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Background Adolescent girls and young women (AGYW) have a high incidence of unplanned pregnancies especially in low resource settings. AGYW assess overlapping risks of pregnancy, contraception, and STIs as they navigate relationships. Few studies have examined how AGYW consider comparative risks of their decisions around sexual and reproductive health in this context and how risk perception influences contraceptive use. Methods The Girls Health Study (GHS) is a longitudinal cohort study in Thika, Kenya assessing HSV-2 incidence in a cohort of AGYW aged 16–20 with not more than one lifetime sexual partners. Twenty in-depth interviews (IDIs) and 5 focus group discussions (FGDs) were conducted with a purposively selected subset of sexually active AGYW enrolled in the parent cohort. IDI interview guide focused on perspectives and decision-making around sexual and reproductive health. IDIs were conducted in both English and Kiswahili, transcribed and coded using inductive and deductive approaches to identify emergent themes. Results Participants described unintended pregnancies as undesirable, and AGYW reported prioritizing contraceptive methods that were effective and reliable in pregnancy prevention, even if not effective in preventing STI/HIV infection. Misconceptions about long-acting reversible contraceptives (LARCs), injectables, and daily oral contraceptive pills strongly disincentivized their use, with many AGYW citing concerns about infertility and structural damage to reproductive organs as deterrents. Though unlikely to use daily or long-term contraceptive methods in anticipation of sexual activity, participants reported that AGYW relied heavily on emergency contraceptive (EC) pills to prevent pregnancy immediately after unprotected sex. Conclusions Our research demonstrated that desire to avoid pregnancy was common, yet on its own was not enough to motivate uptake of long-term contraceptives. However, AGYWs generally favored the use of EC pills to prevent unintended pregnancy due to the EC pill’s convenience, cost-effectiveness and lower perceived risk of side effects. Understanding reasons for AGYW’s acceptance of the EC pill can help future interventions better target communication and counseling about contraceptives to influence key drivers of AGYW behavior and decision-making around sexual and reproductive health.

Background: A healthy vaginal microbiome is dominated by Lactobacillus species that produce lactic acid, lowering vaginal pH and limiting colonization by pathogens. Lactobacillus dominance (LD) is established during puberty, but many women, especially those of Black race, lose LD during their reproductive years. Glycogen is thought to be a key host nutrient that supports vaginal lactobacilli and their fermentative lactic acid production, but mechanisms of glycogen utilization by Lactobacillus species are incompletely understood. By partitioning glycogen and glycogen-derived maltodextrin, as well as the activity of glycogen-degrading amylase and pullulanase enzymes (targeting glycogen α-1,4 and α-1,6 linkages, respectively) in vivo, this work refines understanding of vaginal glycogen catabolism and identifies correlates of LD. Results: Vaginal swab samples were collected from a cohort of young women with limited sexual experience in Thika, Kenya (N=17, ages 16–21). Metagenomic profiling of the vaginal microbiome revealed that most samples exhibited LD, particularly dominant Lactobacillus crispatus. Glycogen and pullulanase activity, but not maltodextrin and amylase activity correlated with lactic acid levels. Amylase activity showed a positive correlation with glycogen-derived maltodextrin, but no relationship with L. crispatus dominance. In contrast, pullulanase activity was 3-fold higher in L. crispatus-dominated samples. Metagenomics and targeted PCR revealed that 36% of L. crispatus-dominated metagenomes from our African cohort lacked a functional L. crispatus pullulanase (pulA) gene, a 3-fold higher frequency of gene loss than that seen in metagenomes from European and North American women. Our findings suggest pulA gene loss or inactivation may correspond with reductions in pullulanase activity, lactic acid, and L. crispatus abundance compared to samples dominated by pulA-competent L. crispatus. Conclusions: Our results indicate that although amylase activity drives the accumulation of glycogen catabolites in vaginal fluid, pullulanase appears to specifically contribute to maximal D-lactic acid production by L. crispatus. However, this is only possible when a functional pulA gene is present, which was not the case in a substantial proportion of young African women with dominant L. crispatus. Scaling this analysis to a larger cohort will address whether genomic and enzymatic indicators of L. crispatus pullulanase activity are predictive of sustained LD and vaginal health.

BACKGROUND: Exclusive breastfeeding (EBF) is the optimal way to feed young infants. Guidelines recommend that women living with HIV on antiretroviral therapy (ART) should EBF for six months and continue breastfeeding for up to 24 months or longer. Parents may face social or logistical barriers creating challenges to EBF. PURPOSE: To explore barriers, facilitators and community norms influencing EBF practices in Kenya. METHODS: This qualitative research was nested within a longitudinal study of intensive maternal counseling to increase EBF among HIV-positive mothers. HIV-negative and HIV-positive mothers were recruited from four public clinics in Nairobi. Women participated in focus group discussions (FGDs) that explored beliefs about and experiences with infant feeding. Conventional content analysis was used to describe and compare barriers and facilitators influencing HIV-positive and HIV-negative women’s EBF experiences. RESULTS: We conducted 17 FGDs with 80 HIV-positive and 53 HIV-negative women between 2009- 2012. Overall, women agreed that breastmilk is good for infants. However, early mixed feeding was a common cultural practice. HIV-positive women perceived that infant feeding methods and durations were their decision. In contrast, HIV-negative women reported less autonomy and more mixed feeding, citing peer pressure and lack of HIV transmission concerns. Autonomy in decision-making was facilitated by receiving EBF counseling and family support, especially from male partners. Low milk production was a barrier to EBF, regardless of HIV status, and perceived to represent poor maternal nutrition. CONCLUSIONS: Despite challenges, counseling empowered women living with HIV to advocate for EBF with spouses and family.

BackgroundAdolescent girls and young women (AGYW) are at high risk of sexually transmitted infections (STIs). It is unknown whether beginning to have sexual intercourse causes changes to immune mediators in the cervicovaginal tract that contribute to this risk.MethodsWe collected cervicovaginal lavages from Kenyan AGYW in the months before and after first penile-vaginal sexual intercourse and measured the concentrations of 20 immune mediators. We compared concentrations pre- and post-first sex using mixed effects models. Secondary analyses included adjustment for possible confounding factors. We additionally performed a systematic review to identify similar studies and combined them with our results by meta-analysis of individual participant data.ResultsWe included 180 samples from 95 AGYW, with 44% providing only pre-first sex samples, 35% matched pre and post, and 21% only post. We consistently detected 19/20 immune mediators, all of which increased post-first sex (median increase 54%; pOur systematic review identified two eligible studies, one of 93 Belgian participants and the other of 18 American participants. Nine immune mediators were measured in at least 2/3 studies. Meta-analysis confirmed higher levels post-first sex for 8/9 immune mediators (median increase 47%; pConclusionsCervicovaginal immune mediator concentrations increased after the beginning of sexual activity independently of confounding factors including STIs. Results were consistent across three studies conducted on three different continents.

