Kenyan Women Research Articles

Protection at First Sexual Intercourse Among Adolescent Girls and Young Women in Kenya.

Adolescent girls and young women (AGYW) are at high risk of HIV and other sexually transmitted infections (STIs), including at first sexual intercourse. The literature is scarce on factors influencing use of protective strategies at this critical time. We conducted 20 in-depth interviews and five focus group discussions with purposively sampled AGYW aged 16-20years who reported first sex while enrolled in a larger cohort study and willing to participate. All AGYW were counseled on HIV prevention and had access to reproductive health information and services. Data collected were transcribed, translated and analyzed thematically. We identified two approaches to first sex. In one approach, the AGYW facilitated protection use, and those AGYW reported intention and preparation to initiate sexual activity and ability to request condom use, as well as their male partner's willingness to use and provide condoms. In another approach, AGYW experienced first sexual intercourse without agency (the feeling of control over actions and their consequences [Moore, 2016]) and described lack of prior intentions and planning, discomfort with discussions about sex and condom use, and desire to experience sexual pleasure as reported by peers. No AGYW mentioned parents/adults as playing any role as facilitators of protection use at first sex, highlighting the need for further research on the missing gap. The AGYW were trusting of verbal reports by male partners describing themselves as having never engaged in sex, HIV negative, and free of STIs. We found that some AGYW were empowered to plan, discuss, and request protection at first sex, and others did not take agency. First sex is a time of vulnerability where innovative strategies are needed to strengthen AGYW's agency and promote condom use and other HIV/STI prevention methods.

Community Perceptions About Use of Pre-exposure Prophylaxis Among Adolescent Girls and Young Women in Kenya

Escudero, Jaclyn N. MPH*; Dettinger, Julia C. MPH; Pintye, Jillian RN, MPH, PhD; Kinuthia, John MBChB, MMed, MPH; Lagat, Harison BSN, MPH; Abuna, Felix BA; Kohler, Pamela RN, MPH, PhD; Baeten, Jared M. MD, PhD; O'Malley, Gabrielle PhD; John-Stewart, Grace C. MD, PhD; Beima-Sofie, Kristin M. MPH, PhD Author Information

Learning through social interaction: Kenyan women against female genital cutting in Kenya

Female Genital Cutting (FGC) is a human rights issue that involves the partial or total removal of the external female genitalia for non-medical reasons. Drawing on in-depth interview data collected in 2017 with 20 women from three FGC-practising ethnic groups in Kenya, I argue that informal learning through social interaction plays a critical role in the ability of Kenyan women to oppose and work against FGC in their communities. In addition to knowledge gained through formal education such as schooling and anti-FGC campaigns, women learned about FGC and ways to resist the practice through social interaction with family members, role models and peers from non-FGC practising communities. These interactions have framed challenging FGC as a worthy behaviour to pursue. They also helped women reframe ‘success.’ While a hallmark of being a successful woman has traditionally been tied to FGC, through these interactions, women learned that they can achieve a respected status as a woman without undergoing FGC. Finally, they provided support for women to stay resilient in resisting FGC. Overall, informal learning is important for understanding how some Kenyan women resist FGC.

Analyzing The Effectiveness Of The Concept Of State Responsibility Under The Convention On The Elimination Of All Forms Of Discrimination Against Women (CEDAW) With Respect To Combating Gender Based Violence

