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Background: The Fogarty International Center-led Adolescent HIV Implementation Science Alliance (AHISA) supports region-/country-specific implementation science (IS) alliances that build collaborations between research, policy, and program partners that respond to local implementation challenges. AHISA supported the development of seven locally-led IS alliances: five countryspecific (i.e., Kenya, South Africa, Tanzania, Uganda, and Zambia), one in Central and West Africa, and one with youth researchers. This article outlines the aims, activities, and outcomes of local alliances, demonstrating how they enhance sustainable IS activities to address local challenges. Methods: We conducted a desk review of each alliance's funding applications, reports, and data from the initial findings of a larger AHISA evaluation. The review analyzes common approaches, highlights their local relevance, and summarizes initial outcomes. Results: The local alliances have a common goal: to expand implementation of successful interventions to improve adolescent HIV. We identified four overarching themes across the local alliances' activities: capacity building, priority setting, stakeholder engagement, and knowledge dissemination. Research capacity building activities include long-term mentorship between junior and senior researchers and short-term training for non-research partners. Setting priorities with members identifies local research needs and streamlines activities. Alliances incorporate substantial engagement between partners, particularly youth, who may serve as leaders and co-create activities. Dissemination shares activities and results broadly. Conclusion: Local IS alliances play a key role in building sustainable IS learning and collaboration platforms, enabling improved uptake of evidence into policy and programs, increased IS research capacity, and shared approaches to addressing implementation challenges. [ABSTRACT FROM AUTHOR]

Objectives: This study investigates the prevalence of the use of reusable menstrual materials in LMICs, examines differences in prevalence between countries and areas, and identifies individual and country-level factors associated with their use. Methods: Data from Multiple Indicator Cluster surveys conducted between 2017 and 2020 in LMICs were used. Prevalence estimates and 95% CIs were calculated for overall, rural, and urban areas. Multivariable logistic regression was used to identify individual and country-level factors associated with the use of reusable menstrual materials. Results: The study included 42 surveys from LMICs, with 1653850 weighted women and girls aged 15–49 years. The overall prevalence of the use of reusable menstrual materials was 12.1% (95% CI 12.1–12.2), with significant variation between and within countries, ranging from 0.5% (0.3–0.8) in Serbia to 97.2% (96.5–97.9) in Sao Tome and Principe. The prevalence was higher in rural areas (23.9% [23.8–24.0]) than in urban areas (6.2% [6.2–6.2]), with significant differences between most countries. Use of reusable menstrual materials was associated with lower education levels, being married, low economic status, living in Asia and Africa, living in countries with lower GDP, living in rural areas, and limited availability of private places to wash menstrual materials. The prevalence of the use of reusable menstrual materials had an inverse linear relationship with the country's GDP. Conclusions: The study found that the use of reusable menstrual materials is more prevalent among women and girls in rural areas, those with lower education levels, lower economic status, and those living in countries with lower GDP. Given these disparities, policies and initiatives targeted at improving menstrual health in LMICs should focus on socioeconomically disadvantaged groups to ensure they have access to safe and appropriate menstrual materials. [ABSTRACT FROM AUTHOR]

We examined the association between serum aflatoxin B1‐lysine adduct (AFB1‐lys) levels in pregnant women and adverse pregnancy outcomes (low birthweight, miscarriage and stillbirth) through a nested matched case–control study of pregnant women enroled at ≤28 weeks' gestation in Mombasa, Kenya, from 2017 to 2019. Cases comprised women with an adverse birth outcome, defined as either delivery of a singleton infant weighing <2500 g, or a miscarriage, or a stillbirth, while controls were women who delivered a singleton live infant with a birthweight of ≥2500 g. Cases were matched to controls at a ratio of 1:2 based on maternal age at enrolment, gestational age at enrolment and study site. The primary exposure was serum AFB1‐lys. The study included 125 cases and 250 controls. The median gestation age when serum samples were collected was 23.0 weeks (interquartile range [IQR]: 18.1–26.0) and 23.5 (IQR: 18.1–26.5) among cases and controls, respectively. Of the 375 tested sera, 145 (38.7%) had detectable serum AFB1‐lys: 36.0% in cases and 40.0% in controls. AFB1‐lys adduct levels were not associated with adverse birth outcomes on multivariable analysis. Mid‐upper arm circumference was associated with a 6% lower odds of adverse birth outcome for every unit increase (p = 0.023). Two‐fifths of pregnant women had detectable levels of aflatoxin midway through pregnancy. However, we did not detect an association with adverse pregnancy outcomes, likely because of low serum AFB1‐lys levels and low power, restricting meaningful comparison. More research is needed to understand the public health risk of aflatoxin in pregnant women to unborn children. Key messages: Aflatoxin B1 (AFB1), a commonly ingested toxin, can cross the placental barrier and cause adverse pregnancy outcomes.Two‐fifths of participants had detectable serum AFB1‐lys levels, a marker of aflatoxin exposure, but the low levels recorded were not associated with adverse pregnancy outcomes.Every unit increase in mid‐upper arm circumference (MUAC) during pregnancy was associated with a 6% reduced likelihood of adverse pregnancy outcomes, highlighting the potential protective role of adequate maternal nutrition.There is need for additional studies in different settings on the determinants and mechanisms of the relationship between aflatoxin exposure and adverse pregnancy outcomes. [ABSTRACT FROM AUTHOR]