BackgroundA healthy vaginal microbiome is dominated by Lactobacillus species that produce lactic acid, lowering vaginal pH and limiting colonization by pathogens. Lactobacillus dominance (LD) is established during puberty, but many women, especially those of Black race, lose LD during their reproductive years. Glycogen is thought to be a key host nutrient that supports vaginal lactobacilli and their fermentative lactic acid production, but mechanisms of glycogen utilization by Lactobacillus species are incompletely understood. By partitioning glycogen and glycogen-derived maltodextrin, as well as the activity of glycogen-degrading pullulanase enzymes, this work refines understanding of vaginal glycogen catabolism and identifies correlates of LD.ResultsVaginal swab samples were collected from a cohort of young women with limited sexual experience in Thika, Kenya (N=17, ages 17–20). Metagenomic profiling of the vaginal microbiome revealed that most samples exhibited LD, particularly dominant Lactobacillus crispatus. Amylopullulanase activity, cleavage of glycogen α-1,4 and α-1,6 linkages by individual/multifunctional enzymes, showed a significant positive correlation with glycogen-derived maltodextrin, but no relationship with L. crispatus dominance. Pullulanase activity, which specifically targets glycogen α-1,6 linkages, was 3-fold higher in L. crispatus-dominated samples and significantly correlated with D-lactic acid levels. Metagenomics and targeted PCR revealed that 36% of L. crispatus-dominated metagenomes from our African cohort lacked a functional L. crispatus pullulanase (pulA) gene, a 3-fold higher frequency of gene loss than that seen in metagenomes from European and North American women. Our findings suggest pulA gene loss or inactivation may correspond with reductions in L. crispatus abundance, pullulanase activity and lactic acid levels compared to samples dominated by pulA-competent L. crispatus.ConclusionsOur results indicate that although amylase activity drives the accumulation of glycogen catabolites in vaginal fluid, pullulanase appears to specifically contribute to maximal D-lactic acid production by L. crispatus. However, this is only possible when a functional pulA gene is present, which was not the case in a substantial proportion of young African women with dominant L. crispatus. Scaling this analysis to a larger cohort will address whether genomic and enzymatic indicators of L. crispatus pullulanase activity are predictive of sustained LD and vaginal health.

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

Background The Seattle, WA, area was ground zero for coronavirus disease 2019 (COVID-19). Its initial emergence in a skilled nursing facility (SNF) not only highlighted the vulnerability of its patients and residents, but also the limited clinical support that led to national headlines. Furthermore, the coronavirus pandemic heightened the need for improved collaboration among healthcare organizations and local and state public health. Methods The University of Washington Medicine's (UWM's) Post-Acute Care (PAC) Network developed and implemented a three-phase approach within its pre-existing network of SNFs to help slow the spread of the disease, support local area SNFs from becoming overwhelmed when inundated with COVID-19 cases or persons under investigation, and help decrease the burden on area hospitals, clinics, and emergency medical services. Results Support of local area SNFs consisted of the following phases that were implemented at various times as COVID-19 impacted each facility at different times. Initial Phase: This phase was designed to (1) optimize communication, (2) review infection control practices, and (3) create a centralized process to track and test the target population. Delayed Phase: The goals of the Delayed Phase were to slow the spread of the disease once it is present in the SNF by providing consistent education and reinforcing infection prevention and control practices to all staff. Surge Phase: This phase aimed to prepare facilities in response to an outbreak by deploying a "Drop Team" within 24 hours to the facility to expeditiously test patients and exposed employees, triage symptomatic patients, and coordinate care and supplies with local public health authorities. Conclusions The COVID-19 Three-Phase Response Plan provides a standardized model of care that may be implemented by other health systems and SNFs to help prepare and respond to COVID-19. J Am Geriatr Soc 68:1155-1161, 2020.

American Indian and Alaska Native (AI/AN) youth disproportionately face barriers accessing healthcare, including lack of access to culturally-specific resources. This paper details the creation of a culturally-specific Toolkit for AI/AN transgender and Two-Spirit youth, their relatives, and their healthcare providers across the United States (U.S.). The Toolkit aims to (1) deliver culturally-grounded resources to youth with diverse gender identities, (2) provide resources for families, and (3) increase healthcare provider awareness. A culturally-appropriate Toolkit, “Celebrating Our Magic”, was created from continual engagement with community partners over a six-month period to address identified needs. The Toolkit has been shared regionally with partners who helped with its creation and nationally with Indian Health Service (IHS), Tribal, and Urban clinics serving AI/AN youth. This Toolkit creation process could be applied to manuals or guides for work in other underserved communities.

Background Hormonal changes during the menstrual cycle play a key role in shaping immunity in the cervicovaginal tract. Cervicovaginal fluid contains cytokines, chemokines, immunoglobulins, and other immune mediators. Many studies have shown that the concentrations of these immune mediators change throughout the menstrual cycle, but the studies have often shown inconsistent results. Our understanding of immunological correlates of the menstrual cycle remains limited and could be improved by meta-analysis of the available evidence. Methods We performed a systematic review and meta-analysis of cervicovaginal immune mediator concentrations throughout the menstrual cycle using individual participant data. Study eligibility included strict definitions of the cycle phase (by progesterone or days since the last menstrual period) and no use of hormonal contraception or intrauterine devices. We performed random-effects meta-analyses using inverse-variance pooling to estimate concentration differences between the follicular and luteal phases. In addition, we performed a new laboratory study, measuring select immune mediators in cervicovaginal lavage samples. Results We screened 1570 abstracts and identified 71 eligible studies. We analyzed data from 31 studies, encompassing 39,589 concentration measurements of 77 immune mediators made on 2112 samples from 871 participants. Meta-analyses were performed on 53 immune mediators. Antibodies, CC-type chemokines, MMPs, IL-6, IL-16, IL-1RA, G-CSF, GNLY, and ICAM1 were lower in the luteal phase than the follicular phase. Only IL-1α, HBD-2, and HBD-3 were elevated in the luteal phase. There was minimal change between the phases for CXCL8, 9, and 10, interferons, TNF, SLPI, elafin, lysozyme, lactoferrin, and interleukins 1β, 2, 10, 12, 13, and 17A. The GRADE strength of evidence was moderate to high for all immune mediators listed here. Conclusions Despite the variability of cervicovaginal immune mediator measurements, our meta-analyses show clear and consistent changes during the menstrual cycle. Many immune mediators were lower in the luteal phase, including chemokines, antibodies, matrix metalloproteinases, and several interleukins. Only interleukin-1α and beta-defensins were higher in the luteal phase. These cyclical differences may have consequences for immunity, susceptibility to infection, and fertility. Our study emphasizes the need to control for the effect of the menstrual cycle on immune mediators in future studies.

