Research increasingly involves cross-cultural work with non-English-speaking populations, necessi... more Research increasingly involves cross-cultural work with non-English-speaking populations, necessitating translation and cultural validation of research tools. This paper describes the process of translating and criterion validation of the Client Diagnostic Questionnaire (CDQ) for use in a multisite study in Kenya and Uganda. The English CDQ was translated into Swahili, Dholuo (Kenya) and Runyankole/Rukiga (Uganda) by expert translators. The translated documents underwent face validation by a bilingual committee, who resolved unclear statements, agreed on final translations and reviewed back translations to English. A diagnostic interview by a mental health specialist was used for criterion validation, and Kappa statistics assessed the strength of agreement between non-specialist scores and mental health professionals' diagnoses. Achieving semantic equivalence between translations was a challenge. Validation analysis was done with 30 participants at each site (median age 32.3 years (IQR = (26.5, 36.3)); 58 (64.4%) female). The sensitivity was 86.7%, specificity 64.4%, positive predictive value 70.9% and negative predictive value 82.9%. Diagnostic accuracy by the non-specialist was 75.6%. Agreement was substantial for major depressive episode and positive alcohol (past 6 months) and alcohol abuse (past 30 days). Agreement was moderate for other depressive disorders, panic disorder and psychosis screen; fair for generalized anxiety, drug abuse (past 6 months) and Post Traumatic Stress Disorder (PTSD); and poor for drug abuse (past 30 days). Variability of agreement between sites was seen for drug use (past 6 months) and PTSD. Our study successfully adapted the CDQ for use among people living with HIV in East Africa. We established that trained non-specialists can use the CDQ to screen for common mental health and substance use disorders with reasonable accuracy. Its use has the potential to increase case identification, improve
Background Consistent engagement in HIV treatment is needed for healthy outcomes, yet substantial... more Background Consistent engagement in HIV treatment is needed for healthy outcomes, yet substantial loss-to-follow up persists, leading to increased morbidity, mortality and onward transmission risk. Although conditional cash transfers (CCTs) address structural barriers, recent ndings suggest that incentive effects are timelimited, with cessation resulting in HIV care engagement deterioration. We explored incentive experiences, perceptions, and effects after cessation to investigate potential mechanisms of this observation. Methods This qualitative study was nested within a larger trial, AdaPT-R (NCT02338739), focused on HIV care engagement in western Kenya. A subset of participants were purposively sampled from AdaPT-R participants: adults with HIV who had recently started ART, received CCTs for one year, completed one year of follow-up without missing a clinic visit, and were randomized to either continue or discontinue CCTs for one more year of follow-up. In-depth interviews were conducted by an experienced qualitative researcher using a semi-structed guide within a month of randomization. Interviews were conducted in the participants' preferred language (Dholuo, Kiswahili, English). Data on patient characteristics, randomization dates, and clinic visit dates to determine care lapses were extracted from the AdaPT-R database. A codebook was developed deductively based on the guide and inductively re ned based on initial transcripts. Transcripts were coded using Dedoose software, and thematic saturation was identi ed. Results Of 38 participants, 15 (39%) continued receiving incentives, while 23 (61%) were discontinued from receiving incentives. Half were female (N = 19), median age was 30 years (range: 19-48), and about three-quarters were married or living with partners. Both groups expressed high intrinsic motivation to engage in care, prioritized clinic attendance regardless of CCTs and felt the incentives expanded their decision-making options. Despite high motivation, some participants reported that cessation of the CCTs affected their ability to access care, especially those with constrained nancial situations. Participants also expressed concerns that incentives might foster dependency. Conclusions This study helps us better understand the durability of nancial incentives for HIV care engagement, including when incentives end. Together with the quantitative ndings in the parent AdaPT-R study, these Page 4/20 results support the idea that careful consideration be exercised when implementing incentives for sustainable engagement effects.
Methods We applied an iterative, four-phased HCD process in Kenya that included: (1) systematic r... more Methods We applied an iterative, four-phased HCD process in Kenya that included: (1) systematic review of extant knowledge, (2) prioritisation of design challenges, (3) a co-creation workshop and (4) translation tables to pair insights with trial intervention adaptations. The co-creation workshop was co-led by youth facilitators employing participatory activities to inform intervention adaptations. Iterative data analysis included rapid thematic analysis of visualised workshop outputs and notes using affinity mapping and dialogue to identify key themes. We conducted a survey to assess workshop acceptability among participants. Results Twenty-two participants engaged in the 4-day workshop. Co-creation activities yielded recommendations for improving planned interventions (eg, message frequency and content; strategies to engage hard-to-reach participants), critical principles to employ across interventions (eg, personalisation, AYA empowerment) and identification of unanticipated AYA HIV treatment priorities (eg, drug holidays, transition from adolescent to adult services). We revised intervention content, peer navigator training materials and study inclusion criteria in response to findings. The youth-led HCD workshop was highly acceptable to participants. Conclusions Research employing HCD among youth can improve interventions preimplementation through empathy, youth-led inquiry and real-time problem solving. Peer navigation may be most influential in improving retention when engagement with young people is based on mutual trust, respect, privacy and extends beyond HIV-specific support. Identifying opportunities for personalisation and adaptation within intervention delivery is important for AYAs. Patient engagement interventions that target young people should prioritise improved transition between youth and adult services, youth HIV status disclosure, AYA empowerment and healthcare worker responsiveness in interactions and episodic adherence interruptions.
