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Kenyan sex worker-led organisations (SWLOs) often play a key role in the national HIV response. Accounts of these organisations frequently focus on their community-led approaches to promote sexual health. This paper addresses sensitisation, an underexplored but significant activity in the political agency of sex workers (SWs). Drawing on ethnographic fieldwork in a male SWLO in Nairobi, we examine how male SWs strategically use their position in the national HIV response to create spaces of police sensitisation. Taking police sensitisation as a manifestation of community-led advocacy and a 'politics of small steps', we examine how SWs respond to, resist and remake the political landscape of police violence. The strategy supports SWs in changing existing power relationships between themselves and the police, albeit within the confines of a criminalising legal system. The analysis of sensitisation practices supports a reimagining of SWLOs that stresses their political agency in the production of new political spaces and expands the focus on African SWLOs beyond HIV work to their political activities, which advance SWs' health, rights and social justice. [ABSTRACT FROM AUTHOR]

The health burden due to mental health has historically been underestimated with focus on communicable diseases and deaths and little consideration of disability and comorbidity effects of poor mental health. Recent data show increasing trends of mental health disorders as a share of global health burdens and vulnerability of adolescents. This paper aims to explore social determinants of mental health as experienced by adolescent girls, drawing attention to gendered risks during the COVID-19 pandemic. Semi-structured interviews with twenty-two adolescent girls in urban informal settlements in Kenya and Nigeria reveal unique environmental, socio-cultural, economic and educational factors that threatened their mental wellbeing. The pandemic exacerbated these determinants. An equitable recovery will require a consideration of not only disproportional mental health outcomes, but also social determinants that contribute to these outcomes. As more than half of the urban population in sub-Saharan Africa reside in informal settlements, this study has implications for youth-focused mental health interventions in these and similar settings. [ABSTRACT FROM AUTHOR]

Approximately 280 million people around the world suffer from depression, and the rates are higher among women than men. For women living in informal settlements in lower – and middle-income countries (LMICs) the prevalence and associated burden of depressive symptoms may be particularly high. The purpose of this paper was to explore factors associated with possible major depressive disorder (MDD) in a probability sample of women living in Mathare informal settlement in Nairobi, Kenya and to identify potential points for intervention and/or support. Quantitative surveys were conducted with 552 women aged 18–75. Possible MDD was measured using the Patient Health Questionnaire and regressed on individual, household/familial-, and community/interpersonal-level factors. Findings highlight the potential importance of factors such as physical health, economic stress, access to water and sanitation, household and family dynamics, and neighbourhood/village differences in possible MDD among women living in informal settlements. We identify potential points for research, intervention and policy including: providing appropriate tangible assistance or interventions to reduce economic stress/strain; expanding access to water and sanitation and, in doing so, reducing potential burdens to physical health; providing and expanding healthcare to include mental healthcare; and investigating family dynamics and bolstering support for families, particularly for those experiencing conflict. [ABSTRACT FROM AUTHOR]

Financial technology tools have been utilised to create readily available mobile loan platforms for urban-based, daily-wage earners in Kenya. From a financial lending perspective, this development signals greater inclusion and equality in formal bank financing systems. In this paper, however, we examine mobile loans and their repayment from the perspective of women who sell sex in Nairobi, drawing upon the qualitative findings of two community-based studies conducted in close collaboration with sex worker-led organisations serving the sexual health needs of their peers. Our findings suggest that mobile loans may undermine the financial security strategies and economic independence of sex workers, leaving these women in more precarious economic circumstances, which have been shown in other instances to have effects on sexual risk taking and vulnerability to HIV infection. [ABSTRACT FROM AUTHOR]

This paper uses empirical data collected from 117 female sex workers living in informal settlements in Nairobi and 15 healthcare providers to highlight specific effects of COVID-19 and related restrictions on healthcare access for the sex workers. We highlight the existing gender and health inequalities that have now been reinforced by the initial outbreak of the COVID-19 pandemic. Specifically, we focus on the most concerning healthcare needs for the sex workers including HIV prevention, care and treatment and sexual and reproductive healthcare. Our study findings reveal that the various restrictions imposed by the government to help curb the spread of COVID-19 to a large extent made it difficult for the sex workers to access their healthcare needs. The paper discusses the challenges of healthcare service delivery reflecting on some innovative and pioneering responses from health care providers to address the emergency situation. [ABSTRACT FROM AUTHOR]