The Committee on CEDAW has made it clear that GBV is a critical obstacle to the achievement of substantive equality between women and men and to the enjoyment by women of their human rights and fundamental freedoms. In a country like Kenya for example gender based violence is rampant and is ranked as among the highest in the world. The Gender Recovery Violence Centre in Kenya reports that between 40-47 percent of Kenyan women experience GBV in their lifetime . This is a high number and one must wonder the role the government plays in ensuring that these high rates of GBV are reduced or brought completely to an end. This is the basis of this paper for it seeks to analyze the role that States like Kenya play in combating GBV by looking in depth at the concept of state responsibility as envisaged under general comment number 35 of CEDAW. The paper in doing so finds that it is apt that general comment number 35 of CEDAW has put in place measures to ensure that states are held responsible in combating GBV. However there are challenges to fully ensuring that this concept of state responsibility works. The paper hence finds that patriarchy still is the main factor which acts as a hindrance to completely eradicating GBV as due to the very common patriarchal societies women’s rights including eradicating GBV have been put on the backseat. The paper gives examples of how women’s rights have been put on the backseat by drawing an interplay between Saudi Arabia’s draconian laws against women and the fact that in spite of the laws Saudi Arabia still gets a nod from 19 powerful countries in the world to host a summit which will have impacts for women worldwide. The paper further elaborates that the mere fact that Saudi Arabia has been given a nod to host a summit as important as the G20 proves that the rule of law worldwide is being blatantly disregarded by world leaders and that this disregard to the rule of law causes a ripple effect worldwide and this ripple effect makes other important rights like women’s rights to be at risk of not being advanced. The paper also makes a point that capitalism is a driving factor to both state and non state actors in disregarding rule of law issues. The paper also depicts that concepts like state sovereignty and state immunity have made effectuating the state responsibility concept under general comment number 35 a hard task and here the paper uses Saudi Arabia as an example in showing how Saudi Arabia uses the state sovereignty and immunity concepts to disregard the provisions of general comment number 35 of CEDAW. The paper concludes by giving a strong recommendation that in order to successfully combat GBV and bring into fruitution the provisions of general comment number 35 of CEDAW then patriarchy must be uprooted completely and that rule of law must be obeyed to the maximum. The paper acknowledges the important work that women human rights activists and defenders play every day in ensuring that women rights are not derogated and ends by simply giving them the hope to continue fighting for it is in their daily fight to advance women’s rights and in this case fight to combat GBV that strides however slow are made.

The Prevalence of Interpersonal Violence (IPV) Against Women and its Associated Variables: An Exploratory Study in the Rongo Sub-County of Migori County, Kenya.

Interpersonal violence (IPV) within intimate partner relationships and gender-based violence remain major public health problems worldwide; 44.8% of Kenyan women have reported experiencing IPV beginning after the age of 15 years (National Bureau of Statistics Nairobi, Kenya, 2015). Combatting IPV and its sequelae is integral to promoting gender equality, a key target of the Sustainable Development Goals. We quantify the lifetime prevalence of IPV among women in two rural Kenyan communities, as well as factors associated with IPV in this area, such as educational attainment and severe depression. We conducted a cross-sectional population-based survey of households in the North and East Kamagambo wards of Migori County, Kenya in May 2018. A questionnaire regarding IPV was given to female respondents. Group-wise comparisons and multiple logistic regression analyses were performed to describe community prevalence and factors associated with IPV against women. A total of 873 women completed questions about IPV, representing a population estimate of 11,252 women in the study area. Lifetime IPV prevalence in the study area was 60.3%. Variables associated with IPV included involvement in a polygamous marriage (adjusted odds ratio [aOR]: 1.81; 95% confidence interval [CI]: [1.13, 2.88]; p = .013), attaining six or fewer years of education (aOR: 1.84; 95% CI: [1.27, 2.66]; p = .001), and IPV exposure in girlhood (aOR: 1.59; 95% CI: [1.12, 2.28]; p = .011). IPV was independently associated with experience of emotional abuse (OR: 11.22; 95% CI: [7.02, 17.95]; p < .001) and severe depression (OR: 3.51; 95% CI: [1.03, 11.97]; p = .045). Violence against women is a public health emergency in Migori County, Kenya. Low educational attainment, IPV exposure in girlhood, and polygamy were significantly associated with experience of IPV. Our results provide hyper-local data necessary for targeted interventions and generalizable data with sampling methods for use by other implementing organizations in sub-Saharan Africa.

Brief Report: High Accuracy of a Real-Time Urine Antibody-Based Tenofovir Point-of-Care Test Compared With Laboratory-Based ELISA in Diverse Populations.