During the COVID-19 pandemic, HIV programs scaled up differentiated service delivery (DSD) models for people living with HIV (PLHIV). We evaluated the effects of COVID-19 on HIV service delivery and viral suppression in facilities in Northern Nigeria, and determined factors associated with viral suppression among adolescents and adults. We analysed a cross-sectional survey data from facility heads, and retrospective, routinely collected patient data from 63 facilities for PLHIV ≥10 years old in care between April 2019-March 2021, defining study periods as "pre-COVID-19" (before April 2020) and "during COVID-19" (after April 2020). For the pre-COVID and the COVID-19 periods we compared uptake of antiretroviral therapy (ART) refills of ≥3 months (MMD3), and ≥6 months (MM6), missed appointments, viral load (VL) testing, VL testing turnaround time (TAT) and viral suppression among those on ART for ≥6 months using two proportions Z-test and t-tests. We fit a multivariable logistic regression model to determine factors associated with maintaining or achieving viral suppression. Of 84,776 patients, 58% were <40 years, 67% were female, 55% on ART for >5 years, 93% from facilities with community-based ART refill, a higher proportion were on MMD3 (95% versus 74%, p<0.001) and MMD6 (56% versus 22%, p<0.001) during COVID-19 than pre-COVID-19, and a higher proportion had VL testing during COVID-19 (55,271/69,630, [84%]) than pre-COVID-19 (47,747/68,934, [73%], p<0.001). Viral suppression was higher during COVID-19 pandemic compared to the pre-COVID era (93% [51,196/55,216] versus 91% [43,336/47,728], p<0.001), and there was a higher proportion of missed visits (40% [28,923/72,359] versus 39% [26,304/67,365], p<0.001) and increased VL TAT (mean number of days: 38 versus 36, p<0.001) during COVID-19 pandemic and pre-COVID period respectively. Factors associated with maintaining or achieving suppression during COVID-19 were receiving MMD3 and MMD6 refills (OR: 2.8 [95% CI: 2.30–3.47] and OR: 6.3 [95% CI: 5.11–7.69], respectively) and attending clinics with community-based ART refill (OR: 1.6 [95% CI: 1.39–1.87]). The program in Northern Nigeria demonstrated resilience during the COVID-19 pandemic and adoption of MMD had a positive impact on HIV care. Though VL TAT and missed clinic visits slightly increased during the pandemic, VL testing improved and viral suppression moved closer to 95%. Adoption of MMD and community-based models of care at scale are recommended for future pandemic preparedness. [ABSTRACT FROM AUTHOR]

Introduction: Adverse birth outcomes particularly preterm births and congenital anomalies, are the leading causes of infant mortality globally, and the burden is highest in developing countries. We set out to determine the frequency of adverse birth outcomes and the risk factors associated with such outcomes in a cohort of pregnant women in Kenya. Methods: From October 2017 to July 2019, pregnant women < 28 weeks gestation were enrolled and followed up until delivery in three hospitals in coastal Kenya. Newborns were examined at delivery. Among women with birth outcome data, we assessed the frequency of congenital anomalies defined as gastroschisis, umbilical hernia, limb abnormalities and Trisomy 21, and adverse birth outcomes, defined as either stillbirth, miscarriage, preterm birth, small for gestational age, or microcephaly. We used log-binomial regression to identify maternal characteristics associated with the presence of at least one adverse outcome. Results: Among the 2312 women enrolled, 1916 (82.9%) had birth outcome data. Overall, 402/1916 (20.9%; 95% confidence interval (CI): 19.1–22.8) pregnancies had adverse birth outcomes. Specifically, 66/1916 (3.4%; 95% CI: 2.7–4.4) were stillbirths, 34/1916 (1.8%; 95% CI: 1.2–2.4) were miscarriages and 23/1816 (1.2%; 95% CI: 0.8–1.9) had congenital anomalies. Among the participants with anthropometric measurements data, 142/1200 (11.8%; 95% CI: 10.1 − 13.8) were small for gestational age and among the participants with ultrasound records, 143/1711 (8.4%; 95% CI: 7.1–9.8) were preterm. Febrile illnesses in current pregnancy (adjusted risk ratio (aRR): 1.7; 95% CI: 1.1–2.8), a history of poor birth outcomes in prior pregnancy (aRR: 1.8; 95% CI: 1.3–2.4) and high blood pressure in pregnancy (aRR: 3.9, 95% CI: (1.7–9.2) were independently associated with adverse birth outcomes in a model that included age, education, human immunodeficiency virus status and high blood pressure at enrolment. Conclusion: We found similar rates of overall adverse birth outcomes, congenital anomalies, and small for gestational age but higher rates of stillbirths and lower rates of prematurity compared to the rates that have been reported in the sub-Saharan Africa region. However, the rates of adverse birth outcomes in this study were comparable to other studies conducted in Kenya. Febrile illnesses during the current pregnancy, previous history of poor birth outcomes and high blood pressure in pregnancy are predictive of an increased risk of adverse birth outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Adolescents with HIV in sub-Saharan Africa face challenges transitioning to adult HIV care, which can affect long-term HIV care adherence and retention. An adolescent transition package (ATP) focused on transition tools can improve post-transition clinical outcomes, but its implementation costs are unknown. Methods: We estimated the average cost per patient of an HIV care visit and ATP provision to adolescents. Data was collected from 13 HIV clinics involved in a randomized clinical trial evaluating ATP in western Kenya. We conducted a micro-costing and activity-driven time estimation to assess costs from the provider perspective. We developed a flow-map, conducted staff interviews, and completed time and motion observation. ATP costs were estimated as the difference in average cost for an HIV care transition visit in the intervention compared to control facilities. We assessed uncertainty in costing estimates via Monte Carlo simulations. Results: The average cost of an adolescent HIV care visit was 29.8USD (95%CI 27.5, 33.4) in the standard of care arm and 32.9USD (95%CI 30.5, 36.8) in the ATP intervention arm, yielding an incremental cost of 3.1USD (95%CI 3.0, 3.4) for the ATP intervention. The majority of the intervention cost (2.8USD) was due ATP booklet discussion with the adolescent. Conclusion: The ATP can be feasibly implemented in HIV care clinics at a modest increase in overall clinic visit cost. Our cost estimates can be used to inform economic evaluations or budgetary planning of adolescent HIV care interventions in Kenya. [ABSTRACT FROM AUTHOR]