Since access to HIV testing, counselling, and drug therapy has improved so dramatically, scholars have investigated ways this ‘scale-up’ has interacted with HIV/AIDS-related stigma in sub-Saharan Africa. Drawing on data collected during ethnographic research in a trading centre in western Kenya, this paper critically analyses two violent and localised case studies of panic over the ill health of particular community residents as a nuanced lens through which to explore the dynamic interplay of gender politics and processes of HIV/AIDS-related stigma in the aftershocks of the AIDS crisis. Gaining theoretical momentum from literatures focusing on stigma, gender, witchcraft, gossip, and accusation, we argue that the cases highlight collective anxieties, as well as local critiques of shifting gender roles and the strain of globalisation and legacies of uneven development on myriad forms of relationships. We further contend that these heightened moments of panic and accusation were deployments of power that ultimately sharpened local gender politics and conflicts on the ground in ways that complicated the social solidarity necessary to tackle social and health inequalities. The paper highlights one community’s challenge to eradicate the stigma associated with HIV/AIDS during a period of increased access to HIV services. [ABSTRACT FROM PUBLISHER]

Despite being highly vulnerable to acquiring HIV, no effective evidence-based interventions (EBI) exist for street-connected young people (SCY) in low- and middle-income countries (LMICs). Therefore, this paper describes the research process of adapting an existing EBI in Eldoret, Kenya using a modified ADAPT-ITT model with a young key population. From May to August 2018 we adapted the combined Stepping Stones and Creating Futures interventions. We used community-based participatory methods, focus group discussions, and working groups with four Peer Facilitators and 24 SCY aged 16–24 years. At the inception of this project, a matched-savings programme was integrated into the intervention to further address structural drivers of HIV. Numerous adaptations came forth through the participatory process. Engaging SCY in the adaptation process ensured the programme was responsive to their needs, relevant to the street context, and respected their right to participate in the research process. [ABSTRACT FROM AUTHOR]

The HIV response is hampered by many obstacles to progression along the HIV care cascade, with men, in particular, experiencing different forms of disruption. One group of men, whose stories remain untold, are those who have succumbed to HIV-related illness. In this paper, we explore how next-of-kin account for the death of a male relative. We conducted 26 qualitative after-death interviews with family members of male PLHIV who had recently died from HIV in health and demographic surveillance sites in Malawi, Tanzania, Kenya, Uganda, Zimbabwe and South Africa. The next-of-kin expressed frustration about the defiance of their male relative to disclose his HIV status and ask for support, and attributed this to shame, fear and a lack of self-acceptance of HIV diagnosis. Next-of-kin painted a picture of their male relative as rebellious. Some claimed that their deceased relative deliberately ignored instructions received by the health worker. Others described their male relatives as unable to maintain caring relationships that would avail day-to-day treatment partners, and give purpose to their lives. Through these accounts, next-of-kin vocalised the perceived rebellious behaviour of these men, and in the process of doing so neutralised their responsibility for the premature death of their relative. [ABSTRACT FROM AUTHOR]

This paper examines the politics and the underlying discourses of water provisioning and how residents of Korogocho and Viwandani slum settlements in Nairobi city cope with challenges relating to water access. We use qualitative data from 36 focus group discussions conducted in the two slums to unravel discourses regarding water provisioning in the rapidly growing slum settlements in African cities. Results show that the problems concerning water provisioning within Nairobi slums are less about water scarcity and more about unequal distribution and the marginalisation of slum areas in development plans. Poor water management, lack of equity-based policies and programmes, and other slum-specific features such as land-tenure systems and insecurity exacerbate water-supply problems within slum areas. It is hard to see how water supply in these communities can improve without the direct and active involvement of the government in infrastructural development and oversight of the water-supply actors. Innovative public-private partnerships in water provision and the harnessing of existing community efforts to improve the water supply would go a long way towards improving the water supply to the rapidly growing urban poor population in Africa. [ABSTRACT FROM AUTHOR]

Little is known about migration during pregnancy related to intimate partner violence (IPV). In this paper, we examine issues of agency in relation to pregnant women's migrations in a high HIV prevalence area of Kenya. We qualitatively explored forced migration among pregnant women, using data from in-depth interviews, focus groups and IPV screening forms. To quantitatively examine migration during pregnancy, we analysed data from a prospective study of 614 pregnant women. The qualitative data revealed that women had varied responses to violence in pregnancy, with some being able to leave the marital home voluntarily as a strategy to escape violence. Others were ‘sent packing’ from their marital homes when they dared to exercise autonomy, in some cases related to HIV status. Quantitative analyses revealed that pregnant women who migrated were more educated, less likely to be living with a partner and had fewer children than other women. Migration among pregnant women in Kenya illustrates the complexity of understanding women's agency in the context of IPV. The findings indicate that there is not a dichotomy between ‘victim’ and ‘agent’, but rather a complex dynamic between and within pregnant women, who may sequentially or simultaneously experience aspects of victimhood and/or agentic response. [ABSTRACT FROM AUTHOR]