Therapeutic drug monitoring measures antiretroviral adherence more accurately than self-report but has not been available at the point-of-care (POC) until now. We compare a novel POC test for urine tenofovir to laboratory-based enzyme-linked immunosorbent assay (ELISA) testing in diverse patient populations urine pre-exposure prophylaxis (PrEP). Urine samples were analyzed using ELISA and the POC lateral flow immunoassay (LFA) test from 2 cohorts of PrEP users taking tenofovir disoproxil fumarate/emtricitabine: the Partners PrEP Study, which recruited Kenyan and Ugandan heterosexual men and women, and the IBrEATHe Study, which recruited US transgender women and men using gender-affirming hormone therapy. We calculated the sensitivity, specificity, and accuracy of the POC test compared with ELISA at a cutoff of 1500 ng/mL. Overall, 684 urine samples were tested from 324 participants in the 2 cohorts. In Partners PrEP, 454 samples from 278 participants (41% women) were tested with a median age of 33 years. In IBrEATHe, 231 samples from 46 individuals (50% transwomen) were tested with a median age of 31 years. Comparison of the LFA read-out to ELISA yielded 100% sensitivity [97.5% one-sided confidence interval (CI) = 99.3%], 98.3% specificity (95% CI = 95.2% to 99.7%), and 99.6% accuracy (95% CI = 98.7% to 99.9%). The sensitivity, specificity, and accuracy of a novel POC test for urine tenofovir all exceeded 98% when compared with a laboratory-based ELISA method when tested in diverse patient populations. Given the LFA's high accuracy and expected low cost, this POC test is a promising tool to support antiretroviral adherence that could be widely scalable to real-world clinical settings.

Male partner testing and sexual behaviour following provision of multiple HIV self-tests to Kenyan women at higher risk of HIV infection in a cluster randomized trial.

IntroductionWithout significant increases in uptake of HIV testing among men, it will be difficult to reduce HIV incidence to disease elimination levels. Secondary distribution of HIV self‐tests by women to their male partners is a promising approach for increasing male testing that is being implemented in several countries. Here, we examine male partner and couples testing outcomes and sexual decision making associated with this approach in a cluster randomized trial.MethodsWe examined data from women at higher risk of HIV participating in the intervention arm of an ongoing pair‐matched cluster randomized trial in Kenya. HIV‐negative women ≥18 years who self‐reported ≥2 partners in the past month were eligible. Participants received self‐tests at enrolment and three‐monthly intervals. They were encouraged to offer tests to sexual partners with whom they anticipated condomless sex. At six months, we collected data on self‐test distribution, male partner and couples testing, and testing and sexual behaviour in the three most recent transactional sex encounters. We used descriptive analyses and generalized estimating equation models to understand how sexual behaviour was influenced by self‐test distribution.ResultsFrom January 2018 to April 2019, 921/1057 (87%) participants completed six‐month follow‐up. Average age was 28 years, 65% were married, and 72% reported income through sex work. Participants received 7283 self‐tests over six months, a median of eight per participant. Participants offered a median three self‐tests to sexual partners. Of participants with a primary partner, 94% offered them a self‐test. Of these, 97% accepted the test. When accepted, couples testing was reported among 91% of participants. Among 1954 transactional sex encounters, 64% included an offer to self‐test. When offered self‐tests were accepted by 93% of partners, and 84% who accepted conducted couples testing. Compared to partners with an HIV‐negative result, condom use was higher when men had a reactive result (56.3% vs. 89.7%, p < 0.01), were not offered a self‐test (56.3% vs. 62.0%, p = 0.02), or refused to self‐test (56.3% vs. 78.3, p < 0.01).ConclusionsProviding women with multiple self‐tests facilitated male partner and couples testing, and led to safer sexual behaviour. These findings suggest secondary distribution is a promising approach for reaching men and has HIV prevention potential. Clinical Trial Number: NCT03135067.

Role of social interpersonal communication in abortion decision making among Kenyan women

Role of social interpersonal communication in abortion decision making among Kenyan women

Sex Work Is Associated With Increased Vaginal Microbiome Diversity in Young Women From Mombasa, Kenya