JAIDS Journal of Acquired Immune Deficiency Syndromes, 2022
Background: A better understanding why people living with HIV (PLHIV) become lost to follow-up (L... more Background: A better understanding why people living with HIV (PLHIV) become lost to follow-up (LTFU) and determining who is LTFU in a program setting is needed to attain HIV epidemic control. Setting: This retrospective cross-sectional study used an evidence-sampling approach to select health facilities and LTFU patients from a large HIV program supporting 61 health facilities in Kisumu County, Kenya. Methods: Eligible PLHIV included adults 18 years and older with at least 1 clinic visit between September 1, 2016, and August 31, 2018, and were LTFU (no clinical contact for ≥90 days after their last expected clinic visit). From March to June 2019, demographic and clinical variables were collected from a sample of LTFU patient files at 12 health facilities. Patient care status and retention outcomes were determined through program tracing. Results: Of 787 LTFU patients selected and traced, 36% were male, median age was 30.5 years (interquartile range: 24.6–38.0), and 78% had their vi...
Objectives Almost 13 million people are estimated to be on antiretroviral therapy in Eastern and ... more Objectives Almost 13 million people are estimated to be on antiretroviral therapy in Eastern and Southern Africa, and their disease course and program effectiveness could be significantly affected by the concurrent use of alcohol. Screening for alcohol use may be important to assess the prevalence of alcohol consumption and its impact on patient and programmatic outcomes. Methods As part of this observational study, data on patient characteristics and alcohol consumption were collected on a cohort of 765 adult patients enrolling in HIV care in East Africa. Alcohol consumption was assessed with the AUDIT questionnaire at enrollment. Subjects were classified as consuming any alcohol (AUDIT score >0), hazardous drinkers (AUDIT score �8) and hyper drinkers (AUDIT score �16). The effects of alcohol consumption on retention in care, death and delays in antiretroviral therapy (ART) initiation were assessed through competing risk (Fine & Gray) models. Results Of all study participants, 41.6% consumed alcohol, 26.7% were classified as hazardous drinkers, and 16.0% as hyper drinkers. Depending on alcohol consumption classification, men were 3-4 times more likely to consume alcohol compared to women. Hazardous drinkers (median age 32.8 years) and hyper drinkers (32.7 years) were slightly older compared to
Aids Care-psychological and Socio-medical Aspects of Aids/hiv, Apr 5, 2021
ABSTRACT Pediatric HIV remains a significant global concern, with 160,000 new infections annually... more ABSTRACT Pediatric HIV remains a significant global concern, with 160,000 new infections annually. Accelerating Children’s HIV/AIDS Treatment (ACT) provided a strategic response to the “treatment gap” for children. We examined whether activities under ACT increased testing and identification of youth living with HIV (YLWH). Family AIDS Care & Education Services implemented ACT across 130 health facilities in western Kenya between October 2015 and September 2016, providing: HIV-testing counselors and space; training on the Family Information Table (FIT) and chart audits; community outreach testing; and text message reminders for pregnant women. We analyzed the number of youths tested and identified with HIV over time and between intervention and control sites using interrupted time series analysis. We tested 268,312 youths (7,183 infants <18 months; 145,833 children 18 months to 9 years; and 115,296 adolescents 10–14 years). Mean monthly number tested per health facility increased from 2.8 to 7.2 (p < 0.0001) in infants, 44.8–142.0 (p < 0.0001) in children, and 30.1–123.3 (p < 0.0001) in adolescents. Mean monthly number identified with HIV per facility increased from 0.06 to 0.37 (p < 0.0001) in infants; 0.34–0.62 (p = 0.008) in children; and 0.17–0.26 (p = 0.04) in adolescents, resulting in 1,328 diagnoses. Among infants, FIT training was associated with increased HIV testing over time, incidence rate ratio (IRR) = 3.85 (95% confidence interval [CI] 2.16-6.84; p < 0.0001). Text messaging increased testing, IRR = 2.10 (95% CI 1.57-2.80; p < 0.0001) and identification of HIV in infants, IRR = 1.83 (95% CI 1.06-3.18; p = 0.0381) and older children, IRR = 2.25 (95% CI 1.62, 3.13; p < 0.0001). Chart audits increased testing over time among adolescents (IRR = 2.11; 95% CI 1.21-3.66; p = 0.0082). Outreach was associated with identification of adolescents with HIV, IRR = 1.58 (95% CI 1.22-2.06; p = 0.0005). In lower-income settings, targeted interventions effective at reaching YLWH can help optimize resource allocation to address gaps in testing and identification to further reduce HIV-related morbidity and mortality.