Objectives: With optimized antiretroviral treatment youth living with HIV (YLH) now spend most of their time in schools, making schools an important venue to optimize outcomes. We evaluated school support for YLH. Methods: We conducted surveys with public secondary/high schools in 3 Kenyan counties (Nairobi, Homa Bay, and Kajiado) to determine policies and training related to HIV. Chi‐squared tests and Poisson regression were used to compare policy availability and staff training by county HIV prevalence and school type. Results: Of 512 schools in the 3 counties, we surveyed 100. The majority (60%) of schools surveyed had boarding facilities. The median student population was 406 (IQR: 200, 775). Only half (49%) of schools had medication use policies; more in boarding than day schools (65% vs 30%, p =.003). While most schools (82%) had clinic attendance policies; policy availability was higher in higher HIV prevalence counties (Homa Bay [100%], Nairobi [82%], Kajiado [56%], p <.05). Overall, 64% had confidentiality policies with higher policy availability in higher HIV prevalence regions (p <.05). Few schools had staff trained in HIV‐related topics: HIV prevention (37%), HIV treatment (18%), HIV stigma reduction (36%). Few were trained in confidentiality (41%), psychosocial support (40%), or mental health (26%). Compared to day schools, boarding school were more likely to have staff trained in HIV prevention (prevalence ratio: 2.1 [95% confidence interval 1.0, 4.0], p =.037). Conclusion: In this survey of Kenyan schools, there were notable gaps in HIV care policy availability and training, despite high HIV burden. Development and implementation of national school HIV policies and staff training as well as strengthening clinic and family support may improve outcomes for YLH. [ABSTRACT FROM AUTHOR]

Abstracted. Median age was 33 years, 64% were female, 91% were started on a dolutegravir (DTG)-based regimen, and 65% were on MMD. Overall, 15,259 (77%) participants were followed for ≥ 6 months, 4136 (27%) had a VL at 6 months and 3640 (24%) had a VL at 12 months after ART initiation. A slightly higher proportion of patients on MMD had undetectable VL levels at 6 months (65% vs 58%) and 12 months (66% vs 62%). In the adjusted analysis, we found no significant differences in undetectable VL at 6 months and 12 months between newly enrolled patients on MMD and those not on MMD. Those on Protease inhibitor-based regimen had 54% lower likelihood of undetectable VL compared to those on DTG-based regimen.Conclusion: MMD does not result in poorer viral suppression among newly enrolled patients. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic resulted in disruptions to routine HIV services for youth living with HIV (YLH), provoking rapid adaptation to mitigate interruptions in care. The Adolescent Transition to Adult Care for HIV-infected adolescents (ATTACH) study (NCT03574129) was a hybrid I cluster randomized trial testing the effectiveness of a healthcare worker (HCW)-delivered disclosure and transition intervention — the Adolescent Transition Package (ATP). During the pandemic, HCWs leveraged phone delivery of the ATP and were supported to make adaptations. We characterized real-time, provider-driven adaptations made to support phone delivery of the ATP. Methods: We conducted continuous quality improvement (CQI) meetings with HCWs involved in phone delivery of the ATP at 10 intervention sites. CQI meetings used plan-do-study-act (PDSA) cycles and were audio-recorded. Adaptations were coded by two-independent coders using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS). Adaptation testing outcomes (adopt, retest, or abandon) and provider experience implementing the adaptations were also recorded. We summarized adaptation characteristics, provider experience, and outcomes. Results: We identified 72 adaptations, 32 were unique. Overall, adaptations included modification to context (53%, n = 38), content (49%, n = 35), and evaluation processes (13%, n = 9). Context adaptations primarily featured changes to personnel, format, and setting, while content and evaluation adaptations were frequently achieved by simple additions, repetition, and tailoring/refining of the phone delivery strategy. Nine adaptations involved abandoning, then returning to phone delivery. HCWs sought to increase reach, improve fidelity, and intervention fit within their context. Most adaptations (96%, n = 69) were perceived to increase the feasibility of phone delivery when compared to before the changes were introduced, and HCWs felt 83% (n = 60) of adaptations made phone delivery easier. Most adaptations were either incorporated into routine workflows (47%) or tested again (47%). Conclusion: Adaptation of phone delivery was a feasible and effective way of addressing challenges with continuity of care for YLH during the COVID-19 pandemic. Adaptations were primarily context adaptions. While FRAME-IS was apt for characterizing adaptations, more use cases are needed to explore the range of its utility. Trial registration: Trial registered on ClinicalTrial.gov as NCT03574129. [ABSTRACT FROM AUTHOR]