Many sexually transmitted infections increase risk of mother-to-child transmission (MTCT) of HIV, but the effect of Mycoplasma genitalium is not known. We hypothesized that M. genitalium infection would be common among HIV-infected pregnant women and could be associated with in-utero and intrapartum MTCT.Observational case-cohort study.The current study used specimens from a Kenyan perinatal MTCT cohort (1999-2005) involving HIV-infected women and their infants, who received short-course zidovudine for prevention of MTCT. Vaginal swabs collected at 32 weeks gestation were tested for M. genitalium using a transcription-mediated amplification assay. Infant perinatal HIV infection was determined at birth and 4 weeks of age by DNA PCR. Using a case-cohort design, a random sample was generated with 3 : 1 control : case ratio; prevalence and correlates of M. genitalium were assessed with chi-squared and t tests; predictors of infant outcomes were analyzed using logistic regression.Among 220 HIV-infected pregnant women evaluated, 47 women (21.4%) had M. genitalium. Antenatal M. genitalium infection was associated with higher HIV RNA in plasma (5.0 vs. 4.6 log10 copies/ml in M. genitalium-positive vs. M. genitalium-negative women, P = 0.02) at 32 weeks. Women with M. genitalium were less likely to report prior sexually transmitted infections and genital ulcers (both P = 0.05). There was no association found between exposure to M. genitalium and perinatal MTCT (odds ratio = 0.72, 95% confidence interval 0.35, 1.51, P = 0.39).Vaginal M. genitalium infection was frequently detected among Kenyan HIV-infected pregnant women and was associated with higher plasma HIV levels, but was not associated with perinatal transmission of HIV.

In the Seattle, Washington metropolitan area, where the first case of novel coronavirus 2019 disease (COVID-19) in the United States was reported (1), a community-level outbreak is ongoing with evidence of rapid spread and high morbidity and mortality among older adults in long-term care skilled nursing facilities (SNFs) (2,3). However, COVID-19 morbidity among residents of senior independent and assisted living communities, in which residents do not live as closely together as do residents in SNFs and do not require skilled nursing services, has not been described. During March 5-9, 2020, two residents of a senior independent and assisted living community in Seattle (facility 1) were hospitalized with confirmed COVID-19 infection; on March 6, social distancing and other preventive measures were implemented in the community. UW Medicine (the health system linked to the University of Washington), Public Health - Seattle & King County, and CDC conducted an investigation at the facility. On March 10, all residents and staff members at facility 1 were tested for SARS-CoV-2, the virus that causes COVID-19, and asked to complete a questionnaire about their symptoms; all residents were tested again 7 days later. Among 142 residents and staff members tested during the initial phase, three of 80 residents (3.8%) and two of 62 staff members (3.2%) had positive test results. The three residents had no symptoms at the time of testing, although one reported an earlier cough that had resolved. A fourth resident, who had negative test results in the initial phase, had positive test results 7 days later. This resident was asymptomatic on both days. Possible explanations for so few cases of COVID-19 in this residential community compared with those in several Seattle SNFs with high morbidity and mortality include more social distancing among residents and less contact with health care providers. In addition, early implementation of stringent isolation and protective measures after identification of two COVID-19 cases might have been effective in minimizing spread of the virus in this type of setting. When investigating a potential outbreak of COVID-19 in senior independent and assisted living communities, symptom screening is unlikely to be sufficient to identify all persons infected with SARS-CoV-2. Adherence to CDC guidance to prevent COVID-19 transmission in senior independent and assisted living communities (4) could be instrumental in preventing a facility outbreak.

Background Home-based human immunodeficiency virus (HIV) testing and education has increased HIV test uptake and access to health services among men. We studied how a home-based antenatal intervention influenced male partner utilization of clinic-based HIV and sexually transmitted infection (STI) services, linkage to HIV care and medical circumcision. Methods We conducted a secondary analysis within a randomized controlled trial of pregnant women attending antenatal care in Kenya. Women and their male partners received either a home-based couple intervention or an invitation letter for clinic-based couple HIV testing. The home-based intervention included education on STI symptoms, STI and HIV treatment and male circumcision for HIV prevention. Male self-reported outcomes were compared using relative risks at 6 months postpartum. Results Among 525 women, we reached 487 (93%) of their male partners; 247 men in the intervention arm and 240 men in the control arm. Men who received the intervention were more likely to report an STI consultation (n = 47 vs. 16; relative risk, 1.59; 95% confidence interval, 1.33-1.89). Among 23 men with newly diagnosed HIV, linkage to HIV care was reported by 4 of 15 in the intervention (3 men had missing linkage data) and 3 of 5 men in the control arms (relative risk, 0.66; 95% confidence interval, 0.34-1.29). Although the intervention identified 3 times more men with new HIV infection, the study lacked power to find significant differences in linkage to HIV care. Few eligible men sought medical circumcision (4 of 72 intervention and 2 of 88 control). Conclusions Home-based couple education and testing increased STI consultations among male partners of pregnant women, but appeared insufficient to overcome the barriers involved in linkage to HIV care and medical circumcision.

Human immunodeficiency virus-serodiscordant couples are an important source of new HIV infections in Africa. When trying to conceive, uninfected partners may be at high risk of infection if the infected partner is not virally suppressed. Multiple strategies targeting safer conception exist, but these services are limited. However, when services are available and used, serodiscordant couples can be protected from HIV transmission, and safe to have children if desired. To successfully introduce, integrate, promote, and optimize the service delivery of safer conception with HIV care, it is crucial to understand how HIV-serodiscordant couples perceive and experience these services. Further, viral load monitoring can be critical to safer conception, but there is limited literature on how it informs the decision of the partners about conception. This qualitative study describes the knowledge, perceptions, and experiences of both safer conception services and viral load monitoring among 26 HIV-serodiscordant couples seeking safer conception care at a referral hospital in Nairobi, Kenya. In-depth interviews of HIV-serodiscordant couples were conducted from April to July 2017, and transcripts were analyzed to identify the themes central to the experience of safer conception services of couples and viral load monitoring. Serodiscordant couples reported success in using some of the safer conception methods and had positive experiences with healthcare providers. However, despite using the services, some were concerned about HIV transmission to the seronegative partner and baby, while others faced challenges when using pre-exposure prophylaxis (PrEP) and vaginal insemination. Overall, their motivation to have children overcame their concern about HIV transmission, and they welcomed discussions on risk reduction. Moreover, supportive clinic staff was identified as key to facilitating trust in safer conception methods. Furthermore, viral load monitoring was identified as integral to safer conception methods, an emerging theme that requires further evaluation, especially where routine viral load monitoring is not performed. In conclusion, healthcare providers offering safer conception services should build trust with couples, and recognize the need for continual couple counseling to encourage the adoption of safer conception services.