For First Few X and household transmission investigations of COVID-19 Evidence-based knowledge fo... more For First Few X and household transmission investigations of COVID-19 Evidence-based knowledge for public health response. Study conducted in Kisumu, Kenya in the year 2020.
As coronavirus disease (COVID-19) was declared a pandemic in 2020, countries around the world imp... more As coronavirus disease (COVID-19) was declared a pandemic in 2020, countries around the world implemented various prevention strategies, such as banning of public and social gatherings, restriction in movement, etc. These efforts may have had a deleterious effect on already vulnerable populations, including people living with HIV (PLWH). PLWH were concerned about contracting COVID-19, the impact of COVID-19 on their social networks that provide social support, and the continued availability of antiretroviral medications during the pandemic. In addition, their mental health may have been exacerbated by the pandemic. The purpose of this study was to explore pandemic-related concerns among a cohort of PLWH in Kenya and investigate social support factors associated with symptoms of depression and anxiety. This study is part of a larger cohort study that recruited from two clinics in Western Kenya. Data are drawn from 130 PLWH who participated in two phone surveys about experiences durin...
Growing literature has shown heterogenous effects of conditional cash incentives (CCIs) on HIV ca... more Growing literature has shown heterogenous effects of conditional cash incentives (CCIs) on HIV care retention. The field lacks insights into reasons why incentives impact various patients in different ways–differences that may be due to variations in psychological and social mechanisms of effect. A deeper understanding of patients’ perceptions and experiences of CCIs for retention may help to clarify these mechanisms. We conducted a qualitative study embedded in the ADAPT-R trial (NCT#02338739), a sequential multiple assignment randomized trial (SMART) that evaluated economic incentives to support retention in HIV care among persons living with HIV (PLHIV) initiating antiretroviral therapy in Kenya. Participants who attended their scheduled clinic visits received an incentive of approximately $4 each visit. Interviews were conducted between July 2016 and June 2017 with 39 participants to explore attitudes and experiences with economic incentives conditional on care engagement. Analy...
<b>Abstract</b><br/><p>In Kenya, only half of children with an HIV-positi... more <b>Abstract</b><br/><p>In Kenya, only half of children with an HIV-positive parent have been tested for HIV. The effectiveness of a family-centred index-testing approach to identify children (0-14 years) living with HIV was examined. A retrospective clinical record review was conducted among adult index patients newly enrolled in HIV care between May–July 2015 and family outcomes were followed through May 2016 at 60 high-volume clinics in western Kenya. HIV testing uptake and results, health facility level, enrollment into care and antiretroviral therapy (ART) initiation were abstracted. Chi-square test compared yield (percentage of HIV tests positive) among children tested through family-centred index testing to outpatient and inpatient testing approaches for the same age category, health facilities and time period. Review of 1,937 index client charts led to the identification of 3,005 eligible children for testing. Of 2,848 (94.8%) children tested through family-centred index testing, 127 (4.5%) were HIV-positive, 100 (78.7%) were linked to care, and 85 of those eligible (91.4%) had initiated ART by May 2016. Family testing resulted in higher yield as compared with inpatient 1.8% (p<0.001) or outpatient testing 1.6% (p<0.001). The absolute number of HIV positive children identified, however, was highest with outpatient testing (338 HIV positive children identified out of 27,402 tested). The family testing approach resulted in a high HIV identification yield for children and demonstrated promise in achieving the first two 90's of the 90-90-90 targets for children, with additional effort required to improve linkage from testing to treatment.</p>
Background Hazardous alcohol use among people living with HIV is associated with poor outcomes an... more Background Hazardous alcohol use among people living with HIV is associated with poor outcomes and increased morbidity and mortality. Understanding the hazardous drinking experiences of people living with HIV is needed to reduce their alcohol use. Methods We conducted 60 interviews among people living with HIV in East Africa with hazardous drinking histories. Interviews and Alcohol Use Disorder Identification Test (AUDIT) scores were conducted 41 – 60 months after their baseline assessment of alcohol use to identify facilitators and barriers to reduced alcohol use over time. Results People living with HIV who stopped or reduced hazardous drinking were primarily motivated by their HIV condition and desire for longevity. Facilitators of reduced drinking included health care workers’ recommendations to reduce drinking (despite little counseling and no referrals) and social support. In those continuing to drink at hazardous levels, barriers to reduced drinking were stress, social enviro...