Although nonoptimal vaginal bacteria and inflammation have been associated with increased HIV risk, the upstream drivers of these phenotypes are poorly defined in young African women. Mombasa, Kenya. We characterized vaginal microbiome and cytokine profiles of sexually active young women aged 14-24 years (n = 168) in 3 study groups: those engaging in formal sex work, in transactional sex, and nonsex workers. Vaginal secretions were collected using self-inserted SoftCup, and assayed for cytokines and vaginal microbiome through multiplex ELISA and 16S rRNA sequencing, respectively. Epidemiological data were captured using a validated questionnaire. The median age of participants was 20 years (interquartile range: 18-22 years). Approximately two-thirds of young women (105/168) had vaginal microbial communities characterized by Gardnerella and/or Prevotella spp. dominance; a further 29% (49/168) were predominantly Lactobacillus iners. Microbiome clustering explained a large proportion of cytokine variation (>50% by the first 2 principal components). Age was not associated with vaginal microbial profiles in bivariable or multivariable analyses. Women self-identifying as sex workers had increased alpha (intraindividual) diversity, independent of age, recent sexual activity, HIV, and other sexually transmitted infections (beta = 0.47, 95% confidence interval: 0.05 to 0.90, P = 0.03). Recent sex (number of partners or sex acts last week, time since last vaginal sex) correlated with increased alpha diversity, particularly in participants who were not involved in sex work. Nonoptimal vaginal microbiomes were common in young Kenyan women and associated with sex work and recent sexual activity, but independent of age. Restoring optimal vaginal microflora may represent a useful HIV prevention strategy.

The syndemic effects of food insecurity, water insecurity, and HIV on depressive symptomatology among Kenyan women

Depression is a leading cause of disability worldwide and a major contributor to the overall global burden of disease, especially for women of childbearing age. Social science scholarship has demonstrated significant relationships between mental health, food insecurity (FI), water insecurity (WI), and HIV. Little is known, however, about the temporal relationships between food and water insecurity or the mechanisms through which these multiple stressors may operate or interact to impact depression. We therefore used syndemic theory to explore the complex relationships between FI, WI, and HIV on depressive symptomatology among Kenyan women of mixed HIV status (n=183, NCT02979418). We sought to 1) understand the temporal relationships between time-variant risk factors for depression, i.e. FI and WI, and 2) assess how these factors potentially interacted with HIV to impact depressive symptomatology. We first assessed the bidirectional relationship between WI and FI using a cross-lagged three-wave, two-variable panel model. Next, we modeled depressive symptomatology at 21 months as a linear function of the potentially syndemic interaction between FI, WI, and HIV status, adjusting for household wealth. WI had a predominant predictive effect on FI (Bayesian posterior predictive p-value=0.13); there was no reverse causality for the influence of FI on WI. The interaction effect of FI, WI, and HIV was significantly associated with greater depressive symptomatology (β=0.06) at 21 months postpartum. These data suggest that water insecurity may be an important determinant of food insecurity. Further, the co-occurrence of FI, WI, and HIV increases the likelihood of maternal depressive symptomatology, i.e. there is a syndemic relationship. These findings suggest that the role of household WI in other adverse health outcomes beyond mental well-being should be examined, and that interventions to improve mental health will be more effective if they also consider concurrent resource insecurities, regardless of HIV status.

Psychosocial Factors, Condomless Sex, and Detectable Viral Load in HIV-Positive Women in Serodiscordant Couples in Nairobi, Kenya.

This prospective study of HIV-positive Kenyan women in serodiscordant couples examined relationships betweenpsychosocial factors, viral suppression, and condomless sex. Participants were screened for alcohol use disorders and intimate partner violence (IPV) annually and depressive symptoms every 6months. Prostate specific antigen (PSA) detection was used as a marker for condomless sex. A total of 151 participants contributed 349 person-years of follow-up. Hazardous/harmful alcohol use was associated with increased risk of detecting PSA in vaginal secretions (aRR 1.99, 95%CI 1.08-3.66, χ2 = 4.85 (1)), while IPV and depression were not. Events representing HIV transmission potential, where there was biological evidence of condomless sex at a visit with a detectable plasma viral load, were observed at 2% of visits. The high prevalence of IPV and association between alcohol use and sexual risk suggest the need for monitoring and support for these conditions as part of comprehensive HIV care for women.