As populations move to urban centres across East Africa, lifestyle habits that affect cardiovascular disease have changed, affecting non-communicable disease risk. In particular, the prevalence of hypertension, and associated awareness of this life-threatening condition, has not been studied in Mombasa, Kenya. This paper assesses the rates of prevalence, awareness, treatment and control of hypertension in Old Town, an urban district of the coastal city. We surveyed 469 subjects, gathered via a clustered sampling technique. Age-adjusted prevalence of hypertension was measured at 32.6% (±2.2) for adults over 18 and was linearly related to age. Results indicate that hypertension awareness was associated with age and sex, as women were substantially more likely to be aware of and to control their hypertension. Only 23.2% (±2.0) of subjects had knowledge of both the causes of and practical solutions to hypertension, and practical hypertension knowledge was associated with hypertension awareness and gender (women had higher rates of knowledge than men). These results indicate that hypertension is a real public health concern in Old Town, and that younger individuals, particularly males, are least likely to be aware of the dangers of hypertension. Public health measures should focus on this population. [ABSTRACT FROM AUTHOR]

Communities' knowledge and management strategies are crucial for mitigating and controlling the threat of existing and emerging diseases. In this study, we conducted randomised control trials (RCT) to examine the impact of health education on households' knowledge and management of three Arboviral Diseases (ADs); Rift Valley fever, Chikungunya fever, and Dengue fever in Kenya. The study was based on a sample of 629 households drawn from the three of Kenya's AD hotspot counties; Baringo, Kwale, and Kilifi. Employing a difference-in-difference method, our findings indicate that health education intervention significantly improved households' understanding of ADs transmission modes, causes, and prevention strategies. However, this intervention did not sufficiently influence households' disease management behaviour. We recommend the implementation of community engagement and outreach initiatives which have the potential to drive behavioural changes at the household level, thus enhancing the management and control of ADs in Kenya. [ABSTRACT FROM AUTHOR]

Global health researchers often discount mutual learning and benefit to address shared health challenges across high and low- and middle-income settings. Drawing from a 30-year partnership called AMPATH that started between Indiana University in the US and Moi University in Kenya, we describe an innovative approach and program for mutual learning and benefit coined 'reciprocal innovation.' Reciprocal innovation harnesses a bidirectional, co-constituted, and iterative exchange of ideas, resources, and innovations to address shared health challenges across diverse global settings. The success of AMPATH in Kenya, particularly in HIV/AIDS and community health, resulted in several innovations being 'brought back' to the US. To promote the bidirectional flow of learning and innovations, the Indiana CTSI reciprocal innovation program hosts annual meetings of multinational researchers and practitioners to identify shared health challenges, supports pilot grants for projects with reciprocal exchange and benefit, and produces educational and training materials for investigators. The transformative power of global health to address systemic health inequities embraces equitable and reciprocal partnerships with mutual benefit across countries and communities of academics, practitioners, and policymakers. Leveraging a long-standing partnership, the Indiana CTSI has built a reciprocal innovation program with promise to redefine global health for shared wellbeing at a global scale. [ABSTRACT FROM AUTHOR]

Social capital predicts many positive health outcomes, including food and water access and sufficiency. Hence, increasing social capital has emerged as one potential strategy to improve food and water security. In this study, we investigate whether social capital generated through participation in a community-based microlending programme based in semi-rural Kenya is associated with water and food insecurity, and explore the interconnectedness of water and food insecurity through mediation analysis. Randomly-selected women participants of the community-based programme (n = 400) were interviewed in June 2018 and again in June 2019. Survey measures included water insecurity, food insecurity and an index of social capital constructs, namely group cohesion, trust, expectations of mutual support, sense of belonging and frequency of attendance in the programme. Random effects linear regression showed that an increase the social capital index was associated with lower water and food insecurity. The mediation analysis indicated that the association between social capital and food insecurity was completely mediated by water insecurity. This study demonstrates the need for further investigation into how social capital-generating programmes can contribute to systems approaches for collaborative food and water security programmes, especially among rural communities in low- and middle-income countries. [ABSTRACT FROM AUTHOR]