HIV stigma remains a barrier in achieving optimal HIV treatment. We studied the prevalence and predictors of HIV stigma among adolescents and youth with HIV (AYWHIV) ages 15–24 years in Western Kenya. Of 1011 AYWHIV, 69% were female with a median age of 18 years. Most (59%) attended adolescent clinic days, and 40% attended support groups. One-quarter (27%) had experienced physical, 18% emotional, and 7% sexual violence. The majority of AYWHIV (88%) reported disclosure concerns, 48% reported perceived community stigma, 36% experienced, and 24% internalized stigma. Compared to AYWHIV attending adolescent clinics, those in general/adult clinics had higher internalized stigma. Similarly, having dropped out of school was associated with higher internalized stigma. AYWHIV in sexual relationships had higher experienced stigma and disclosure concerns. Lastly, exposure to violence was associated with higher experienced, internalized, perceived community stigma and disclosure concerns. These risk factors can be targeted when developing stigma-prevention interventions. [ABSTRACT FROM AUTHOR]

Differentiated service delivery (DSD) and multi-month dispensing (MMD) of antiretroviral therapy (ART) have improved treatment adherence and viral suppression among people living with HIV (PLHIV), and service delivery efficiency. We assessed the experiences of PLHIV and providers with DSD and MMD in Northern Nigeria. We conducted in-depth interviews (IDI) with 40 PLHIV and 6 focus group discussions (FGD) with 39 health care providers across 5 states, exploring their experiences with 6 DSD models. Qualitative data were analyzed using NVivo®1.6.1. Most PLHIV and providers found the models acceptable and expressed satisfaction with service delivery. The DSD model preference of PLHIV was influenced by convenience, stigma, trust, and cost of care. Both PLHIV and providers indicated improvements in adherence and viral suppression; they also raised concerns about quality of care within community-based models. PLHIV and provider experiences suggest that DSD and MMD have the potential to improve patient retention rates and service delivery efficiency. [ABSTRACT FROM AUTHOR]

Mortality and loss to follow-up (LTFU) among adolescents and youth living with HIV (AYLHIV) remain high. We evaluated mortality and LTFU during the test and treat era. We abstracted medical records of AYLHIV for 10–24 years between January 2016 and December 2017 in 87 HIV clinics in Kenya. Using competing risk survival analysis, we compared incidence rates and determined correlates of mortality and LTFU among newly enrolled [<2 years since antiretroviral therapy (ART) initiation] and AYLHIV on ART for ≥2 years. Among 4201 AYLHIV, 1452 (35%) and 2749 (65%) were new enrollments and on ART for ≥2 years, respectively. AYLHIV on antiretroviral therapy (ART) for ≥2 years were younger and more likely to have perinatally acquired HIV (p < 0.001). Incidence of mortality and LTFU per 100 person-years were 2.32 [95% confidence interval (CI): 1.64–3.28] and 37.8 (95% CI: 34.7–41.3), respectively, among new enrollments and 1.22 (95% CI: 0.94–1.59) and 10.2 (95% CI: 9.3–11.1), respectively, among those on ART for ≥2 years. New enrollments had almost twice higher risk of mortality [subdistribution hazard ratio (sHR) 1.92 (1.30, 2.84), p = 0.001] and sevenfold higher risk of LTFU [sHR 7.71 (6.76, 8.79), p < 0.001] than those on ART for ≥2 years. Among new enrollments, mortality was higher in males and those with World Health Organization (WHO) stage III/IV disease at enrollment, and LTFU was associated with pregnancy, older age, and nonperinatal acquisition. Female sex and WHO stage (I/II) were associated with LTFU among those on ART for ≥2 years. During the study period from January 1, 2016, to December 31, 2017, the mortality incidence observed did not demonstrate improvement from earlier studies despite universal test and treat and better ART regimens. This trial was registered with ClinicalTrials.gov, NCT03574129. [ABSTRACT FROM AUTHOR]

Objective: HIV stigma and discrimination is widespread in sub‐Saharan Africa and is associated with poor clinical outcomes. Schools play a critical role in the life of youth and have been identified as a potentially stigmatising environment. We sought to explore school HIV stigma drivers, facilitators, manifestations and outcomes among youth living with HIV (YLH) as well as potential stigma reduction interventions in Kenya. Methods: Semi‐structured in‐depth qualitative interviews with 28 school‐attending YLH aged 14–19 years and 24 caregivers of YLH were analysed using directed content analysis. Results were summarised using the Health and Stigma Framework. Results: Drivers and facilitators of HIV stigma in the school environment included misconceptions about HIV transmission, HIV treatment outcomes and long‐term overall health of people living with HIV. HIV stigma manifested largely as gossip, isolation and loss of friendships. Fear of HIV stigma or experienced stigma resulted in poor adherence to antiretroviral treatment—particularly among YLH in boarding schools—and poor mental health. Stigma also impacted school choice (boarding vs. day school) and prevented HIV disclosure to schools which was necessary for optimal support for care. Proposed interventions to address HIV stigma in schools included HIV education, psychosocial support for YLH, support for HIV disclosure to schools while ensuring confidentiality and building YLH resilience. Conclusion: There is an urgent need to develop interventions to address HIV stigma in schools to ensure optimised health and social outcomes for YLH. Future studies to understand the most effective and efficient interventions are needed. [ABSTRACT FROM AUTHOR]