SUN-359 Antenatal Oral Iron Supplementation, FGF23 and Bone Metabolism in Kenyan Women and Their Offspring: A Randomised Controlled Trial

Objectives: FGF23 decreases reabsorption and increases phosphate excretion in the kidney and regulates vitamin D metabolism. Maternal iron deficiency may be implicated in the pathogenesis of hypophosphataemia-driven rickets in offspring through perturbed FGF23 expression. We aimed to determine the effect of antenatal oral iron supplementation on maternal and neonatal markers of bone mineral regulation. Methods: 470 rural Kenyan women with singleton pregnancies and haemoglobin concentrations ≥90g/L were randomly allocated to daily, supervised supplementation iron (60mg as ferrous fumarate) or placebo from 13–23 weeks gestational age until 1 month postpartum. We analysed maternal and neonatal plasma samples collected at birth, with primary outcomes being concentrations of FGF23 in its intact form (I-FGF23, the phosphate- and vitamin D-regulating hormone) and its C-terminal fragment (C-FGF23). Results: In mothers and neonates, antenatal iron supplementation reduced C-FGF23 concentration by 62.6% (95%CI: -70.3% to -53.0%) and 15.2% (-28.4% to 0.3%), respectively; increased neonatal I-FGF23 concentration by 21.6% (1.2% to 46.1%); increased maternal hepcidin concentration by 136%, (86% to 200%); and decreased maternal 25-hydroxyvitamin D concentrations by 6.1nmol/L (1.2 to 11.0nmol/L). We found no effect on markers of bone turnover in either mothers or neonates. The magnitude of the effect of antenatal iron supplementation on concentrations of C-FGF23, I-FGF23 and phosphate, and on estimated glomerular filtration rate (a measure of kidney glomerular function) depended on maternal iron status at baseline Conclusions: Antenatal iron supplementation may provide health benefits to pregnant women and their offspring beyond increasing iron status. Whether iron supplementation reduces present and future infant risk of rickets remains unclear.

The Burden of Childlessness to Luo Women in Kenya

In the contemporary world, the issue of childbearing is a matter of choice. A couple may decide to bear children or not. However, within the Luo community, childbearing is an obligation that must be fulfilled by every couple; when this is not met, the couple faces several challenges. This is due to the importance the Luo community have on children. Children ensure the continuity of the lineage, and they ensure the immortality of the dead parents, among others. This article examines the burden the Luo childlessness women have to bear. The findings in this article are based on a cross-sectional field study conducted among the Catholic Luo childless couples in Western Kenya. The Luo Catholic childless couples were sampled using snowball, the Catholic priests and catechists were purposively sampled, and, the Small Christian Community (SCC) leaders were systematically sampled. Data was collected through in-depth oral interviews and Focus Group Discussions. These generated qualitative data that was transcribed, coded, analyzed thematically and presented in a descriptive form and verbatim narratives as stated by the key informants. The findings of the study indicate that the Luo childless women face a number of challenges such as alienation, stigmatization, and ridicule, among others. These challenges affect their lives within the families and at the entire community. The study recommends that childless couples to undergo a medical examination to ascertain if they can be assisted.

Cost-effectiveness analysis of pre-ART HIV drug resistance testing in Kenyan women

BackgroundThe prevalence of pre-treatment drug resistance (PDR) to non-nucleoside reverse-transcriptase inhibitor (NNRTI) agents is increasing in sub-Saharan Africa, which may decrease the effectiveness of efavirenz-based antiretroviral therapy (ART) programs. However, due to recent safety concerns, there has been hesitancy to replace efavirenz-based ART with dolutegravir in women of reproductive potential. Our objective was to evaluate whether PDR testing for women not initiating dolutegravir-based ART would be a cost-effective strategy to address the challenges posed by PDR. MethodsWe developed an HIV drug resistance model that simulates the emergence and transmission of resistance mutations, calibrated to the Kenyan epidemic. We modeled three care strategies for PDR testing among women not initiating dolutegravir-based ART: no PDR testing, PDR testing with a low-cost point mutation assay, known as oligonucleotide ligation assay (OLA), and PDR testing with consensus sequencing. Using a health sector perspective, this model was used to evaluate the health outcomes, lifetime costs, and cost-effectiveness under each strategy over a 15-year time horizon starting in 2019. FindingsOLA and CS PDR testing were projected to have incremental cost-effectiveness ratios (ICER) of $10,741/QALY gained and $134,396/QALY gained, respectively, which are not cost-effective by national income standards. Viral suppression rates among women at 12 months after ART initiation were 87·8%, 89·0%, and 89·3% with no testing, OLA testing, and CS testing, respectively. PDR testing with OLA and CS were associated with a 0.5% and 0.6% reduction in incidence rate compared to no PDR testing. Initial PDR prevalence among women was 13.1% in 2019. By 2034, this prevalence was 17·6%, 17·4%, and 17·3% with no testing, OLA testing, and CS testing, respectively. InterpretationPDR testing for women is unlikely to be cost-effective in Kenya whether one uses a low-cost assay, such as OLA, or consensus sequencing. FundingNational Institutes of Health, Gilead Sciences.

