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Background Exclusive breastfeeding (EBF) during the first 6 months of life is widely promoted as a key strategy to enhance child health, growth, and development. Even though a high proportion of children in Kenya are currently breastfed exclusively, there is little evidence regarding the developmental benefits during the first year of life. This paper aims to fill this gap by establishing an association between EBF and early childhood developmental outcomes among children below the age of 6 months in Kenya. Methods We used data collected as part of a cluster-randomized controlled trial conducted in Bondo sub-county in the western part of Kenya to assess the associations between EBF and development in the first year of life. The primary exposure variable was EBF, and the outcome variable was child development as measured by the Ages and Stages Questionnaire–Third Edition (ASQ-3). Results We analyzed data from 570 children aged below 6 months at the time of the interview. Breastfeeding children exclusively between 3 and 6 months was associated with 0.61 standard deviation (SD) higher ASQ-3 scores in the adjusted model. When specific domains were considered, in the adjusted models, EBF in the 3–6 months period was associated with 0.44 SD, 0.34 SD and 0.36 SD higher ASQ-3 scores in communication, gross motor, and problem solving domains, respectively. There were weak associations in the fine motor and social-emotional domains. Conclusion EBF in the 3- to 6-month age range has significant positive associations with child development, especially for communication, gross motor, and problem-solving. Programs encouraging mothers to continue EBF in this period may have substantial benefits for children.

Background Assisted partner service (APS) is effective for increasing HIV testing services (HTS) uptake among sexual partners of people diagnosed with HIV with rare social harm. The acceptability of APS to HTS providers is important for the quality and effectiveness of APS delivery. Within a larger ongoing implementation science study of APS in western Kenya, we qualitatively evaluated the provider acceptability of APS. Methods From May–June 2020, we conducted virtual, semi-structured in-depth interviews with 14 HTS providers recruited from 8 of 31 study health facilities in Homa Bay and Kisumu counties. Participants were selected using criteria-based purposive sampling to maximize variation on patient volume (assessed by the number of index clients tested for HIV) and APS performance (assessed by sexual partners elicitation and enrollment). Interviews inquired providers’ experiences providing APS including challenges and facilitators and the impact of contextual factors. Data were analyzed using an inductive approach. Results Overall, HTS providers found APS acceptable. It was consistently reported that doing APS was a continuous process rather than a one-day job, which required building rapport and persistent efforts. Benefits of APS including efficiency in HIV case finding, expanded testing coverage in men, and increased HIV status awareness and linkage to care motivated the providers. Provider referral was perceived advantageous in terms of independent contact with partners on behalf of index clients and efficiency in partner tracing. Challenges of providing APS included protecting clients’ confidentiality, difficulty obtaining partners’ accurate contact information, logistic barriers of tracing, and clients’ refusal due to fear of being judged for multiple sexual partners, fear of breach of confidentiality, and HIV stigma. Building rapport with clients, communicating with patience and nonjudgmental attitude and assuring confidentiality were examples of facilitators. Working in rural areas and bigger facilities, training, supportive supervision, and community awareness of APS promoted APS delivery while low salaries, lack of equipment, and high workload undermined it. Conclusions HTS providers found APS acceptable. Delivering APS as a process was the key to success. Future scale-up of APS could consider encouraging provider referral instead of the other APS methods to improve efficiency and reduce potential harm to clients.

BACKGROUND Despite the effective scale-up of HIV testing and treatment programs worldwide, only 75% of persons living with HIV (PLWH) globally know their status, with lower rates among men. This highlights the importance of implementing HIV testing and linkage interventions with high uptake in this population group. In a cluster randomized controlled trial conducted between 2013 and 2015, our team found that assisted partner services (APS) for HIV-exposed partners of newly diagnosed PLWH, safely reached more at-risk individuals to conduct testing compared to client referral alone. However, more data is needed to assess APS implementation in a real-world setting. OBJECTIVE This study evaluates the effectiveness, acceptability, fidelity, and cost of APS when integrated into existing HIV testing services (HTS) in Western Kenya. METHODS In a collaboration between the University of Washington and PATH, we are integrating APS into 31 health facilities in Western Kenya and enrolling female index clients newly diagnosed with HIV who receive APS, their male sexual partners, and female sexual partners of the male sexual partners who test HIV positive. Female index clients and all sexual partners testing HIV-positive will be followed up at 6 weeks, 6 months, and 12 months to assess linkage to care, antiretroviral therapy (ART) initiation, and HIV viral load suppression. We will evaluate acceptability, fidelity and cost of real-world implementation of APS via in-depth interviews conducted with national, county, and sub-county level policymakers responsible for HIV testing services. Facility health staff providing HIV testing services and APS, in addition to staff working with the study project team will also be interviewed. We will also conduct direct observations of facility infrastructure and clinic procedures, and extract data from facility and county/national databases. RESULTS As of March 2020, we have recruited 1724 index clients, 3201 male partners, and 1585 female partners. We have completed all recruitment for this study and have completed all 6-week (99%), 6-month (97%) and 12-month (91%) follow-up visits. Preliminary analyses demonstrate that through scaling-up APS, facilities are able to identify 12-18 new HIV-positive males for every 100 men contacted and tested. We are now in the process of completing the remaining follow-up interviews and building a self-testing component of the study as an adaptation to the COVID-19 pandemic. CONCLUSIONS Results will be used to bridge the gap between clinical research findings and everyday practice, and provide guidance on optimal strategies for APS integration into HIV service delivery. CLINICALTRIAL N/A