HIV self-testing (HIVST) can improve testing completion among adolescents and young adults (AYA), although its influence on sexual behaviors is unclear. We evaluated whether HIVST was associated with changes in talking with sexual partners about HIVST, condom use, and HIV risk perception among AYA ages 15–24 years in a study of HIVST distribution through homes, pharmacies, and nightclubs in Nairobi, Kenya. All participants had negative HIVST results. Regression models were used to evaluate changes between pre-HIVST and 4 months post-HIVST. Overall, there was a significant increase in talking with sexual partners about HIVST. There was a significant reduction in number of condomless sex acts among AYA recruited through pharmacies and homes. Unexpectedly, among females, there was a significant decrease in consistent condom use with casual partners. HIVST services for AYA may benefit from including strategies to support condom use and partner communication about self-testing adapted to specific populations and partnerships. [ABSTRACT FROM AUTHOR]

Background: There is mixed evidence on the influence of self-disclosure of one's HIV status on mental health, health behaviours and clinical outcomes. We studied the patterns of self-disclosure among parents living with HIV, and factors that influence parental disclosure. Methods: This mixed-methods study was among adults in HIV care participating in a study assessing the uptake of pediatric index-case testing. They completed a survey to provide demographic and HIV-related health information, and assess self-disclosure to partners, children and others. We ran generalized linear models to determine factors associated with disclosure and reported prevalence ratios (PR). Eighteen participants also participated in in-depth interviews to explore perceived barriers and facilitators of self-disclosure to one's child. A content analysis approach was used to analyze interview transcripts. Results: Of 493 caregivers, 238 (48%) had a child ≥ 6 years old who could potentially be disclosed to about their parent's HIV status. Of 238 participants, 205 (86%) were female, median age was 35 years, and 132 (55%) were in a stable relationship. Among those in a stable relationship, 96 (73%) knew their partner's HIV status, with 79 (60%) reporting that their partner was living with HIV. Caregivers had known their HIV status for a median 2 years, and the median age of their oldest child was 11 years old. Older caregiver age and older first born child's age were each associated with 10% higher likelihood of having disclosed to a child (PR: 1.10 [1.06–1.13] and PR: 1.10 [1.06–1.15], per year of age, respectively). The child's age or perceived maturity and fear of causing anxiety to the child inhibited disclosure. Child's sexual activity was a motivator for disclosure, as well as the belief that disclosing was the "right thing to do". Caregivers advocated for peer and counseling support to gain insight on appropriate ways to disclose their status. Conclusions: Child's age is a key consideration for parents to disclose their own HIV status to their children. While parents were open to disclosing their HIV status to their children, there is a need to address barriers including anticipated stigma, and fear that disclosure will cause distress to their children. [ABSTRACT FROM AUTHOR]

Social support is a critical component of achieving positive health outcomes for youth living with HIV (YLWH). Mobile health (mHealth) has significant potential for providing social support to YLWH. However, little is known about the domains of social support most needed by YLWH which mHealth interventions might address. Drawing on the spontaneous creation of WhatsApp support groups by YLWH in Nairobi, Kenya, we characterized Kenyan YLWH's social support needs and potential roles of social media groups in meeting them. We conducted interviews and focus-groups with 68 YLWH, 24 caregivers and 20 healthcare workers, and observed two YLWH-led WhatsApp groups for 6 weeks. Youth reported that existing support systems, including family and healthcare workers, already provided informational and instrumental support. However, they emphasized unmet companionship and emotional support needs, leading to isolation, hopelessness, and medication adherence challenges. Participants identified connection with other YLWH as a unique source of emotional and companionship support that allowed them to feel more secure and less isolated. Interviews and observed WhatsApp chats demonstrated that WhatsApp groups were a desirable medium for companionship support that overcame barriers to in-person connection. [ABSTRACT FROM AUTHOR]

Background: Zika virus (ZIKV), first discovered in Uganda in 1947, re-emerged globally in 2013 and was later associated with microcephaly and other birth defects. We determined the incidence of ZIKV infection and its association with adverse pregnancy and fetal outcomes in a pregnancy cohort in Kenya.Methods: From October 2017 to July 2019, we recruited and followed up women aged ≥ 15 years and ≤ 28 weeks pregnant in three hospitals in coastal Mombasa. Monthly follow-up included risk factor questions and a blood sample collected for ZIKV serology. We collected anthropometric measures (including head circumference), cord blood, venous blood from newborns, and any evidence of birth defects. Microcephaly was defined as a head circumference (HC) < 2 standard deviations (SD) for sex and gestational age. Severe microcephaly was defined as HC < 3 SD for sex and age. We tested sera for anti-ZIKV IgM antibodies using capture enzyme-linked immunosorbent assay (ELISA) and confirmed positives using the plaque reduction neutralization test (PRNT90) for ZIKV and for dengue (DENV) on the samples that were ZIKV neutralizing antibody positive. We collected blood and urine from participants reporting fever or rash for ZIKV testing.Results: Of 2889 pregnant women screened for eligibility, 2312 (80%) were enrolled. Of 1916 recorded deliveries, 1816 (94.6%) were live births and 100 (5.2%) were either stillbirths or spontaneous abortions (< 22 weeks of gestation). Among 1236 newborns with complete anthropometric measures, 11 (0.9%) had microcephaly and 3 (0.2%) had severe microcephaly. A total of 166 (7.2%) participants were positive for anti-ZIKV IgM, 136 of whom became seropositive during follow-up. Among the 166 anti-ZIKV IgM positive, 3 and 18 participants were further seropositive for ZIKV and DENV neutralizing antibodies, respectively. Of these 3 and 18 pregnant women, one and 13 (72.2%) seroconverted with antibodies to ZIKV and DENV, respectively. All 308 samples (serum and urine samples collected during sick visits and samples that were anti-ZIKV IgM positive) tested by RT-PCR were negative for ZIKV. No adverse pregnancy or neonatal outcomes were reported among the three participants with confirmed ZIKV exposure. Among newborns from pregnant women with DENV exposure, four (22.2%) were small for gestational age and one (5.6%) had microcephaly.Conclusions: The prevalence of severe microcephaly among newborns in coastal Kenya was high relative to published estimates from facility-based studies in Europe and Latin America, but little evidence of ZIKV transmission. There is a need for improved surveillance for microcephaly and other congenital malformations in Kenya. [ABSTRACT FROM AUTHOR]