Adverse Childhood Experiences and Changing Levels of Psychosocial Distress Scores Across Pregnancy in Kenyan Women.

Background: Adverse childhood experiences (ACEs) have been associated with deleterious effects on mental health in pregnancy. Methods: The ACE International Questionnaire (ACE-IQ) was used to measure neglect, abuse, and household dysfunction. Longitudinal mixed effect modelling was used to test the effect of ACEs on pregnancy-related anxiety, depressive symptoms, and perceived stress at two time points (12–19 and 22–29 weeks) during pregnancy. Results: A total of 215 women who were predominantly married (81%) and had attained tertiary education (96%) were enrolled. Total ACEs were significantly associated with depressive symptoms (r = 0.23, p < 0.05) and perceived stress (r = 0.18, p < 0.05). As depressive symptoms decreased, t (167) = −8.44, p < 0.001, perceived stress increased, t (167) = 4.60, p < 0.001, and pregnancy-related anxiety remained unchanged as pregnancy progressed. Contact sexual abuse (p < 0.01) and parental death or divorce (p = 0.01) were significantly associated with depression over time (p < 0.01). Total ACEs in this study were associated with depressive symptoms early but not late in pregnancy. Conclusions: Higher total ACEs were positively associated with depressive symptoms and perceived stress during pregnancy, suggesting that mental disorders may have an impact on pregnancy outcomes and ought to be addressed. Further validation of the Edinburgh Postnatal Depression Scale (EPDS) tool in local settings is required.

Frequency and Predictors of Tenofovir-diphosphate Detection Among Young Kenyan Women in a Real-world Pre-exposure Prophylaxis Implementation Program.

In a pre-exposure prophylaxis program for Kenyan women, we detected tenofovir-diphosphate in 61% (125/201) of randomly selected dried blood spots collected at the first follow-up visit. Tenofovir-diphosphate was detected more frequently among women who had partners living with human immunodeficiency virus, who were not pregnant, and who were ≥24 years.

Women as Fighters for their Land Freedom in Wa Thiongo's A Grain of Wheat (1967)

This paper is planned to show how A Grain of Wheat (1967) epitomizes the Africana womanist vision. It attempts to sketch out the Africana womanist mottos that are adopted by Kenyan female figures within the Emergency period (1952-1962); a stage before Kenyan Independence. In this concern, it pays abundant attention to the cause of Kenyan women during that time and uncovers the conditions they have been put inside. Kenyan women have suffered under inimical situations and unfavorable provocations which could not be easily. Still, illuminated by the Africana womanist principles, Kenyan women have been able to persist and demonstrate their distinct capacities. With regard to this, the present paper tries to pinpoint all the aspects of domination they have been yoked by in the years preceding Independence, on the basis of Hudson-Weems' Africana Womanism hypothesis. It gets into consideration some of the particular Africana notions embodied certain elements such as the women harmony, the collective resistance to Africana patriarchal reality, the reverence for the aged, the female fellowship, the spirit of concerted enterprise, and certainly some of Kenyan female merits. These aspects are to be thoroughly examined to prove the relevance of Wa Thiongo's Africana views throughout the Emergency phase.

Predictors of Health Insurance Enrollment among HIV Positive Pregnant Women in Kenya: Potential for Adverse Selection and Implications for HIV Treatment and Prevention.