HIGHLIGHTS • SARS-CoV-2 is an important cause of healthcare-acquired infection. • Asymptomatic SARS-CoV-2 infection was common in this cohort of elderly individuals. • Duration of PCR positivity was similar among symptomatic and asymptomatic patients. • Virus cycle thresholds were similar among symptomatic and asymptomatic patients., Background We describe key characteristics, interventions, and outcomes of a SARS-CoV-2 outbreak within an inpatient geriatric psychiatry unit at the University of Washington Medical Center – Northwest (UWMC – NW). Methods After identifying two patients with SARS-CoV-2 infection on March 11, 2020, we conducted an outbreak investigation and employed targeted interventions including: screening of patients and staff; isolation and cohorting of confirmed cases; serial testing; and enhanced infection prevention measures. Results We identified 10 patients and 7 staff members with SARS-CoV-2 infection. Thirty percent of patients (n=3) remained asymptomatic over the course of infection. Among SARS-CoV-2 positive patients, fever (n=5, 50%) and cough (n=4, 40%) were the most common symptoms. Median duration of RT-PCR positivity was 25.5 days (IQR 22.8 – 41.8) among symptomatic patients and 22.0 days (IQR 19.5 – 25.5) among asymptomatic patients. Median initial (19.0, IQR 18.7 – 25.7 vs. 21.7, IQR 20.7 – 25.6) and nadir (18.9, IQR 18.2 – 20.3 vs. 19.8, IQR 17.0 – 20.7) cycle threshold values were similar across symptomatic and asymptomatic patients, respectively. Conclusions Asymptomatic infection was common in this cohort of hospitalized, elderly individuals despite similar duration of SARS-CoV-2 RT-PCR positivity and cycle threshold values among symptomatic and asymptomatic patients.

Background Housing characteristics and neighbourhood context are considered risk factors for COVID-19 mortality among older adults. The aim of this study was to investigate how individual-level housing and neighbourhood characteristics are associated with COVID-19 mortality in older adults. Methods For this population-based, observational study, we used data from the cause-of-death register held by the Swedish National Board of Health and Welfare to identify recorded COVID-19 mortality and mortality from other causes among individuals (aged ≥70 years) in Stockholm county, Sweden, between March 12 and May 8, 2020. This information was linked to population-register data from December, 2019, including socioeconomic, demographic, and residential characteristics. We ran Cox proportional hazards regressions for the risk of dying from COVID-19 and from all other causes. The independent variables were area (m2) per individual in the household, the age structure of the household, type of housing, confirmed cases of COVID-19 in the borough, and neighbourhood population density. All models were adjusted for individual age, sex, country of birth, income, and education. Findings Of 279 961 individuals identified to be aged 70 years or older on March 12, 2020, and residing in Stockholm in December, 2019, 274 712 met the eligibility criteria and were included in the study population. Between March 12 and May 8, 2020, 3386 deaths occurred, of which 1301 were reported as COVID-19 deaths. In fully adjusted models, household and neighbourhood characteristics were independently associated with COVID-19 mortality among older adults. Compared with living in a household with individuals aged 66 years or older, living with someone of working age (

Background Skilled nursing facilities (SNFs) are high-risk settings for SARS-CoV-2 transmission. Infection rates among employees are infrequently described. Objective To describe SARS-CoV-2 rates among SNF employees and residents during a non-outbreak time period, we measured cross-sectional SARS-CoV-2 prevalence across multiple sites in the Seattle area. Design SARS-CoV-2 testing was performed for SNF employees and residents using quantitative real-time reverse transcription polymerase chain reaction. A subset of employees completed a sociodemographic and symptom questionnaire. Participants Between March 29 and May 13, 2020, we tested 1583 employees and 1208 residents at 16 SNFs for SARS-CoV-2. Main Measure SARS-CoV-2 testing results and symptom report among employees and residents. Key Results Eleven of the 16 SNFs had one or more resident or employee test positive. Overall, 46 (2.9%) employees had positive or inconclusive testing for SARS-CoV-2, and among those who completed surveys, most were asymptomatic and involved in direct patient care. The majority of employees tested were female (934, 73%), and most employees were Asian (392, 30%), Black (360, 28%), or white (360, 28%). Among the 1208 residents tested, 110 (9.1%) had positive or inconclusive results. There was no association between the presence of positive residents and positive employees within a SNF (p = 0.62, McNemar’s test). Conclusions In the largest study of SNFs to date, SARS-CoV-2 infections were detected among both employees and residents. Employees testing positive were often asymptomatic and involved in direct patient care. Surveillance testing is needed for SNF employees and residents during the pandemic response.

Objectives: Globally, the highest rates of sexually transmitted infections (STIs) are among the 15-24 age group. Studying adolescent girls and young women (AGYW) pre-sexual debut could identify risk factors for STI acquisition. Methods: We recruited a prospective cohort of low-risk AGYW aged 16-20 in Kenya. Participants were HIV and HSV-2 seronegative and reported no history of sexual intercourse or reported sex with one partner. Participants underwent genital exams, nucleic acid testing of vaginal swabs for Neisseria gonorrhea (NG), Chlamydia trachomatis (CT), Trichomonas vaginalis (TV), and vaginal gram stains for vaginal dysbiosis by Nugent score. STI correlates were described using χ2 test and t-test. Results: We enrolled 400 AGYW, of which 322 (80.5%) reported never having had sex, while 78 (19.5%) reported prior sex with 1 partner. Among the 78 participants reporting prior sex, 20 (25.6%) reported contraception use in the last 3 months, with 60% using only emergency contraceptive pills. Despite self-reported history, of 373 subjects who underwent STI testing, 49 subjects (13.1%) tested positive for STIs, with 41 CT, 5 GC, and 3 TV cases. Of these 49 subjects, 33 (67.3%) reported no prior sexual intercourse. Bacterial vaginosis was rare and 90% of subjects had a normal Nugent score (0-3). Conclusions: Upon baseline evaluation of a cohort of low risk AGYW, we found high numbers of STIs, especially CT, which is not routinely screened for in Kenyan settings. Interventions to address STIs and unintended pregnancy should target girls pre-sexual debut, including those who do not self-identify as at risk.

Background The vaginal microbiome plays a key role in women’s reproductive health. Use of exogenous hormones, such as intramuscular depot medroxyprogesterone acetate (DMPA-IM), may alter the composition of vaginal bacterial community. Methods Vaginal swab samples were collected from postpartum Kenyan women initiating DMPA-IM or nonhormonal contraception (non-HC). Bacterial vaginosis was assessed by Nugent score (Nugent-BV) and bacterial community composition was evaluated using broad-range 16S ribosomal RNA gene polymerase chain reaction with high-throughput sequencing. Changes in Nugent score, alpha diversity (Shannon diversity index), and total bacterial load between contraceptive groups from enrollment to 3 months after initiation were estimated using multivariable linear mixed effects regression. Results Among 54 human immunodeficiency virus–negative women, 33 choosing DMPA-IM and 21 choosing non-HC, Nugent-BV was more common among DMPA-IM users at enrollment. At follow-up, Nugent score had decreased significantly among DMPA-IM users (change, −1.89; 95% confidence interval [CI], −3.53 to −.25; P = .02) while alpha diversity remained stable (0.03; −.24 to .30; P = .83). Conversely, Nugent score remained relatively stable among non-HC users (change, −0.73; 95% CI, −2.18 to .73; P = .33) while alpha diversity decreased (−0.34; −.67 to −.001; P = .05). The total bacterial load decreased slightly in DMPA-IM users and increased slightly among non-HC users, resulting in a significant difference in change between the contraceptive groups (difference, −0.64 log10 gene copies per swab sample; 95% CI, −1.19 to −.08; P = .02). While significant changes in Nugent score and alpha diversity were observed within contraceptive groups, changes between groups were not significantly different. Conclusions Postpartum vaginal bacterial diversity did not change in DMPA-IM users despite a reduction in Nugent-BV, but it decreased significantly among women using non-HC. Choice of contraception may influence Lactobacillus recovery in postpartum women.