Urban refugees often face tremendous adversities during displacement that exacerbate mental health and psychosocial outcomes. Given the lack of research on how extended displacement affects mental health in urban refugee youth, this study examines the differential effects of country of birth on trauma exposure and psychosocial factors that influence mental health experiences among Somali refugee youth in urban Kenya (n = 303). Findings reveals that childhood trauma and impeded social functioning predicted mental health outcomes. Being born in Kenya was a significant predictor of poor mental health despite there being no significant difference in trauma exposures and psychosocial factors between Somali-born and Kenya-born youth. This difference can be attributed to prolonged displacement, disrupted development of cultural identity, and discrimination experienced in the host country. Given the widely devastating effects of childhood trauma and community violence, mental health interventions need to be two-prolonged: addressing and preventing intergenerational trauma sequelae through family-based interventions; and community-level programs and advocacy for safety and protection for the displaced. Our findings also emphasize that future interventions for urban refugee communities should be inclusive to all community members, considering shared vulnerability to community violence as well as intergenerational transmission of traumas through childhood adversities and lacking support. [ABSTRACT FROM AUTHOR]

Oral fluid-based HIV self-testing (HIVST) has emerged as a promising approach to increasing HIV testing coverage, particularly among high-risk populations. Understanding the experiences of women using self-tests and offering them to their sexual partners (secondary distribution) is crucial for determining the potential of HIVST. Qualitative in-depth interviews were conducted among 32 women at high risk of HIV infection, including women who engage in transactional sex, who participated in a cluster randomised trial of a secondary distribution strategy in western Kenya. Interviews explored how women used self-tests within relationships and how this affected their sexual decision-making. Three key themes emerged: women used HIVST to assess risk prior to engaging in sex with partners; HIVST provided women with increased agency to engage in or end relationships; and women appreciated these benefits and urged expanded access to self-tests. HIVST has the potential to support HIV prevention objectives in settings with high prevalence of HIV. Trial registration: ClinicalTrials.gov identifier: NCT03135067. [ABSTRACT FROM AUTHOR]

Literature on dynamics of change in female genital mutilation/cutting (FGM/C) portray two common but conflicting views. On one side, FGM/C is seen as static and deeply entrenched, with parents lacking agency to interpret culture, evaluate options and adopt changes. An alternative perspective focuses on the fluidity of social norms, influencing whether and how FGM/C is practised. This study asks: in counties where FGM/C persists at high rates, Kisii and Narok, are there changes in the way that FGM/C is performed? and what drives these changes? In-depth interviews and focus group discussions were conducted to illuminate these questions. Data showed five ways that FGM/C practices have changed: (1) reduction in severity of cutting, (2) medicalised cutting, (3) performing FGM/C at younger ages, (4) cutting in secret, and (5) occasionally, abandonment of FGM/C. Messaging on health risks of FGM/C and fear of criminal punishment have motivated less severe cutting and medicalisation. Legislation has also driven the practice underground. Programmes aimed at ending FGM/C should create a critical dialogue on changes in norms with the intent of reducing stigmatisation of uncut girls and their families, and the ways cutting practices are shifting, thereby building on change that is already underway. [ABSTRACT FROM AUTHOR]

The places where adolescents live, learn, and play are thought to influence behaviours and health, but we have limited tools for measuring environmental risk on a hyperlocal (e.g. neighbourhood) level. Working with 218 adolescents and their parents/guardians in rural western Kenya, we combined participatory mapping activities with satellite imagery to identify adolescent activity spaces and create a novel measure of social-ecological risks. We then examined the associations between social-ecological risk and individual HIV risk beliefs and behaviours. We found support for the conjecture that social-ecological risks may be associated with individual beliefs and behaviours. As social-ecological risk increased for a sample of Kenyan adolescents, so did their reports of riskier sex beliefs and behaviours, as well as unsupervised outings at night. This study reinforces calls for disease prevention approaches that go beyond emphasising individual behaviour change. [ABSTRACT FROM AUTHOR]

Over the last decade, many countries have adopted policies addressing menstrual needs. Our research explores the opportunities and challenges that have shaped these initiatives and critically examines their scope and substantive focus. Our study analyses developments in four countries: India, Kenya, Senegal, and the United States. It is based on an analysis of 34 policy documents and interviews with 85 participants active in policy-making or advocacy. Across countries, we found a predominant policy focus on tangible and material outcomes, such as menstrual products and facilities, that is informed by a narrow perception of menstrual needs as the management of bleeding. A number of drivers influenced policy-makers to keep this focus, especially the key narrative around menstrual pads as a perceived solution to school absenteeism combined with sensationalisation in the media and the quest for quantifiable results. Menstrual stigma is so ingrained that it continues to constrain policy-makers and advocates themselves by perceiving and presenting menstruation as a problem to be fixed, managed, and hidden. When considering new policy directions, we need to create capacity for a holistic menstrual policy landscape that overcomes systemic barriers to addressing the needs of menstruators that are largely rooted in menstrual stigma. [ABSTRACT FROM AUTHOR]