Background: The global push to achieve the 90-90-90 targets designed to end the HIV epidemic has called for the removing of policy barriers to prevention and treatment, and ensuring financial sustainability of HIV programs. Universal health insurance is one tool that can be used to this end. In sub-Saharan Africa, where HIV prevalence and incidence remain high, the use of health insurance to provide comprehensive HIV care is limited. This study looked at the factors that best predict social health insurance enrollment among HIV positive pregnant women using data from the Academic Model Providing Access to Healthcare (AMPATH) in western Kenya. Methods: Cross-sectional clinical encounter data were extracted from the electronic medical records (EMR) at AMPATH. We used univariate and multivariate logistic regressions to estimate the predictors of health insurance enrollment among HIV positive pregnant women. The analysis was further stratified by HIV disease severity (based on CD4 cell count <350 and 350>) to test the possibility of differential enrollment given HIV disease state. Results: Approximately 7% of HIV infected women delivering at a healthcare facility had health insurance. HIV positive pregnant women who deliver at a health facility had twice the odds of enrolling in insurance [2.46 Adjusted Odds Ratio (AOR), Confidence Interval (CI) 1.24–4.87]. They were 10 times more likely to have insurance if they were lost to follow-up to HIV care during pregnancy [9.90 AOR; CI 3.42–28.67], and three times more likely to enroll if they sought care at an urban clinic [2.50 AOR; 95% CI 1.53–4.12]. Being on HIV treatment was negatively associated with health insurance enrollment [0.22 AOR; CI 0.10–0.49]. Stratifying the analysis by HIV disease severity while statistically significant did not change these results. Conclusions: The findings indicated that health insurance enrollment among HIV positive pregnant women was low mirroring national levels. Additionally, structural factors, such as access to institutional delivery and location of healthcare facilities, increased the likelihood of health insurance enrollment within this population. However, behavioral aspects, such as being lost to follow-up to HIV care during pregnancy and being on HIV treatment, had an ambiguous effect on insurance enrollment. This may potentially be because of adverse selection and information asymmetries. Further understanding of the relationship between insurance and HIV is needed if health insurance is to be utilized for HIV treatment and prevention in limited resource settings.

Drivers and barriers of vaccine acceptance among pregnant women in Kenya

ABSTRACT Maternal vaccination coverage remains suboptimal globally and is lowest in low- and middle-income countries. Attitudes toward maternal vaccines have been characterized in middle-high income settings, however data from African countries are limited. We assessed drivers and barriers of vaccine acceptance among pregnant women in Kenya. We conducted a cross-sectional survey among pregnant women aged 15–49 y. We enrolled a convenience sample of women presenting for antenatal care at seven health-care facilities in four diverse counties (Nairobi, Mombasa, Marsabit, Siaya) of Kenya and from the community in two counties (Nairobi, Siaya). We described frequencies of socio-demographic characteristics of participants and their knowledge, attitudes, and beliefs regarding maternal vaccination. We enrolled 604 pregnant women with a median age of 26.5 y, of whom 48.2% had primary education or less. More than 95% agreed that maternal vaccines are “important for my health” and that getting vaccinated is “a good way to protect myself from disease”. The most commonly cited reason in favor of maternal vaccination was disease prevention (53.2%). Fear of side effects to mother/baby (15.1%) was the most frequently reported potential barrier. Influenza vaccine is not in routine use in Kenya; however, 77.8% reported willingness to accept influenza vaccination during pregnancy. Maternal vaccination is well accepted among Kenyan pregnant women. We identified the provision of adequate vaccine information and addressing safety concerns as opportunities to improve maternal vaccine uptake. The expressed willingness to receive a vaccine not currently in routine use bodes well for implementation of new maternal vaccines in Kenya.

Social Support Mitigates Negative Impact of Food Insecurity on Antiretroviral Adherence Among Postpartum Women in Western Kenya.

Food insecurity (FI), low social support, and low health-related quality of life (HRQoL) are associated with self-reported nonadherence to antiretroviral therapy (ART) among postpartum women, but these relationships have not been evaluated using objective adherence indicators. Hair samples were therefore analyzed among 83 postpartum Kenyan women living with HIV on efavirenz and nevirapine ART drug regimens in an observational cohort (NCT02974972). FI (0-27), social support (0-40), and HRQoL (8-40) in the prior month were also assessed. In multivariable models, each point increase in FI and decrease in HRQoL were associated with a 45.1% (95% CI:-64.3%,-15.6%) and 10.5% decrease (95% CI: 1.0%, 22.1%) in hair ART drug concentrations respectively, when social support was held constant. A significant interaction between social support and FI (β = 0.02, p = 0.017) indicated that greater social support was predicted to mitigate the negative impacts of FI on ART adherence. Addressing these modifiable barriers could improve ART adherence during this critical period.