Novel “differentiated service delivery” models for HIV treatment that reduce clinic visit frequen... more Novel “differentiated service delivery” models for HIV treatment that reduce clinic visit frequency, minimize waiting time, and deliver treatment in the community promise retention improvement for HIV treatment in Sub-Saharan Africa. Quantitative assessments of differentiated service delivery (DSD) feature most preferred by patient populations do not widely exist but could inform selection and prioritization of different DSD models. We used a discrete choice experiment (DCE) to elicit patient preferences of HIV treatment services and how they differ across DSD models. We surveyed 18+year-olds, enrolled in HIV care for ≥6 months between February-March, 2019 at four facilities in Kisumu County, Kenya. DCE offered patients a series of comparisons between three treatment models, each varying across seven attributes: ART refill location, quantity of dispensed ART at each refill, medication pick-up hours, type of adherence support, clinical visit frequency, staff attitude, and professiona...
We investigated the first 152 laboratory-confirmed SARS-CoV-2 cases (125 primary and 27 secondary... more We investigated the first 152 laboratory-confirmed SARS-CoV-2 cases (125 primary and 27 secondary) and their 248 close contacts in Kisumu County, Kenya. Conducted June 10–October 8, 2020, this study included interviews and sample collection at enrolment and 14–21 days later. Median age was 35 years (IQR 28–44); 69.0% reported COVID-19 related symptoms, most commonly cough (60.0%), headache (55.2%), fever (53.3%) and loss of taste or smell (43.8%). One in five were hospitalized, 34.4% >25 years of age had at least one comorbidity, and all deaths had comorbidities. Adults ≥25 years with a comorbidity were 3.15 (95% CI 1.37–7.26) times more likely to have been hospitalized or died than participants without a comorbidity. Infectious comorbidities included HIV, tuberculosis, and malaria, but no current cases of influenza, respiratory syncytial virus, dengue fever, leptospirosis or chikungunya were identified. Thirteen (10.4%) of the 125 primary infections transmitted COVID-19 to 27 cl...
In Kenya, only half of children with an HIV-positive parent have been tested for HIV. The effecti... more In Kenya, only half of children with an HIV-positive parent have been tested for HIV. The effectiveness of a family-centred index-testing approach to identify children (0-14 years) living with HIV was examined. A retrospective clinical record review was conducted among adult index patients newly enrolled in HIV care between May–July 2015 and family outcomes were followed through May 2016 at 60 high-volume clinics in western Kenya. HIV testing uptake and results, health facility level, enrollment into care and antiretroviral therapy (ART) initiation were abstracted. Chi-square test compared yield (percentage of HIV tests positive) among children tested through family-centred index testing to outpatient and inpatient testing approaches for the same age category, health facilities and time period. Review of 1,937 index client charts led to the identification of 3,005 eligible children for testing. Of 2,848 (94.8%) children tested through family-centred index testing, 127 (4.5%) were HI...
Background: Nyanza Province, Kenya, had the highest HIV prevalence in the country at 14.9 % in 20... more Background: Nyanza Province, Kenya, had the highest HIV prevalence in the country at 14.9 % in 2007, more than twice the national HIV prevalence of 7.1%. Only 16 % of HIV-infected adults in the country accurately knew their HIV status. Targeted strategies to reach and test individuals are urgently needed to curb the HIV epidemic. The family unit is one important portal. Methods: A family model of care was designed to build on the strengths of Kenyan families. Providers use a family information table (FIT) to guide index patients through the steps of identifying family members at HIV risk, address disclosure, facilitate family testing, and work to enrol HIV-positive members and to prevent new infections. Comprehensive family-centred clinical services are built around these steps. To assess the approach, a retrospective study of patients receiving HIV care between September 2007 and September 2009 at Lumumba Health Centre in Kisumu was conducted. A random sample of FITs was examined t...
HIV departments within Kenyan health facilities are usually better staffed and equipped than depa... more HIV departments within Kenyan health facilities are usually better staffed and equipped than departments offering non-HIV services. Integration of HIV services into primary care may address this issue of skewed resource allocation. Between 2008 and 2010, we piloted a system of integrating HIV services into primary care in rural Kenya. Before integration, we conducted a survey among returning adults ≥18-year old attending the HIV clinic. We then integrated HIV and primary care services. Three and twelve months after integration, we administered the same questionnaires to a sample of returning adults attending the integrated clinic. Changes in patient responses were assessed using truncated linear regression and logistic regression. At 12 months after integration, respondents were more likely to be satisfied with reception services (adjusted odds ratio, aOR 2.71, 95% CI 1.32–5.56), HIV education (aOR 3.28, 95% CI 1.92–6.83), and wait time (aOR 1.97 95% CI 1.03–3.76). Men's comfort...