Parkinson's disease (PD) is the second most common neurodegenerative disease globally. It is a progressive neurological disorder which can lead to a decline in wellbeing and quality of life for people living with PD (PwP) and their families/caregivers. However, little is known about the experience of PwP in low- and middle-income countries. In high-income countries, the benefits of support groups in providing social support, preventing social isolation and normalising the PD experience have been established. As part of a wider ethnographic study over 10 months, we explored the role of support groups in the management of PD in Kenya, sub-Saharan Africa. Fifty-five PwP and 23 informal family caregivers took part, and observations took place over ten support group meetings. Both positives and drawbacks were identified. The groups played a role in filling in gaps in information and services that the healing landscape in Kenya was unable to provide, while acting as an important source of care and support for PwP and caregivers, enabling 'sociality' and legitimacy. Drawbacks included limited reach and accessibility, 'social comparisons', and seeing the severity of progressed PD in others. Findings suggest PD support groups could become important components within resource-constrained healthcare settings. [ABSTRACT FROM AUTHOR]

There exist significant inequities in access to family planning (FP) in Kenya, particularly for nomadic and semi-nomadic pastoralists. Health care providers (HCP), are key in delivering FP services. Community leaders and religious leaders are also key influencers in women's decisions to use FP. We found limited research exploring the perspectives of both HCPs and these local leaders in this context. We conducted semi-structured interviews with HCPs (n=4) working in facilities in Wajir and Mandera, and community leaders (n=4) and religious leaders (n=4) from the nomadic and semi-nomadic populations the facilities serve. We conducted deductive and inductive thematic analysis. Three overarching themes emerged: perception of FP as a health priority, explanations for low FP use, and recommendations to improve access. Four overlapping sub-themes explained low FP use: desire for large families, tension in FP decision-making, religion and culture, and fears about FP. Providers were from different socio-demographic backgrounds to the communities they served, who faced structural marginalisation from health and other services. Programmes to improve FP access should be delivered alongside interventions targeting the immediate health concerns of pastoralist communities, incorporating structural changes. HCPs that are aware of religious and cultural reasons for non-use, play a key role in improving access. [ABSTRACT FROM AUTHOR]

District health managers (DHMs) lead and manage Ministry of Health programmes and system performance. We report on the acceptability and feasibility of inter-related activities to increase the agency of DHMs in Kenya, Nigeria, South Africa and Uganda using a cross-sectional rapid appraisal with 372 DHMs employing structured questionnaires. We found differences and similarities between the countries, in particular, who becomes a DHM. The opportunity to provide leadership and effect change and being part of a team were reported as rewarding aspects of DHMs' work. Demotivating factors included limited resources, bureaucracy, staff shortages, lack of support from leadership and inadequate delegation of authority. District managers ranked the acceptability of the inter-related activities similarly despite differences between contexts. Activities highly ranked by DHMs were to employ someone to support primary care staff to compile and analyse district-level data; to undertake study tours to well-functioning districts; and joining an African Regional DHM Association. DHMs rated these activities as feasible to implement. This study confirms that DHMs are in support of a process to promote bottom-up, data-driven, context-specific actions that can promote self-actualisation, recognises the roles DHMs play, provides opportunities for peer learning and can potentially improve quality of care. [ABSTRACT FROM AUTHOR]

Shifting environmental conditions and poor or insufficient hygiene facilitates the transmission of bacteria and viruses between and within species of animals; between humans; and between humans and animals. Taking a One Health perspective, we used interviews to explore with 20 women living on low income in Kenya: their gendered hygiene practices and daily contact with animals; how and why they access water and sanitation facilities for themselves, their families, and any livestock; and their understandings of (zoonotic) health risks and disease transmission within their local environments. The women described how they worked every day to keep bodies and homes clean by washing bodies, surfaces and clothes. Women's hygiene practices focussed on removing visible dirt partly because of concerns for health but also to support their families' social standing in their community. While they were less aware of any 'invisible' risks to health through contact with animals or other hazards present in their daily living environments, most exercised care to source and manage water for drinking. Contaminated water was recognised as a risk to health suggesting that in this case, women accepted that there were 'invisible risks' to health, even in clear water, and took steps to mitigate them. [ABSTRACT FROM AUTHOR]