Background: Approximately 250 million (43%) children under five years in low- and middle-income countries are at risk of sub-optimal development. Of these, 67% are found in sub-Saharan Africa due to exposure to multiple risks, including inadequate stimulation at home. In order to promote early childhood development (ECD), an intervention integrating ECD content into routine facility-based health services and supporting ECD policy and advocacy is currently being implemented in Siaya County. In addition, parental counseling on early stimulation is integrated into home-based visits by community health volunteers. We aim to evaluate the intervention’s operational feasibility, effectiveness and cost-effectiveness.Methods: The study is a cluster-randomized controlled trial using a mixed-methods approach. The study is being conducted in Bondo sub-county in Siaya County. The study has three arms. Arm 1 will receive a health facility-based ECD intervention. Arm 2 will receive the health facility-based ECD intervention combined with home-based ECD counselling. Arm 3 (control) will receive standard care. Six health facilities in each study arm (18 in total) will be randomly selected from wards within the sub-county. We aim to recruit and follow-up 699 mother/caregiver-child dyads, 233 in each arm. Pregnant women are recruited when they visit health facilities during the third trimester. Analysis will involve estimating the effect of the intervention using mixed linear models and the Difference-in-Differences estimator.Conclusions: The data generated from this study will provide much-needed information for program design and implementation of interventions aimed at promoting ECD in Kenya and other sub-Saharan African countries.Trial Registration: Current Control Trial is ISRCTN11561283.

BACKGROUND There is a pressing need to ensure that youth in high HIV prevalence settings are prepared for a safer sexual debut. Smartphone ownership is increasing dramatically in low-income and middle-income countries. Smartphone games that are appropriately grounded in behavioral theory and evidence-based practice have the potential to become valuable tools in youth HIV prevention efforts in Sub-Saharan Africa. OBJECTIVE To pilot-test a theory-based, empirically grounded smartphone game for young Kenyans designed to increase age and condom use at first sex, aiming to establish directionality of effects on behavior change. METHODS Tumaini (“hope for the future” in Swahili) is an interactive, narrative-based game grounded in social cognitive theory. A randomized controlled pilot study was conducted in Kisumu, Western Kenya, from April to June 2017 with 60 participants aged 11-14 (mean 12.7) years. Intervention arm participants (n=30) were provided with an Android smartphone with Tumaini installed on it and were instructed to play the game for at least 1 hour a day for 16 days; control arm participants (n=30) received no intervention. All participants completed a survey on behavioral mediators, delivered via an audio computer-assisted self-interview system at baseline (T1), post intervention (T2), and at 6 weeks postintervention (T3). The postintervention survey for intervention arm participants included questions eliciting feedback on the game. Intervention arm participants and their parents participated in 8 postintervention focus group discussions. Game log files were analyzed to calculate the length of exposure to the game. Behavioral survey data were analyzed using two-sample t tests to compare mean change from T1 to T2 and to T3 for intervention versus control arm participants. Descriptive statistics on game feedback questions were computed. Focus group transcripts were uploaded to MAXQDA software, where they were labeled with deductive and inductive codes. Data were analyzed thematically and compared across demographics. RESULTS Intervention arm participants played Tumaini for a mean of approximately 27 hours. The intervention arm showed significant gains in sexual health-related knowledge and self-efficacy (both P CONCLUSIONS The study supports the need for further research to assess the efficacy of the game-based intervention. If proven efficacious, smartphone games have the potential to dramatically increase the reach of culturally adapted behavioral interventions while ensuring fidelity to intervention design. CLINICALTRIAL ClinicalTrials.gov NCT03054051; http://clinicaltrials.gov/ct2/show/NCT03054051 (Archived by WebCite at http://www.webcitation.org/70U2gCNtW)