Research increasingly involves cross-cultural work with non-English-speaking populations, necessi... more Research increasingly involves cross-cultural work with non-English-speaking populations, necessitating translation and cultural validation of research tools. This paper describes the process of translating and criterion validation of the Client Diagnostic Questionnaire (CDQ) for use in a multisite study in Kenya and Uganda. The English CDQ was translated into Swahili, Dholuo (Kenya) and Runyankole/Rukiga (Uganda) by expert translators. The translated documents underwent face validation by a bilingual committee, who resolved unclear statements, agreed on final translations and reviewed back translations to English. A diagnostic interview by a mental health specialist was used for criterion validation, and Kappa statistics assessed the strength of agreement between non-specialist scores and mental health professionals' diagnoses. Achieving semantic equivalence between translations was a challenge. Validation analysis was done with 30 participants at each site (median age 32.3 years (IQR = (26.5, 36.3)); 58 (64.4%) female). The sensitivity was 86.7%, specificity 64.4%, positive predictive value 70.9% and negative predictive value 82.9%. Diagnostic accuracy by the non-specialist was 75.6%. Agreement was substantial for major depressive episode and positive alcohol (past 6 months) and alcohol abuse (past 30 days). Agreement was moderate for other depressive disorders, panic disorder and psychosis screen; fair for generalized anxiety, drug abuse (past 6 months) and Post Traumatic Stress Disorder (PTSD); and poor for drug abuse (past 30 days). Variability of agreement between sites was seen for drug use (past 6 months) and PTSD. Our study successfully adapted the CDQ for use among people living with HIV in East Africa. We established that trained non-specialists can use the CDQ to screen for common mental health and substance use disorders with reasonable accuracy. Its use has the potential to increase case identification, improve
Background Consistent engagement in HIV treatment is needed for healthy outcomes, yet substantial... more Background Consistent engagement in HIV treatment is needed for healthy outcomes, yet substantial loss-to-follow up persists, leading to increased morbidity, mortality and onward transmission risk. Although conditional cash transfers (CCTs) address structural barriers, recent ndings suggest that incentive effects are timelimited, with cessation resulting in HIV care engagement deterioration. We explored incentive experiences, perceptions, and effects after cessation to investigate potential mechanisms of this observation. Methods This qualitative study was nested within a larger trial, AdaPT-R (NCT02338739), focused on HIV care engagement in western Kenya. A subset of participants were purposively sampled from AdaPT-R participants: adults with HIV who had recently started ART, received CCTs for one year, completed one year of follow-up without missing a clinic visit, and were randomized to either continue or discontinue CCTs for one more year of follow-up. In-depth interviews were conducted by an experienced qualitative researcher using a semi-structed guide within a month of randomization. Interviews were conducted in the participants' preferred language (Dholuo, Kiswahili, English). Data on patient characteristics, randomization dates, and clinic visit dates to determine care lapses were extracted from the AdaPT-R database. A codebook was developed deductively based on the guide and inductively re ned based on initial transcripts. Transcripts were coded using Dedoose software, and thematic saturation was identi ed. Results Of 38 participants, 15 (39%) continued receiving incentives, while 23 (61%) were discontinued from receiving incentives. Half were female (N = 19), median age was 30 years (range: 19-48), and about three-quarters were married or living with partners. Both groups expressed high intrinsic motivation to engage in care, prioritized clinic attendance regardless of CCTs and felt the incentives expanded their decision-making options. Despite high motivation, some participants reported that cessation of the CCTs affected their ability to access care, especially those with constrained nancial situations. Participants also expressed concerns that incentives might foster dependency. Conclusions This study helps us better understand the durability of nancial incentives for HIV care engagement, including when incentives end. Together with the quantitative ndings in the parent AdaPT-R study, these Page 4/20 results support the idea that careful consideration be exercised when implementing incentives for sustainable engagement effects.
Methods We applied an iterative, four-phased HCD process in Kenya that included: (1) systematic r... more Methods We applied an iterative, four-phased HCD process in Kenya that included: (1) systematic review of extant knowledge, (2) prioritisation of design challenges, (3) a co-creation workshop and (4) translation tables to pair insights with trial intervention adaptations. The co-creation workshop was co-led by youth facilitators employing participatory activities to inform intervention adaptations. Iterative data analysis included rapid thematic analysis of visualised workshop outputs and notes using affinity mapping and dialogue to identify key themes. We conducted a survey to assess workshop acceptability among participants. Results Twenty-two participants engaged in the 4-day workshop. Co-creation activities yielded recommendations for improving planned interventions (eg, message frequency and content; strategies to engage hard-to-reach participants), critical principles to employ across interventions (eg, personalisation, AYA empowerment) and identification of unanticipated AYA HIV treatment priorities (eg, drug holidays, transition from adolescent to adult services). We revised intervention content, peer navigator training materials and study inclusion criteria in response to findings. The youth-led HCD workshop was highly acceptable to participants. Conclusions Research employing HCD among youth can improve interventions preimplementation through empathy, youth-led inquiry and real-time problem solving. Peer navigation may be most influential in improving retention when engagement with young people is based on mutual trust, respect, privacy and extends beyond HIV-specific support. Identifying opportunities for personalisation and adaptation within intervention delivery is important for AYAs. Patient engagement interventions that target young people should prioritise improved transition between youth and adult services, youth HIV status disclosure, AYA empowerment and healthcare worker responsiveness in interactions and episodic adherence interruptions.