The study purpose was to determine the prevalence and determinants of suicidal thoughts and behaviours in a rural community sample of 15–19-year-old Kenyan adolescents in a region with high HIV burden. Data were from an observational study examining ethical issues in adolescent HIV research (N=4084). Participants reporting suicidal ideation were assessed for suicide risk. Directed content analyses were conducted using assessment reports. Logistic regression was used to identify factors associated with suicide outcomes. Prevalence of suicidal ideation was 16%. Of these, 38% were low risk and 12% were moderate/high-risk. Females and sexually active adolescents had higher odds of suicidal ideation and being categorised as moderate/high-risk. Adolescents with higher depression scores had higher odds of reporting ideation. Pregnancy was protective for females while impregnating a partner was a risk factor for males. Abuse from a family member, financial stress and health concerns were the most frequently mentioned precipitants of ideation. However, only abuse increased odds of suicide behaviour. Effective programmes to identify and support sexually active, pregnant, and distressed adolescents at risk for suicide are needed. Approaches involving families, schools, health facilities, and community gatekeepers may have the most promise in sub-Saharan African rural areas with limited mental health services. [ABSTRACT FROM AUTHOR]

Little is known about how young children in low- and middle-income countries (LMICs) experience violence in their homes, and how different types of household violence may affect child development. This study reports on levels of exposure to household violence and associations with child behavioural outcomes in preschool-aged children in western Kenya. A sample of 465 caregivers, whose children (n = 497) attended early learning centres supported by an international NGO, were enrolled in the study. Caregivers reported on exposure to intimate partner violence (IPV), household discipline practices, attitudes about gender roles, and child behavioural outcomes. Multivariable analysis showed significant predictive effects of IPV (regression coefficient = 1.35, SE = 0.54, p = 0.01) and harsh psychological child discipline (regression coefficient = 0.74, SE = 0.22, p = 0.001), but not physical discipline (regression coefficient = 0.42, SE = 0.24, p = 0.08), on worse child behavioural problems. These findings indicate that child exposure to violence in different forms is highly prevalent, and associated with poorer outcomes in young children. Community-based programmes focused on parenting and early child development are well-positioned to address household violence in LMIC settings, but must be supported to provide a broader understanding of violence and its immediate and long-term consequences. [ABSTRACT FROM AUTHOR]

Adult HIV prevalence in Kenya was 5.9% in 2017. However, in the counties of Kisumu, Siaya, and Homa Bay, HIV prevalence was over 15%. Biomedical interventions, including home-based testing and counselling (HBTC), HIV treatment and pre-exposure prophylaxis (PrEP) provide opportunities to reduce HIV transmission, particularly in rural communities with limited access to health services. Faith-based institutions play an important role in the Kenyan social fabric, providing over 40% of all health care services in Kenya, but have played limited roles in promoting HIV prevention interventions. We conducted qualitative interviews with 45 medical professionals and focus groups with 93 faith leaders in Kisumu and Busia Counties, Kenya. We explored their knowledge, opinions, and experiences in promoting biomedical HIV prevention modalities, including HBTC and PrEP. Knowledge about and engagement in efforts to promote HIV prevention modalities varied; few health providers had partnered with faith leaders on HIV prevention programmes. Faith leaders and health providers agreed about the importance of increasing faith leaders' participation in HIV prevention and were positive about increasing their HIV prevention partnerships. Most faith leaders requested capacity building to better understand biomedical HIV prevention modalities and expressed interest in collaborating with clinical partners to spread awareness about HIV prevention modalities. [ABSTRACT FROM AUTHOR]

Sub-Saharan Africa is at the intersection of the HIV epidemic and the highest burden of alcohol-related disease and injury. Alcohol consumption is associated with an increased likelihood of HIV infection, high rates of intimate partner violence and is considered both a cause and a contributor of economic stress and poverty. Our study integrates the syndemic and socio-ecological system theoretical frameworks to qualitatively explore the effect of second-generation alcohol consumption on sexual risk behaviours, alcohol misuse, violence and economic stress (SAVE) factors and HIV infection risk. We recruited 80 people from rural Kenya to participate in 12 focus groups. Consistent with the literature, we found evidence of syndemic associations of second-generation alcohol consumption with SAVE factors, including HIV infection risk. Structural-level factors including availability of cheap second-generation alcohol and widespread unemployment are the biggest risk factors for alcohol misuse. Because of the psychological effect of women's increasing economic independence on men, gendered syndemic programming – that includes both men and women – and addresses the complex web of risk factors for second-generation alcohol misuse can interrupt the vicious cycle of poverty, violence, sexual risk behaviours and mitigate HIV infection risk in rural Kenya. [ABSTRACT FROM AUTHOR]