Importance Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused epidemic spread of coronavirus disease 2019 (COVID-19) in the Seattle, Washington, metropolitan area, with morbidity and mortality concentrated among residents of skilled nursing facilities. The prevalence of COVID-19 among older adults in independent/assisted living is not understood. Objectives To conduct surveillance for SARS-CoV-2 and describe symptoms of COVID-19 among residents and staff of an independent/assisted living community. Design, Setting, and Participants In March 2020, public health surveillance of staff and residents was conducted on site at an assisted and independent living residence for older adults in Seattle, Washington, after exposure to 2 residents who were hospitalized with COVID-19. Exposures Surveillance for SARS-CoV-2 infection in a congregate setting implementing social isolation and infection prevention protocols. Main Outcomes and Measures SARS-CoV-2 real-time polymerase chain reaction was performed on nasopharyngeal swabs from residents and staff; a symptom questionnaire was completed assessing fever, cough, and other symptoms for the preceding 14 days. Residents were retested for SARS-CoV-2 7 days after initial screening. Results Testing was performed on 80 residents; 62 were women (77%), with mean age of 86 (range, 69-102) years. SARS-CoV-2 was detected in 3 of 80 residents (3.8%); none felt ill, 1 male resident reported resolved cough and 1 loose stool during the preceding 14 days. Virus was also detected in 2 of 62 staff (3.2%); both were symptomatic. One week later, resident SARS-CoV-2 testing was repeated and 1 new infection detected (asymptomatic). All residents remained in isolation and were clinically stable 14 days after the second test. Conclusions and Relevance Detection of SARS-CoV-2 in asymptomatic residents highlights challenges in protecting older adults living in congregate settings. In this study, symptom screening failed to identify residents with infections and all 4 residents with SARS-CoV-2 remained asymptomatic after 14 days. Although 1 asymptomatic infection was found on retesting, a widespread facility outbreak was avoided. Compared with skilled nursing settings, in assisted/independent living communities, early surveillance to identify asymptomatic persons among residents and staff, in combination with adherence to recommended preventive strategies, may reduce viral spread.

We found low prevalence of SARS-CoV-2 (2.7% [5/188]) among pregnant and postpartum patients with universal testing. Prevalence among symptomatic patients was similar under initial targeted screening (22.2% [4/18]) and universal approaches (19.1% [8/42]). Among 170 asymptomatic patients, 2 were positive or inconclusive, respectively; repeat testing at 24 hours was negative.

BackgroundThe ECHO trial has relieved apprehension about intramuscular depot medroxyprogesterone acetate (DMPA-IM), however it is still important to understand how DMPA-IM affects the vaginal environment. We sought to describe how DMPA-IM initiation influences vaginal bacteria associated with HIV acquisition in postpartum women.MethodsVaginal swabs were collected for Nugent score determination and taxon-specific quantitative PCR of eight bacteria. Enrollment occurred at contraceptive initiation (DMPA-IM or non-hormonal contraception (non-HC)) and repeat vaginal swabs were collected after three months. Generalized estimating equations were used to estimate changes in Nugent score, total bacterial load, and taxa concentrations among contraceptive groups.ResultsWomen who chose DMPA-IM (n = 33) were more likely to be married (97%vs.67%) and have resumed intercourse since delivery (52%vs.29%) compared to women who chose non-HC (n = 21). After three months, significant decreases in the concentrations of Sneathia species, Mycoplasma hominis, and Parvimonas species Type 1 were seen among non-HC users, however concentrations remained stable among DMPA-IM users; contraceptive method was associated with significantly different changes in M. hominis concentration between groups (p = 0.010).ConclusionsOur findings suggest that postpartum use of DMPA-IM and non-HC may have differential impacts on the vaginal concentrations of some bacteria that have previously been associated with HIV acquisition.

Background Few men are tested for syphilis or human immunodeficiency virus (HIV) during their partner's pregnancy, a high-risk period for HIV and syphilis transmission. Offering home-based rapid testing of syphilis to couples during pregnancy can support prevention efforts to reduce transmission of sexually transmitted diseases and adverse pregnancy outcomes. Methods We assessed men's uptake of paired (separate tests, single blood draw) point-of-care syphilis and HIV tests within a randomized controlled trial of pregnant women who received clinic or home partner HIV testing. We evaluated acceptance of paired HIV-syphilis testing during pregnancy or at 6 months postpartum, and evaluated whether addition of syphilis testing affected the uptake of HIV testing among men. Results Of 601 women, we were unable to meet 101 male partners, and 180 tested before syphilis tests were available. Paired syphilis and HIV testing was offered at home to 80 men during pregnancy and to 230 men postpartum. For syphilis, 93% of men agreed to test during pregnancy and 98% agreed postpartum. For paired syphilis and HIV testing, 91% of men tested for both during pregnancy and 96% tested postpartum. Before syphilis test introduction, 96% of men accepted HIV testing, compared with 95% of men who accepted HIV testing when paired testing was offered. Conclusions Uptake of syphilis and HIV testing was high among male partners offered couple testing at home. Introducing syphilis testing did not adversely affect HIV testing among men. Point-of-care diagnostics outside facilities can increase testing of male partners who rarely accompany women to antenatal clinics.

Background Vaginal dysbiosis is a risk factor for sexually transmitted infections (STI) and HIV in young women, and is highly prevalent in Africa. We sought to describe the microbiota of younger African women, before engaging in sexual behavior. Methods Adolescent girls aged 16–21 were recruited in Thika, Kenya. Eligible participants were HIV and HSV-2 seronegative, and reported sexual naivete or one lifetime sexual partner. Nugent score was determined from vaginal Gram stains. Girls were tested for Neisseria gonorrhea (NG), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV). Chi-square testing was used to compare BV with other variables. Results We enrolled 400 girls with a median age of 18.6 years (range 16–21). The majority (322 girls, 80.5%) reported no history of sexual intercourse, while 78 (19.5%) reported sex with 1 lifetime partner. Reported sexual partners were older, with median age of 22 years (IQR 19–25). At enrollment, 375 girls had vaginal Gram stains: 338 girls (90%) had a normal Nugent score of 0-3. BV (Nugent score ≥7) was uncommon (21 girls, 5.6%). Girls with BV were older (median age 19.3, IQR 17.9–20.3) than girls with Nugent score 0-3 (median age 18.6, IQR 17.6–19.3) and Nugent score 4-6 (median age 18.6, 17.9–19.8). Of 373 girls with STI testing, 49 girls were diagnosed with STIs and 7 girls had both STI and BV. BV was significantly associated with self-reported sexual intercourse: 52% of girls with Nugent score ≥7 reported prior sex, compared to 18% of those with Nugent score 0-3 (p = 0.001). Conclusion Kenyan adolescent girls in a low-risk cohort have Lactobacillus-dominated vaginal microbiota, and only 5.6% of girls had evidence of BV. BV was found more often in girls who self-reported sexual intercourse. Interventions to prevent the onset of vaginal dysbiosis could be beneficial for African women. Disclosure No significant relationships.