JAIDS Journal of Acquired Immune Deficiency Syndromes, 2022
Background: A better understanding why people living with HIV (PLHIV) become lost to follow-up (L... more Background: A better understanding why people living with HIV (PLHIV) become lost to follow-up (LTFU) and determining who is LTFU in a program setting is needed to attain HIV epidemic control. Setting: This retrospective cross-sectional study used an evidence-sampling approach to select health facilities and LTFU patients from a large HIV program supporting 61 health facilities in Kisumu County, Kenya. Methods: Eligible PLHIV included adults 18 years and older with at least 1 clinic visit between September 1, 2016, and August 31, 2018, and were LTFU (no clinical contact for ≥90 days after their last expected clinic visit). From March to June 2019, demographic and clinical variables were collected from a sample of LTFU patient files at 12 health facilities. Patient care status and retention outcomes were determined through program tracing. Results: Of 787 LTFU patients selected and traced, 36% were male, median age was 30.5 years (interquartile range: 24.6–38.0), and 78% had their vi...
Objectives Almost 13 million people are estimated to be on antiretroviral therapy in Eastern and ... more Objectives Almost 13 million people are estimated to be on antiretroviral therapy in Eastern and Southern Africa, and their disease course and program effectiveness could be significantly affected by the concurrent use of alcohol. Screening for alcohol use may be important to assess the prevalence of alcohol consumption and its impact on patient and programmatic outcomes. Methods As part of this observational study, data on patient characteristics and alcohol consumption were collected on a cohort of 765 adult patients enrolling in HIV care in East Africa. Alcohol consumption was assessed with the AUDIT questionnaire at enrollment. Subjects were classified as consuming any alcohol (AUDIT score >0), hazardous drinkers (AUDIT score �8) and hyper drinkers (AUDIT score �16). The effects of alcohol consumption on retention in care, death and delays in antiretroviral therapy (ART) initiation were assessed through competing risk (Fine & Gray) models. Results Of all study participants, 41.6% consumed alcohol, 26.7% were classified as hazardous drinkers, and 16.0% as hyper drinkers. Depending on alcohol consumption classification, men were 3-4 times more likely to consume alcohol compared to women. Hazardous drinkers (median age 32.8 years) and hyper drinkers (32.7 years) were slightly older compared to
Aids Care-psychological and Socio-medical Aspects of Aids/hiv, Apr 5, 2021
ABSTRACT Pediatric HIV remains a significant global concern, with 160,000 new infections annually... more ABSTRACT Pediatric HIV remains a significant global concern, with 160,000 new infections annually. Accelerating Children’s HIV/AIDS Treatment (ACT) provided a strategic response to the “treatment gap” for children. We examined whether activities under ACT increased testing and identification of youth living with HIV (YLWH). Family AIDS Care & Education Services implemented ACT across 130 health facilities in western Kenya between October 2015 and September 2016, providing: HIV-testing counselors and space; training on the Family Information Table (FIT) and chart audits; community outreach testing; and text message reminders for pregnant women. We analyzed the number of youths tested and identified with HIV over time and between intervention and control sites using interrupted time series analysis. We tested 268,312 youths (7,183 infants <18 months; 145,833 children 18 months to 9 years; and 115,296 adolescents 10–14 years). Mean monthly number tested per health facility increased from 2.8 to 7.2 (p < 0.0001) in infants, 44.8–142.0 (p < 0.0001) in children, and 30.1–123.3 (p < 0.0001) in adolescents. Mean monthly number identified with HIV per facility increased from 0.06 to 0.37 (p < 0.0001) in infants; 0.34–0.62 (p = 0.008) in children; and 0.17–0.26 (p = 0.04) in adolescents, resulting in 1,328 diagnoses. Among infants, FIT training was associated with increased HIV testing over time, incidence rate ratio (IRR) = 3.85 (95% confidence interval [CI] 2.16-6.84; p < 0.0001). Text messaging increased testing, IRR = 2.10 (95% CI 1.57-2.80; p < 0.0001) and identification of HIV in infants, IRR = 1.83 (95% CI 1.06-3.18; p = 0.0381) and older children, IRR = 2.25 (95% CI 1.62, 3.13; p < 0.0001). Chart audits increased testing over time among adolescents (IRR = 2.11; 95% CI 1.21-3.66; p = 0.0082). Outreach was associated with identification of adolescents with HIV, IRR = 1.58 (95% CI 1.22-2.06; p = 0.0005). In lower-income settings, targeted interventions effective at reaching YLWH can help optimize resource allocation to address gaps in testing and identification to further reduce HIV-related morbidity and mortality.