To catalyse national scale up of PrEP for HIV serodiscordant couples in public health facilities in Kenya, the Partners Scale-Up Project, using a two-day case-based interactive curriculum, trained health care providers working in 24 high volume facilities in central and western Kenya on PrEP service delivery. Using a standardised test with questions about PrEP and antiretroviral-based HIV prevention we assessed gain in knowledge and confidence gain by comparing pre-and post-training test scores. We explored experiences of the training through key informant interviews after clinics started delivering PrEP. Of 716 health care providers trained, 235 (32.9%) were nurses, 144 (20.2%) were clinical officers and 155 (21.7%) were HIV counsellors. There was a significant improvement between the means of pre-test and post-test scores (61.7% (SD 17.4) vs 86.4% (SD 12.7) p < 0.001). The proportion of those who reported being 'very comfortable' providing care to HIV serodiscordant couples increased from 22.8% to 67.3% (p < 0.001). Key themes that training increasing both knowledge of PrEP and confidence to deliver PrEP to HIV serodiscordant couples emerged from interviews. This short, standardised training resulted in a substantial increase in knowledge of PrEP and in the confidence of the health providers to provide PrEP to HIV serodiscordant couples. Trial registration ClinicalTrials.gov NCT03052010 [ABSTRACT FROM AUTHOR]

Increasing numbers of people living with HIV (PLHIV) in sub-Saharan Africa are experiencing failure of first-line antiretroviral therapy and transitioning onto second-line regimens. However, there is a dearth of research on their treatment experiences. We conducted in-depth interviews with 43 PLHIV on second- or third-line antiretroviral therapy and 15 HIV health workers in Kenya, Malawi and Mozambique to explore patients' and health workers' perspectives on these transitions. Interviews were audio-recorded, transcribed and translated into English. Data were coded inductively and analysed thematically. In all settings, experiences of treatment failure and associated episodes of ill-health disrupted daily social and economic activities, and recalled earlier fears of dying from HIV. Transitioning onto more effective regimens often represented a second (or third) chance to (re-)engage with HIV care, with patients prioritising their health over other aspects of their lives. However, many patients struggled to maintain these transformations, particularly when faced with persistent social challenges to pill-taking, alongside the burden of more complex regimens and an inability to mobilise sufficient resources to accommodate change. Efforts to identify treatment failure and support regimen change must account for these patients' unique illness and treatment histories, and interventions should incorporate tailored counselling and social and economic support. [ABSTRACT FROM AUTHOR]

Until recently, HIV in Africa was presumed to be driven by poverty, gender inequality and poor governance. The last decade has seen a shift in global and national public health discourses, especially in eastern Africa where new statistical evidence is used to justify prevention efforts to target Key Populations, i.e. men who have sex with men (MSM), injecting drug users, and sex workers. In this article, we focus on Kenya to examine state, NGO and community HIV treatment and prevention efforts targeting MSM, specifically male sex workers. We combine ethnographic fieldwork with a critical analysis of policy(making) and implementation practices to sketch the contours of the global, national and local forces that have combined to (re)make male homosexual sex to be understood as a practice that contributes to HIV incidence in Kenya. We also show that HIV-related MSM programmes in Kenya primarily enrol male sex workers in HIV treatment programmes, which focus on mainly on treatment adherence and pay insufficient attention to the economic and psycho-social problems experienced by male sex workers. Although upper and middle class MSM are involved in running LGTBI rights-based interventions and in mobilising male sex workers for HIV interventions, they are rarely targeted by those interventions. [ABSTRACT FROM AUTHOR]

Kenya maintains an extraordinary treatment gap for mental health services because the need for and availability of mental health services are extraordinarily misaligned. One way to narrow the treatment gap is task-sharing, where specialists rationally distribute tasks across the health system, with many responsibilities falling upon frontline health workers, including nurses. Yet, little is known about how nurses perceive task-sharing mental health services. This article investigates nurses’ perceptions of mental healthcare delivery within primary-care settings in Kenya. We conducted a cross-sectional study of 60 nurses from a public urban (n = 20), private urban (n = 20), and public rural (n = 20) hospitals. Nurses participated in a one-hour interview about their perceptions of mental healthcare delivery. Nurses viewed mental health services as a priority and believed integrating it into a basic package of primary care would protect it from competing health priorities, financial barriers, stigma, and social problems. Many nurses believed that integrating mental healthcare into primary care was acceptable and feasible, but low levels of knowledge of healthcare providers, especially in rural areas, and few specialists, would be barriers. These data underscore the need for task-sharing mental health services into existing primary healthcare in Kenya. [ABSTRACT FROM PUBLISHER]