BackgroundThe Option B+ strategy streamlines delivery of HIV antiretroviral therapy (ART) to pregnant women, but concerns remain about ART treatment adherence and long term outcomes.MethodsWe conducted a retrospective analysis of a cohort of HIV-positive, postpartum breastfeeding women receiving ART via Option B+ in Nairobi, Kenya. The primary outcome was virologic failure in plasma (HIV RNA >1000 copies/mL), and detection in breast milk (>150 copies/mL) and endocervical secretions (>100 copies/mL) at 2 postpartum timepoints. Correlates of virologic failure were assessed using univariate tests and multivariate logistic regression.ResultsOf 42 women at 6-14 weeks postpartum, 21.4% of women had HIV RNA detected in plasma; 14.3% in breast milk, and 23.7% in endocervical secretions. At 18-24 weeks postpartum, the percentages were 21.1%, 7.1%, and 14.3%, respectively. Younger maternal age, intent to breastfeed for longer, and later ART start in pregnancy were significantly associated with plasma virologic failure (p < 0.05 for each). Odds of plasma virologic failure at 6-14 weeks postpartum were 1.25 times higher (95% CI 1.04, 1.51) for each increase in week of gestation at ART initiation. Only 3 women had resistance mutations to their regimen.ConclusionsDespite months of ART, nearly one-quarter of the women in our cohort did not achieve plasma virologic suppression in the postpartum period. After adjusting for time on ART, earlier ART initiation in pregnancy was significantly associated with plasma suppression. Our findings suggest that postpartum HIV RNA monitoring in Option B+ programs will be needed to achieve elimination of MTCT.

BACKGROUND Depot medroxyprogesterone acetate (DMPA) is associated with HIV acquisition. We studied changes in vaginal microbiota and inflammatory milieu after DMPA initiation. METHODS In a cohort of HIV-negative Kenyan women, we collected monthly vaginal swabs over 1 year before and after DMPA. Using quantitative polymerase chain reaction, we compared quantities of Lactobacillus crispatus, Lactobacillus jensenii, Lactobacillus iners, Gardnerella vaginalis, and total bacterial load (16S ribosomal RNA gene levels). Six vaginal immune mediators were measured with enzyme-linked immunosorbent assay. Trends in the detection and quantity of bacteria were estimated by logistic and linear mixed-effects regression. RESULTS From 2010 to 2012, 15 HIV-seronegative women initiated DMPA, contributing 85 visits (median, 6 visits/woman; range, 3-8 visits/woman). The median time of DMPA-exposed follow-up was 8.4 months (range, 1.5-11.6 months). Seven women (46%) had bacterial vaginosis within 70 days before DMPA start. L. iners was detected in 13 women (87%) before DMPA start, but other lactobacilli were rarely detected. Gardnerella vaginalis decreased by 0.21 log10 copies per swab per month after DMPA exposure (P = 0.01). Total bacterial load decreased by 0.08 log10 copies per swab per month of DMPA (P = 0.02). Sustained decreases in interleukin (IL)-6 (P = 0.03), IL-8 (P = 0.04), and IL-1 receptor antagonist (P < 0.001) were also noted. Nine women (60%) had L. crispatus detected post-DMPA, which significantly correlated with reduced IL-6 (P < 0.01) and IL-8 (P = 0.02). CONCLUSIONS Initiation of DMPA led to sustained shifts in vaginal bacterial concentrations and levels of inflammatory mediators. Further studies are warranted to outline components of the vaginal microbiota influenced by DMPA use and impact on HIV susceptibility.

Background World Health Organization (WHO) guidelines recommend dual contraceptive method use with condoms and another contraceptive to reduce both incidence of HIV/sexually transmitted infection transmission and unintended pregnancies. This qualitative study assessed the barriers to and motivations for dual contraceptive use in Kenyan HIV-serodiscordant couples. Methods HIV-serodiscordant couples in Nairobi, Kenya, were recruited from two longitudinal cohorts. Qualitative semistructured interviews were conducted using a semistructured questionnaire. Twelve male and 12 female members of serodiscordant couples and 10 women with incident pregnancies during the cohort studies were included. Results Few couples reported using dual contraceptive methods, with men reporting more condom use than women. No HIV-seropositive men or HIV-seronegative women reported using non-condom contraception. Men and women agreed that men play a dominant role in decisions to use both condoms and contraception in HIV-serodiscordant couples. Participants reported that perceptions of side effects, male partner preference, and reproductive desire were critical factors in contraceptive decisions. Both men and women saw dual contraceptive method use as redundant and a sign of possible unfaithfulness. Many participants actively desired pregnancy, but few were able to accurately define monthly fertility windows. Conclusions Dual contraceptive method use was low in these HIV-serodiscordant couples, with some couples finding it unnecessary while using condoms, and others being more focused on conceiving a child. Biomedical HIV prevention, including male circumcision, pre-exposure prophylaxis or antiretroviral therapy to reduce HIV transmission, may be more acceptable strategies to promote safer sexual relations among HIV-serodiscordant couples and safer conception when desired.

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

Safe firearm storage is associated with lower risk of unintentional and intentionally self-inflicted firearm injuries among children and adolescents. Ten community-based firearm safety events were conducted across Washington state from 2015 to 2018. We sought to describe characteristics of event participants and assess whether presence and age of children in the household were associated with household firearm locking practices. We assessed demographic characteristics and baseline firearm storage behaviors of participants using a 13-item survey. Multivariable Poisson regression models were used to estimate prevalence ratios (PR) and corresponding confidence intervals (CI) for the association of presence and age of children in households with prevalence of storing a household firearm unlocked. Of 2956 participants, 58.3% were male and 57.9% lived with an individual under 18 years. Among the 89.8% participants living with firearms, 40.1% stored at least one firearm unlocked and 39.1% stored at least one firearm loaded. In adjusted analyses, there was no statistically significant difference in prevalence of storing a household firearm unlocked between those living with no children (reference group) and those living with a child11 years (PR = 0.91; 95% CI: 0.80,1.04), or a child aged 11-18 years (PR = 0.94; 95% CI: 0.81,1.09). A high proportion of participants stored a firearm unlocked or loaded at home and neither living with young children nor adolescents was associated with safe locking practices. In comparison with firearm safety interventions conducted in clinic settings, a majority of the participants in these community-based interventions were male and owned firearms.