For First Few X and household transmission investigations of COVID-19 Evidence-based knowledge fo... more For First Few X and household transmission investigations of COVID-19 Evidence-based knowledge for public health response. Study conducted in Kisumu, Kenya in the year 2020.
As coronavirus disease (COVID-19) was declared a pandemic in 2020, countries around the world imp... more As coronavirus disease (COVID-19) was declared a pandemic in 2020, countries around the world implemented various prevention strategies, such as banning of public and social gatherings, restriction in movement, etc. These efforts may have had a deleterious effect on already vulnerable populations, including people living with HIV (PLWH). PLWH were concerned about contracting COVID-19, the impact of COVID-19 on their social networks that provide social support, and the continued availability of antiretroviral medications during the pandemic. In addition, their mental health may have been exacerbated by the pandemic. The purpose of this study was to explore pandemic-related concerns among a cohort of PLWH in Kenya and investigate social support factors associated with symptoms of depression and anxiety. This study is part of a larger cohort study that recruited from two clinics in Western Kenya. Data are drawn from 130 PLWH who participated in two phone surveys about experiences durin...
Growing literature has shown heterogenous effects of conditional cash incentives (CCIs) on HIV ca... more Growing literature has shown heterogenous effects of conditional cash incentives (CCIs) on HIV care retention. The field lacks insights into reasons why incentives impact various patients in different ways–differences that may be due to variations in psychological and social mechanisms of effect. A deeper understanding of patients’ perceptions and experiences of CCIs for retention may help to clarify these mechanisms. We conducted a qualitative study embedded in the ADAPT-R trial (NCT#02338739), a sequential multiple assignment randomized trial (SMART) that evaluated economic incentives to support retention in HIV care among persons living with HIV (PLHIV) initiating antiretroviral therapy in Kenya. Participants who attended their scheduled clinic visits received an incentive of approximately $4 each visit. Interviews were conducted between July 2016 and June 2017 with 39 participants to explore attitudes and experiences with economic incentives conditional on care engagement. Analy...
<b>Abstract</b><br/><p>In Kenya, only half of children with an HIV-positi... more <b>Abstract</b><br/><p>In Kenya, only half of children with an HIV-positive parent have been tested for HIV. The effectiveness of a family-centred index-testing approach to identify children (0-14 years) living with HIV was examined. A retrospective clinical record review was conducted among adult index patients newly enrolled in HIV care between May–July 2015 and family outcomes were followed through May 2016 at 60 high-volume clinics in western Kenya. HIV testing uptake and results, health facility level, enrollment into care and antiretroviral therapy (ART) initiation were abstracted. Chi-square test compared yield (percentage of HIV tests positive) among children tested through family-centred index testing to outpatient and inpatient testing approaches for the same age category, health facilities and time period. Review of 1,937 index client charts led to the identification of 3,005 eligible children for testing. Of 2,848 (94.8%) children tested through family-centred index testing, 127 (4.5%) were HIV-positive, 100 (78.7%) were linked to care, and 85 of those eligible (91.4%) had initiated ART by May 2016. Family testing resulted in higher yield as compared with inpatient 1.8% (p<0.001) or outpatient testing 1.6% (p<0.001). The absolute number of HIV positive children identified, however, was highest with outpatient testing (338 HIV positive children identified out of 27,402 tested). The family testing approach resulted in a high HIV identification yield for children and demonstrated promise in achieving the first two 90's of the 90-90-90 targets for children, with additional effort required to improve linkage from testing to treatment.</p>
Background Hazardous alcohol use among people living with HIV is associated with poor outcomes an... more Background Hazardous alcohol use among people living with HIV is associated with poor outcomes and increased morbidity and mortality. Understanding the hazardous drinking experiences of people living with HIV is needed to reduce their alcohol use. Methods We conducted 60 interviews among people living with HIV in East Africa with hazardous drinking histories. Interviews and Alcohol Use Disorder Identification Test (AUDIT) scores were conducted 41 – 60 months after their baseline assessment of alcohol use to identify facilitators and barriers to reduced alcohol use over time. Results People living with HIV who stopped or reduced hazardous drinking were primarily motivated by their HIV condition and desire for longevity. Facilitators of reduced drinking included health care workers’ recommendations to reduce drinking (despite little counseling and no referrals) and social support. In those continuing to drink at hazardous levels, barriers to reduced drinking were stress, social enviro...
