, medication preference, and disposal of medical waste in the community. The Kenya AIDS Indicator Survey 2012 was a nationally representative population-based survey. Among participants aged 15-64 years, data were collected regarding medical injections received in the year preceding the interview; blood samples were collected from participants for HIV testing. Of the 13,673 participants who answered questions on medical injections, 35.9% [95% confidence interval (CI): 34.5 to 37.3] reported receiving ≥1 injection in the past 12 months and 51.2% (95% CI: 49.7 to 52.8) preferred receiving an injection over a pill. Among those who received an injection from a health care provider, 95.9% (95% CI: 95.2 to 96.7) observed him/her open a new injection pack, and 7.4% (95% CI: 6.4 to 8.4) had seen a used syringe or needle near their home or community in the past 12 months. Men who had received ≥1 injection in the past 12 months (adjusted odds ratio, 3.2; 95% CI: 1.2 to 8.9) and women who had received an injection in the past 12 months, not for family planning purposes (adjusted odds ratio, 2.6; 95% CI: 1.2 to 5.5), were significantly more likely to be HIV infected compared with those who had not received medical injection in the past 12 months. Injection preference may contribute to high rates of injections in Kenya. Exposure to unsafe medical waste in the community poses risks for injury and infection. We recommend that community- and facility-based injection safety strategies be integrated in disease prevention programs.

The Effect of Absenteeism and Clinic Protocol on Health Outcomes: The Case of Mother-to-Child Transmission of HIV in Kenya

The Effect of Absenteeism and Clinic Protocol on Health Outcomes: The Case of Mother-to-Child Transmission of HIV in Kenya

The Effect of Absenteeism and Clinic Protocol on Health Outcomes: The Case of Mother-to-Child Transmission of HIV in Kenya

Absenteeism of health workers in developing countries is widespread with some estimates indicating rates of provider absence of nearly 40% (Chaudhury et. al. 2006). This is the first paper to present evidence of the impact of health provider absence combined with limitations in health clinic protocol on health outcomes. Using longitudinal data from nearly 600 ante-natal care seekers at a rural ante-natal clinic in Western Kenya, we find that nurse absence on a patient's first visit significantly reduces the probability that a woman tests for HIV over her entire pregnancy. Since the benefits of PMTCT services depend on HIV status, we proxy HIV status with self-reported pre-test expectations of being HIV-positive and estimate the heterogeneous impact of absence based on these self-reported expectations. We find that women with a high pre-test expectation of testing HIV-positive and whose first ANC visit coincides with nurse attendance are 25 percentage points more likely to deliver in a hospital or health center, 7.4 percentage points more likely to receive PMTCT medication, 9 percentage points less likely to breastfeed and 10 percentage points more likely to enroll in the free AIDS treatment program at the clinic than similar women whose first visit coincides with nurse absence. The procedural shortcomings in our study setting, shortcomings that do not enable pregnant women to test on a subsequent clinic visit, appear common in other countries in sub-Saharan Africa. They suggest that nurse absence in the context of this medical system translates into sizable reductions in child and maternal health.

Investing In HIV Services While Building Kenya’s Health System: PEPFAR’s Support To Prevent Mother-To-Child HIV Transmission

Trade-offs may exist between investments to promote health system strengthening, such as investments in facilities and training, and the rapid scale-up of HIV/AIDS services. We analyzed trends in expenditures to support the prevention of mother-to-child transmission of HIV in Kenya under the President's Emergency Plan for AIDS Relief (PEPFAR) from 2005 to 2010. We examined how expenditures changed over time, considering health system strengthening alongside direct treatment of patients. We focused on two organizations carrying out contracts under PEPFAR: the Elizabeth Glaser Pediatric AIDS Foundation and FHI360 (formerly Family Health International), a nonprofit health and development organization. We found that the average unit expenditure, or the spending on goods and services per mother living with HIV who was provided with antiretroviral drugs, declined by 52 percent, from $567 to $271, during this time period. The unit expenditure per mother-to-infant transmission averted declined by 66 percent, from $7,117 to $2,440. Meanwhile, the health system strengthening proportion of unit expenditure increased from 12 percent to 33 percent during the same time period. The analysis suggests that PEPFAR investments in prevention of mother-to-child transmission of HIV in Kenya became more efficient over time, and that there was no strong evidence of a trade-off between scaling up services and investing in health systems.

Reduced risk of transfusion-transmitted HIV in Kenya through centrally co-ordinated blood centres, stringent donor selection and effective p24 antigen-HIV antibody screening

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. 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. 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%). 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.

Formula Feeding Reduces HIV Transmission in Kenya

With seroprevalence of HIV infection among pregnant women living in urban, sub-Saharan Africa higher than 30% in some countries, identifying strategies