The health care transition (HCT) from pediatric to adult care is a potential contributor to poor clinical outcomes among adolescents living with HIV (ALHIV). In sub-Saharan Africa (SSA), there is limited information on effective tools and processes to prepare and support ALHIV through this transition. This study elicited perspectives of policy-makers regarding barriers and facilitators to successful HCT among ALHIV in Kenya. Twenty in-depth interviews (IDIs) were conducted with policy-makers using a semi-structured guide. Using the socio-ecological model (SEM) as an organizing framework, directed content and thematic network analyses methods were used to characterize themes related to key influences on HCT processes and to describe actionable recommendations for improved tools and resources. Policy-makers identified multilevel support, including the development of a triadic relationship between the caregiver, healthcare worker (HCW) and adolescent, as an essential strategy for improved HCT success. Across the SEM, policy-makers described the importance of actively engaging adolescents in their care to promote increased ownership and autonomy over health decisions. At the structural level, the need for more comprehensive HCT guidelines and improved HCW training was highlighted. Expanded HCT tools and guidelines, that emphasize supportive relationships and intensified adolescent engagement, may improve HCT processes and outcomes. [ABSTRACT FROM AUTHOR]

Expanding index and family-based testing (HBT) is a priority for identifying children living with HIV. Our study characterizes predictors that drive testing location choice for children of parents living with HIV. Kenyan adults living with HIV were offered a choice of HBT or clinic-based testing (CBT) for any of their children (0–12 years) of unknown HIV status. Multilevel generalized linear models were used to identify correlates of choosing HBT or CBT for children and testing all versus some children within a family, including caregiver demographics, HIV history, social support, cost, and child demographics and HIV prevention history. Among 244 caregivers living with HIV and their children of unknown HIV status, most (72%) caregivers tested children using CBT. In multivariate analysis, female caregivers [aRR 0.52 (95% CI 0.34–0.80)] were less likely to choose HBT than male caregivers. Caregivers with more children requiring testing [aRR 1.23 (95% CI 1.05–1.44)] were more likely to choose HBT than those with fewer children requiring testing. In subgroup univariate analysis, female caregivers with a known HIV negative spouse were significantly more likely to choose HBT over CBT than those with a known HIV positive spouse [RR 2.57 (95% CI 1.28–5.14), p = 0.008], no association was found for male caregivers. Child demographics and clinical history was not associated with study outcomes. Caregiver-specific factors were more influential than child-specific factors in caregiver choice of pediatric HIV testing location. Home-based testing may be preferable to families with higher child care needs and may encourage pediatric HIV testing if offered as an alternative to clinic testing. [ABSTRACT FROM AUTHOR]

Background: The impact of human immunodeficiency virus (HIV) on pregnancy outcomes for women on antiretroviral therapy (ART) in sub-Saharan Africa remains unclear.Methods: Pregnant women in Kenya were enrolled in the second trimester and followed up to delivery. We estimated effects of treated HIV with 3 pregnancy outcomes: loss, premature birth, and low birth weight and factors associated with HIV-positive status.Results: Of 2113 participants, 311 (15%) were HIV infected and on ART. Ninety-one of 1762 (5%) experienced a pregnancy loss, 169/1725 (10%) a premature birth (<37 weeks), and 74/1317 (6%) had a low-birth-weight newborn (<2500 g). There was no evidence of associations between treated HIV infection and pregnancy loss (adjusted relative risk [aRR], 1.19; 95% confidence interval [CI], .65-2.16; P = .57), prematurity (aRR, 1.09; 95% CI, .70-1.70; P = .69), and low birth weight (aRR, 1.36; 95% CI, .77-2.40; P = .27). Factors associated with an HIV-positive status included older age, food insecurity, lower education level, higher parity, lower gestation at first antenatal clinic, anemia, and syphilis. Women who were overweight or underweight were less likely to be HIV infected compared to those with normal weight.Conclusions: Currently treated HIV was not significantly associated with adverse pregnancy outcomes. HIV-infected women, however, had a higher prevalence of other factors associated with adverse pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Oral HIV self-testing (HIVST) may expand access to testing among hard-to-reach reach adolescents and young adults (AYA). We evaluated community-based HIVST services for AYA in an urban settlement in Kenya. Peer-mobilizers recruited AYA ages 15–24 through homes, bars/clubs, and pharmacies. Participants were offered oral HIVST, optional assistance and post-test counseling. Outcomes were HIVST acceptance and completion (self-report and returned kits). Surveys were given at enrollment, post-testing, and 4 months. Log-binomial regression evaluated HIVST preferences by venue. Among 315 reached, 87% enrolled. HIVST acceptance was higher in bars/clubs (94%) than homes (86%) or pharmacies (75%). HIVST completion was 97%, with one confirmed positive result. Participants wanted future HIVST at multiple locations, include PrEP, and cost ≤ $5USD. Participants from bars/clubs and pharmacies were more likely to prefer unassisted testing and peer-distributers compared to participants from homes. This differentiated community-based HIVST strategy could facilitate engagement in HIV testing and prevention among AYA. [ABSTRACT FROM AUTHOR]