IntroductionThere is unmet need for male contraceptive options, but a recent injectable combination male contraceptive trial was terminated early due to adverse events (AEs).MethodsWe examined the frequency of reported AEs by male research participants compared with AEs reported in prescribing information of approved female hormonal contraceptive methods. Published data from trials of the top five most-used female hormonal contraceptives, supplemented by contemporary contraceptive research, were compared with the frequency of AEs reported in a male injectable hormonal contraceptive trial.ResultsWe observed similar frequencies of AEs reported by users of male contraceptives compared with those reported by female users. Among quantitatively comparable AEs, compared with men, women reported experiencing higher frequencies of headaches, pelvic pain, and weight gain and similar frequencies of decreased libido. Compared with women, men reported experiencing higher frequencies of acne and mood changes. Men discontinued participation due to AEs at a lower frequency than women.ConclusionsFemale hormonal methods generally have similar frequencies of AEs to those reported in a recent male hormonal contraceptive trial, and male users had lower rates of discontinuation due to AEs. There were fewer serious AEs of the male contraceptive than reported in contemporary female trials which resulted in FDA licensure. This suggests there may be implicit bias in the scientific community regarding the level of acceptable risk for users of male contraceptive methods.

ObjectiveThe effects of sex hormones on the immune defenses of the female genital mucosa and its susceptibility to infections are poorly understood. The injectable hormonal contraceptive depot medroxyprogesterone acetate (DMPA) may increase the risk for HIV-1 acquisition. We assessed the local concentration in the female genital mucosa of cationic polypeptides with reported antiviral activity in relation to DMPA use.MethodsHIV-1-uninfected women were recruited from among couples testing for HIV in Nairobi, Kenya. Cervicovaginal secretion samples were collected, and the concentrations of HNP1-3, LL-37, lactoferrin, HBD-2, and SLPI were measured by enzyme-linked immunosorbent assays. Levels of cationic polypeptides in cervicovaginal secretions were compared between women who were not using hormonal contraception and those using DMPA, oral, or implantable contraception.ResultsAmong 228 women, 165 (72%) reported not using hormonal contraception at enrollment, 41 (18%) used DMPA, 16 (7%) used an oral contraceptive, and 6 (3%) used a contraceptive implant. Compared with nonusers of hormonal contraception, DMPA users had significantly higher mean levels of HNP1-3 (2.38 vs. 2.04 log₁₀ ng/mL; P = 0.024), LL-37 (0.81 vs. 0.40 log10 ng/mL; P = 0.027), and lactoferrin (3.03 vs. 2.60 log₁₀ ng/mL; P = 0.002), whereas SLPI and HBD-2 were similar.ConclusionsAlthough all analyzed cationic polypeptides have intrinsic antiviral capacity, their interaction and cumulative effect on female genital mucosa susceptibility to infections in vivo has yet to be unraveled. This study suggests a potential mechanism underlying the effect of DMPA on the innate immune defenses, providing a rationale to investigate its effect on HIV-1 acquisition risk.

Introduction Few men are tested for syphilis or HIV during their partners’ pregnancy, a period of high HIV transmission risk and preventable adverse pregnancy outcomes. Offering home-based STI education and point-of-care (POC) testing of syphilis to couples can support HIV programs to reduce transmission of sexually transmitted infections and adverse pregnancy outcomes. Methods We assessed male partner uptake of paired POC syphilis and HIV tests within a randomised controlled trial (RCT) of 600 pregnant women and their male partners in Kenya. Married or cohabiting women were unaccompanied and attending a clinic-based first antenatal visit at recruitment. Participating men received a couple home-based visit with testing during pregnancy or at 6 months postpartum. We also evaluated whether the addition of syphilis testing has an effect on the uptake of HIV testing among men. Results From September 2013 to June 2014, male participation in home-based visits was 85% among women remaining enrolled (260 during pregnancy, 240 postpartum). Paired testing was offered to subsets of 80 and 230 men during pregnancy and postpartum. In both groups, test uptake was high: 1) For syphilis, 91% men agreed to test during pregnancy and 96% agreed postpartum; 2) For paired syphilis and HIV testing, 91% of men tested for both during pregnancy and 98% tested postpartum. Third, adding syphilis testing did not adversely affect home-based male partner HIV testing during pregnancy among 260 men, as HIV test uptake was 96% before (of 180), 95% after (of 80) syphilis test introduction, and remained 2-times greater than clinic-based HIV testing alone within the RCT (39%). Finally, men intended to seek clinic treatment if they received a positive test result during pregnancy and postpartum (94% and 95%, respectively). Conclusion Men were likely to accept both syphilis and HIV tests when offered at home without adversely affecting HIV testing approaches. POC diagnostics can work well outside facilities and increase testing of male partners who rarely accompany women to antenatal clinics.

Introduction Offering couples education and HIV rapid testing during pregnancy can increase testing of male partners, identify sero-discordant couples, and help link men to HIV care services. We aim to understand how a home-based antenatal couple HIV testing intervention affects male partner follow-up to clinic-based STI services during pregnancy. Methods We conducted a randomised controlled trial of un-accompanied pregnant women attending a first visit at Kisumu County Hospital from September 2013 to June 2014. Women and their partners received either home-based couple education with HIV and syphilis testing during pregnancy or an invitation letter to clinic-based couple HIV testing. Men’s self-reported health seeking outcomes during pregnancy were compared at 6 months postpartum. Results Among 601 enrolled women, we reached 247 and 240 men in the intervention and control arms, respectively (85% participation). Men who received the intervention were more likely to seek an STI consultation based on symptoms or a positive syphilis test [RR=1.59; 95%CI=1.33–1.89]. Postpartum, 39 (16%) intervention and 21 (9%) control men reported known HIV-positive status during pregnancy. Despite increased knowledge of HIV-positive status within the intervention group, men were less likely to link to HIV care services [RR=0.69; 95%CI=0.50–0.96], as 41% (16 of 39) of men were newly diagnosed with HIV. No differences were observed for uptake of male circumcision within the study period [RR=1.59; 95%CI=0.89–2.87] or attendance of subsequent clinic-based antenatal care with the female partner [RR=1.11; 95%CI=0.85–1.41]. Conclusion Home-based couple education and testing resulted in greater uptake of clinic-based STI consultation services among men. However, increased knowledge of HIV-status in the home did not lead to increased HIV care service uptake for men, potentially because there was a greater proportion of men with new HIV diagnoses in the intervention arm. This group of newly diagnosed men should be targeted with research to increase linkage and engagement to HIV care.