Community health workers (CHWs) have a unique position between communities and the health sector. The strength of CHWs’ relationships with both sides influences their motivation and performance. This qualitative comparative study aimed at understanding similarities and differences in how relationships between CHWs, communities and the health sector were shaped in different Sub-Saharan African settings. The study demonstrates a complex interplay of influences on trust and CHWs’ relationships with their communities and actors in the health sector. Mechanisms influencing relationships were feelings of (dis)connectedness, (un)familiarity and serving the same goals, and perceptions of received support, respect, competence, honesty, fairness and recognition. Sometimes, constrained relationships between CHWs and the health sector resulted in weaker relationships between CHWs and communities. The broader context (such as the socio-economic situation) and programme context (related to, for example, task-shifting, volunteering and supervision) in which these mechanisms took place were identified. Policy-makers and programme managers should take into account the broader context and could adjust CHW programmes so that they trigger mechanisms that generate trusting relationships between CHWs, communities and other actors in the health system. This can contribute to enabling CHWs to perform well and responding to the opportunities offered by their unique intermediary position. [ABSTRACT FROM PUBLISHER]

Risks are a central part of life for households in low-income countries and health shocks in particular are associated with poverty. Formal mechanisms protecting households against the financial consequences of shocks are largely absent, especially among poor rural households. Our aim is to identify the relative importance of health shocks and to explore factors associated with coping behaviour and foregone care. We use a cross-sectional survey among 1226 randomly selected agricultural households in Kenya. In our sample, illness and injury shocks dominate all other shocks in prevalence. Almost 2% of households incurred catastrophic health expenditure in the last year. Using a probit model we identified the main coping strategies associated with facing a health shock: (1) use savings, (2) sell assets and (3) ask for gifts or loans. One in five households forewent necessary care in the last 12 months. We conclude that health shocks pose a significant risk to households. Implementing pre-payment or saving mechanisms might help protect households against the financial consequences of ill health. Such mechanisms, however, should take into account the competing shocks that agricultural households face, making it almost impossible to reserve a share of their limited resources for the protection against health shocks only. [ABSTRACT FROM PUBLISHER]

Cash transfer programmes have recently emerged as promising interventions for HIV prevention among adolescents in Africa. However, the pathways through which risk reduction occurs are not well understood. We examine data on 1429 adolescents and youth from the Kenya Cash Transfer for Orphans and Vulnerable Children, which has been shown to result in delayed sexual debut among adolescents. We explored three potential mediating pathways: schooling, socio-economic status and psycho-social status. None of these hypothesised mediators greatly altered the main effect. However, school attendance had a larger protective effect on sexual debut among females but was only increased by the programme among males. This gendered pattern of effects may explain why we did not see a mediating effect of the cash transfer through schooling, despite schooling's protective effects against early sexual debut. Results also suggest that cash transfer programmes in Africa can contribute to the reduction of HIV related risk behaviours. [ABSTRACT FROM AUTHOR]

Urban and rural areas have distinctive health problems, which require consideration. To examine sociocultural features of cholera and its community context, a semi-structured explanatory model interview based on vignettes depicting typical clinical features of cholera was used to interview 379 urban and rural respondents in Western Kenya. Findings included common and distinctive urban and rural ideas about cholera, and its prevention and treatment. The three most commonly perceived causes among urban and rural respondents collectively were drinking contaminated water, living in a dirty environment and lacking latrines. However, a dirty environment and flies were more prominently perceived causes among urban respondents. Rural respondents were less likely to identify additional symptoms and more likely to identify biomedically irrelevant perceived causes of cholera. Oral rehydration therapy was the most frequently reported home treatment. Health facilities were recommended unanimously at both sites. For prevention, rural respondents were more likely to suggest medicines, and urban respondents were more likely to suggest health education and clean food. Findings indicate community priority, demand for and potential effectiveness of enhanced efforts to control cholera in Western Kenya, and they suggest strategies that are particularly well suited for control of cholera in urban and rural areas. [ABSTRACT FROM PUBLISHER]