Novel “differentiated service delivery” models for HIV treatment that reduce clinic visit frequen... more Novel “differentiated service delivery” models for HIV treatment that reduce clinic visit frequency, minimize waiting time, and deliver treatment in the community promise retention improvement for HIV treatment in Sub-Saharan Africa. Quantitative assessments of differentiated service delivery (DSD) feature most preferred by patient populations do not widely exist but could inform selection and prioritization of different DSD models. We used a discrete choice experiment (DCE) to elicit patient preferences of HIV treatment services and how they differ across DSD models. We surveyed 18+year-olds, enrolled in HIV care for ≥6 months between February-March, 2019 at four facilities in Kisumu County, Kenya. DCE offered patients a series of comparisons between three treatment models, each varying across seven attributes: ART refill location, quantity of dispensed ART at each refill, medication pick-up hours, type of adherence support, clinical visit frequency, staff attitude, and professiona...
We investigated the first 152 laboratory-confirmed SARS-CoV-2 cases (125 primary and 27 secondary... more We investigated the first 152 laboratory-confirmed SARS-CoV-2 cases (125 primary and 27 secondary) and their 248 close contacts in Kisumu County, Kenya. Conducted June 10–October 8, 2020, this study included interviews and sample collection at enrolment and 14–21 days later. Median age was 35 years (IQR 28–44); 69.0% reported COVID-19 related symptoms, most commonly cough (60.0%), headache (55.2%), fever (53.3%) and loss of taste or smell (43.8%). One in five were hospitalized, 34.4% >25 years of age had at least one comorbidity, and all deaths had comorbidities. Adults ≥25 years with a comorbidity were 3.15 (95% CI 1.37–7.26) times more likely to have been hospitalized or died than participants without a comorbidity. Infectious comorbidities included HIV, tuberculosis, and malaria, but no current cases of influenza, respiratory syncytial virus, dengue fever, leptospirosis or chikungunya were identified. Thirteen (10.4%) of the 125 primary infections transmitted COVID-19 to 27 cl...
In Kenya, only half of children with an HIV-positive parent have been tested for HIV. The effecti... more In Kenya, only half of children with an HIV-positive parent have been tested for HIV. The effectiveness of a family-centred index-testing approach to identify children (0-14 years) living with HIV was examined. A retrospective clinical record review was conducted among adult index patients newly enrolled in HIV care between May–July 2015 and family outcomes were followed through May 2016 at 60 high-volume clinics in western Kenya. HIV testing uptake and results, health facility level, enrollment into care and antiretroviral therapy (ART) initiation were abstracted. Chi-square test compared yield (percentage of HIV tests positive) among children tested through family-centred index testing to outpatient and inpatient testing approaches for the same age category, health facilities and time period. Review of 1,937 index client charts led to the identification of 3,005 eligible children for testing. Of 2,848 (94.8%) children tested through family-centred index testing, 127 (4.5%) were HI...
Background: Nyanza Province, Kenya, had the highest HIV prevalence in the country at 14.9 % in 20... more Background: Nyanza Province, Kenya, had the highest HIV prevalence in the country at 14.9 % in 2007, more than twice the national HIV prevalence of 7.1%. Only 16 % of HIV-infected adults in the country accurately knew their HIV status. Targeted strategies to reach and test individuals are urgently needed to curb the HIV epidemic. The family unit is one important portal. Methods: A family model of care was designed to build on the strengths of Kenyan families. Providers use a family information table (FIT) to guide index patients through the steps of identifying family members at HIV risk, address disclosure, facilitate family testing, and work to enrol HIV-positive members and to prevent new infections. Comprehensive family-centred clinical services are built around these steps. To assess the approach, a retrospective study of patients receiving HIV care between September 2007 and September 2009 at Lumumba Health Centre in Kisumu was conducted. A random sample of FITs was examined t...
HIV departments within Kenyan health facilities are usually better staffed and equipped than depa... more HIV departments within Kenyan health facilities are usually better staffed and equipped than departments offering non-HIV services. Integration of HIV services into primary care may address this issue of skewed resource allocation. Between 2008 and 2010, we piloted a system of integrating HIV services into primary care in rural Kenya. Before integration, we conducted a survey among returning adults ≥18-year old attending the HIV clinic. We then integrated HIV and primary care services. Three and twelve months after integration, we administered the same questionnaires to a sample of returning adults attending the integrated clinic. Changes in patient responses were assessed using truncated linear regression and logistic regression. At 12 months after integration, respondents were more likely to be satisfied with reception services (adjusted odds ratio, aOR 2.71, 95% CI 1.32–5.56), HIV education (aOR 3.28, 95% CI 1.92–6.83), and wait time (aOR 1.97 95% CI 1.03–3.76). Men's comfort...
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Papers by Jayne Lewis