We examined patterns of disclosure among youth living with HIV (YLHIV) in Kenya, and the association between self-disclosure and antiretroviral therapy adherence, stigma, depression, resilience, and social support. Of 96 YLHIV, 78% were female, 33% were ages 14–18, and 40% acquired HIV perinatally. Sixty-three (66%) YLHIV had self-disclosed their HIV status; 67% to family and 43% to non-family members. Older YLHIV were 75% more likely to have self-disclosed than those 14–18 years. Of the 68 either married or ever sexually active, 45 (66%) did not disclose to their partners. Those who had self-disclosed were more likely to report internalized stigma (50% vs. 21%, prevalence ratio [PR] 2.3, 1.1–4.6), experienced stigma (26% vs. 3%, PR 11.0, 1.4–86), and elevated depressive symptoms (57% vs. 30%, PR 1.8, 1.0–3.1). The association with stigma was stronger with self-disclosure to family than non-family. Support should be provided to YLHIV during self-disclosure to mitigate psychosocial harms. [ABSTRACT FROM AUTHOR]

Stakeholder engagement between researchers, policymakers and practitioners is critical for the successful translation of research into policy and practice. The Counseling and Testing for Children at Home (CATCH) study evaluated a paediatric index case testing model, targeting the children of HIV-infected adults in care in Kenya. Researchers collaborated with stakeholders in the planning, execution and evaluation, and dissemination phases of CATCH. They included a community advisory board, the national HIV programme, County health departments, institutional ethics review bodies, a paediatric bioethics group, facility heads and frontline healthcare workers . Stakeholder analysis considered the power and interest of each stakeholder in the study. All stakeholders had some power to influence the success of the project in the different phases. However, support from institutions with higher hierarchical power increased acceptance of the study by stakeholders lower in the hierarchy. During the planning, execution and evaluation, and dissemination phases, the study benefitted from deliberate stakeholder engagement. Through engagement, changes were made in the approach to recruitment to ensure high external validity, placing recruitment optimally within existing clinic flow patterns. Choices in staffing home visits were made to include the appropriate cadre of staff. Adaptations were made to the consenting process that balanced the child's evolving autonomy and risks of HIV disclosure. Dissemination involved delivering site-specific results in each HIV clinic, local and international conferences and sharing of study tools, resulting in the study approach being scaled up nationally. The deliberate engagement of stakeholders early in intervention development optimized study validity and accelerated adoption of the CATCH approach in nationwide HIV testing campaigns by the Ministry of Health and inclusion of paediatric index-case testing in national HIV testing guidelines. Involving policymakers and frontline healthcare workers throughout the study cycle builds capacity in the implementing team for quick adoption and scale-up of the evidence-based practice. [ABSTRACT FROM AUTHOR]

Newly diagnosed HIV positive children may be unique index cases to identify undiagnosed parents. Data was used from the Pediatric Urgent Start of HAART (NCT02063880) trial, which enrolled hospitalized, ART-naïve, HIV positive children ages 0–12 years in Kenya. Exact McNemar's tests were used to compare proportions of mothers and fathers tested for HIV, linked to care, and on ART at baseline and 6 months. This analysis included 87 newly diagnosed children with HIV who completed 6 months of follow-up. Among 83 children with living mothers, there were improvements in maternal linkage to care and treatment comparing baseline to 6 months (36% vs. 78%; p < 0.0001 and 22% vs. 52%; p < 0.0001). Among 80 children with living fathers, there were increases from baseline to 6 months in the number of fathers who knew the child's HIV status (34% vs. 78%; p < 0.0001), fathers ever tested for HIV (43% vs. 65%; p < 0.0001), fathers ever tested HIV positive (21% vs. 43%; p < 0.0001), fathers ever linked to care (15% vs. 35%; p < 0.0001), and fathers ever initiated on ART (11% vs. 23%; p = 0.0039). Newly diagnosed HIV positive children can be important index cases to identify parents with undiagnosed HIV or poor engagement in care. [ABSTRACT FROM AUTHOR]

Lack of health care worker (HCW) training is a barrier to implementing youth-friendly services. We examined training coverage and self-reported competence, defined as knowledge, abilities, and attitudes, of HCWs caring for adolescents living with HIV (ALWH) in Kenya. Surveys were conducted with 24 managers and 142 HCWs. Competence measures were guided by expert input and Kalamazoo II Consensus items. Health care workers had a median of 3 (interquartile range [IQR]: 1-6) years of experience working with ALWH, and 40.1% reported exposure to any ALWH training. Median overall competence was 78.1% (IQR: 68.8-84.4). In multivariable linear regression analyses, more years caring for ALWH and any prior training in adolescent HIV care were associated with significantly higher self-rated competence. Training coverage for adolescent HIV care remains suboptimal. Targeting HCWs with less work experience and training exposure may be a useful and efficient approach to improve quality of youth-friendly HIV services. [ABSTRACT FROM AUTHOR]