Antiretroviral postexposure prophylaxis (PEP) may be underutilized in sexual assault cases in Kenya. This study evaluated the characteristics of survivors of sexual violence attending the Gender-Based Violence Recovery Center (GBVRC) at the Kenyatta National Hospital and reviewed the uptake, adherence, and outcomes of those initiated on PEP. In a retrospective cohort, data from charts of the assaulted seen at the GBVRC from 2009 to 2012 were abstracted. Data were collected describing sociodemographic characteristics, nature of sexual assault, HIV serostatus, and aspects of the PEP care cascade. Characteristics of participants who received PEP were compared with those who did not receive PEP. We enrolled 385 assaulted persons; 331 (86%) were female; the median age of the assaulted persons was 21 (interquartile range 14-28) years; and 61 (15.8%) were children aged 10 years and younger. Of 379 assaults with descriptions, 330 (85.7%) were vaginal assaults and 40 (10.3%) were penile-anal assaults. Most perpetrators were unknown to the assaulted 220 of 384 (57.3%). All assaulted persons were offered HIV testing and 359 (93%) accepted testing; 346 (96.4%) of 359 assaulted persons tested HIV negative. In total, 207 (53.8%) of 385 sexual assault survivors initiated PEP. Only 70 (34%) completed 28 days of PEP, and only 21 (10.1%) returned for repeat HIV test at 3 months. In conclusion, PEP was only initiated in 54% of sexual assault cases. The care cascade showed that late presentation and poor adherence were the greatest gaps in PEP provision. Earlier presentation for PEP should be promoted among sexual assault in areas of high HIV prevalence.

Drug-induced liver injury related to Triumeq (abacavir/lamivudine/dolutegravir) has not been reported in clinical trials. We report a case of hepatotoxicity related to Triumeq exposure in a human immunodeficiency virus–infected patient. Clinicians should remain aware of the risk for acute and late-onset hepatitis with these agents. Close monitoring is recommended.

The role of antibiotic prophylaxis for prevention of infective endocarditis is unknown. Endocarditis prophylaxis is recommended for certain high-risk individuals prior to dental procedures. To our knowledge, this is the first case reported in the literature of a patient with complex congenital heart disease developing endocarditis in the period immediately following otherwise uncomplicated intrauterine device insertion.

Cytomegalovirus (CMV) infection can cause substantial morbidity in infancy. During maternal primary or reinfection, in utero CMV transmission is associated with a high risk of congenital disease and permanent sensorineural deficits [1]. Premature infants acquiring CMV by breast milk are at risk of developing symptomatic disease in the neonatal period [2] and may also experience long-term cognitive and psychomotor development [3, 4]. In the setting of infant human immunodeficiency virus type 1 (HIV-1) infection, both in utero and postnatally acquired CMV are associated with accelerated HIV-1 disease progression, neurologic disease, and death [5, 6]. CMV can be transmitted from mother-to-infant in utero, intrapartum, or postpartum by exposure to breast milk or saliva. Endothelial and epithelial cells support productive CMV infection and may facilitate systemic dispersion of virus [7]. CMV is frequently detected in saliva, urine, semen, cervical secretions, and breast milk, but detection in blood is rare in the absence of significant immunosuppression. In the cervix of healthy, HIV-negative women, CMV can be detected in approximately 10% of nonpregnant women and 11%–35% of pregnant women in the third trimester [8–10]. A small study of women with CMV cervicitis found inclusion bodies within glandular epithelial cells, endothelial cells, and mesenchymal stromal cells [11], suggesting these cells might be involved in CMV reactivation in the cervix. In breast milk, nearly all healthy women have detectable CMV DNA [12, 13]. CMV is found in both whey and cellular fractions of breast milk [13] and could have multiple sources, including mammary epithelial cells and migrating monocyte/macrophages and lymphocytes. In the setting of maternal HIV-1 infection, local HIV-1 replication and immunosuppression within tissues could increase CMV shedding at sites relevant for CMV transmission. In Nairobi, Kenya, 97% of adult blood donors in the general population are CMV seropositive [14] and virtually all HIV-infected women are coinfected with CMV [15, 16]. We previously found the rate of congenital CMV infection was 6.3% in HIV-exposed but uninfected infants and 29% in HIV-infected infants; by 6 months of age, 90% of HIV-exposed but uninfected infants and 89% of HIV-infected infants had experienced plasma CMV DNAemia, and 46% of HIV-unexposed infants were CMV seropositive [16]. Preventing or delaying CMV infection may represent a novel strategy to improve the health of both HIV-infected and HIV-exposed uninfected infants in sub–Saharan Africa, but requires a better understanding of CMV replication and transmission in the setting of maternal HIV-1. Using specimens and data from a randomized trial of valacyclovir suppressive therapy in Nairobi, we examined associations between HIV-1 RNA level, immunosuppression, and CMV replication in different maternal compartments and identified maternal correlates of infant CMV infection.

Background Globally, the rates of sexually transmitted infections (STIs) are highest among 15- to 24-year-old girls, especially in Sub-Saharan African countries where the adolescent sexual health is poor. Recruiting girls presexual debut could identify risk factors for STI acquisition. Methods We recruited a prospective cohort of “low-risk” adolescent girls aged 16–20 in Kenya. To be eligible, girls were HIV and HSV-2 seronegative and reported no history of sexual intercourse or reported having sex with only one partner. Demographic data were collected, and girls had nucleic acid testing of vaginal swabs for Neisseria gonorrhea, Chlamydia trachomatis, and Trichomonas vaginalis, and vaginal gram stains for bacterial vaginosis (BV). Results We enrolled 400 girls, with a median age of 18.6 years. In this cohort, 322 (80.5%) girls reported never having had sex, while 78 (19.5%) reported prior sex with 1 partner. Of those reporting prior sex, only 20 (25.6%) reported contraception use in the last 3 months, with 60% using only emergency contraceptive pills. The median age of sexual partners was 22 (IQR 19–25). Of the 373 participants with an STI swab result, 49 participants (13.1%) tested positive for STIs at entry into the study, with 41 chlamydia, 5 gonorrhea, and 3 trichomonas cases. Of these 49 participants, 33 (67.3%) had denied prior sexual intercourse. Testing positive for STIs was, however, significantly different among those reporting prior sexual intercourse vs. reporting never having had sex, 21.1% vs. 11.1% (P = 0.02). BV was rare (5.6%) in the cohort, with 90% of participants with a normal Nugent score of 0–3. Conclusion In the initial testing of a sexually inexperienced cohort of girls, we found unexpectedly high numbers of prevalent STIs, especially chlamydia which is not routinely screened for in Kenyan settings. Additionally, lack of sexual activity appeared overreported. BV was rare, with much lower prevalence than in adult women in Africa. Our data suggest that prior to initiation of sexual activity, most girls in this Kenyan cohort have vaginal microflora that is dominated by Lactobacillus. Interventions to address STIs, including pre-exposure prophylaxis for HIV, should be targeted at girls at a young age, presexual debut, and in nonmedical settings where girls can be reached who do not selfidentify as at risk for STI. Disclosures All authors: No reported disclosures.