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Poor retention in HIV care remains a major problem for Adolescents and Young Adults (AYA). A Standardized Patient (SP) clinical training intervention was developed to improve healthcare worker (HCW) "adolescent-friendly" competencies in Kenya. Professional actors were trained to portray HIV-infected AYA according to standardized scripts. HCWs completed a 2-day SP training that included didactic sessions, 7 video-recorded SP encounters, and group debriefing. AYA health experts rated HCWs by reviewing the video recordings. All HCWs (10/10) reported high satisfaction with the intervention and overall improvement in self-rated competency in caring for HIV-infected AYA. Cases were reported to be realistic and relevant by between 7 and 10 of 10 HCWs. The case on disclosure and adherence was rated as most challenging in communication and making medical decisions by HCWs. Areas identified by SPs for improvement by HCWs included allowing patients time to ask questions, and enabling SP to share sensitive information. The overall ICC by experts was low 0.27 (95% CI: −0.79 to 0.95), however, ICCs in assessment of HIV disclosure 0.78 (95% CI: 0.17–0.98), and sexual behavior 0.97 (95% CI: 0.89–0.99) were high. This intervention was acceptable for Kenyan HCWs and improved self-rated competency in caring for HIV-infected AYA. [ABSTRACT FROM AUTHOR]

HIV incidence and mortality are high among adolescents and young adults (AYA) in sub-Saharan Africa, but testing rates are low. Understanding how support people (SP), such as peers, partners, or parents, influence AYA may improve HIV testing uptake. AYA aged 14-24 seeking HIV testing at a referral hospital in Nairobi, Kenya completed a post-test survey assessing the role of SP. Among 1062 AYA, median age was 21. Overall, 12% reported their decision to test was influenced by a parent, 20% by a partner, and 22% by a peer. Young adults (20-24 years old) were more likely than adolescents (14-19 years old) to be influenced to test by partners (23% vs. 12%, p < .001), and less likely by parents (6.6% vs. 27%, p < .001), healthcare workers (11% vs. 16%, p < .05), or counselors (9.4% vs. 19%, p < .001). Half of AYA were accompanied for testing (9.9% with parent, 10% partner, 23% peer, 4.3% others, and 2.1% multiple types). Young adults were more likely than adolescents to present alone (58% vs. 32%, p < .001) or with a partner (12% vs. 6.7%, p < .05), and less likely with a parent (1.6% vs. 31%, p < .001). Similar proportions of adolescents and young adults came with a peer or in a group. Correlates of presenting with SP included: younger age (aRR = 1.55 [95%CI = 1.30-1.85]), female sex (aRR = 1.45 [95%CI = 1.21-1.73]), and school enrollment (aRR = 1.41 [95%CI = 1.05-1.88]). SP play an important role in AYAs' HIV testing and varies with age. Leveraging SP may promote uptake of HIV testing and subsequent linkage care for AYA. [ABSTRACT FROM AUTHOR]

Background: Adolescent-friendly policies aim to tailor HIV services for adolescents and young adults aged 10-24 years (AYA) to promote health outcomes and improve retention in HIV care and treatment. However, few interventions focus on improving healthcare worker (HCW) competencies and skills for provision of high-quality adolescent care. Standardized patients (SPs) are trained actors who work with HCWs in mock clinical encounters to improve clinical assessment, communication, and empathy skills. This stepped-wedge randomized controlled trial will evaluate a clinical training intervention utilizing SPs to improve HCW skills in caring for HIV-positive AYA, resulting in increased retention in care.Methods/design: The trial will utilize a stepped-wedge design to evaluate a training intervention using SPs to train HCWs in assessment, communication, and empathy skills for AYA HIV care. We will recruit 24 clinics in Kenya with an active electronic medical record (EMR) system and at least 40 adolescents enrolled in HIV care per site. Stratified randomization by county will be used to assign clinics to one of four waves - time periods when they receive the intervention - with each wave including six clinics. From each clinic, up to 10 HCWs will participate in the training intervention. SP training includes didactic sessions in adolescent health, current guidelines, communication skills, and motivational interviewing techniques. HCW participants will rotate through seven standardized SP scenarios, followed by SP feedback, group debriefing, and remote expert evaluation. AYA outcomes will be assessed using routine clinic data. The primary outcome is AYA retention in HIV care, defined as returning for first follow-up visit within 6 months of presenting to care, or returning for a first follow-up visit after re-engagement in care in AYA with a previous history of being lost to follow-up. Secondary outcomes include HCW competency scores, AYA satisfaction with care, and AYA clinical outcomes including CD4 and viral load. Additional analyses will determine cost-effectiveness of the intervention.Discussion: This trial will contribute valuable information to HIV programs in Kenya and other low-resource settings, providing a potentially scalable strategy to improve quality of care and retention in critical HIV services in this population.Trial Registration: ClinicalTrials.gov, ID: NCT02928900. Registered 26 August 2016. [ABSTRACT FROM AUTHOR]