Loss to Follow-Up among Youth Accessing Outpatient HIV Care & Treatment Services in Kisumu, Kenya

Youth are particularly vulnerable to acquiring HIV, yet reaching them with HIV prevention interventions and engaging and retaining those infected in care and treatment remains a challenge. 

We sought to determine the incidence rate of loss to follow-up (LTFU) and explore socio-demographic and clinical characteristics associated with LTFU among HIV-positive youth aged 15-21 years accessing outpatient care and treatment clinics in Kisumu, Kenya. Between July 2007 and September 2010, youth were enrolled into two different HIV care and treatment clinics, one youth specific and the other family oriented. An individual was defined as LTFU when absent from the HIV treatment clinic for ≥ 4 months regardless of their antiretroviral treatment status. 

The incidence rate of LTFU was calculated and Cox regression analysis used to identify factors associated with LTFU. A total of 924 youth (79% female) were enrolled, with a median age of 20 years (IQR 18-21). Over half, (529 (57%)), were documented as LTFU, of whom 139 (26%) were LTFU immediately after enrollment. The overall incidence rate of LTFU was 52.9 per 100 person-years (p-y). Factors associated with LTFU were pregnancy during the study period; CD4 cell count >350 (adjusted hazard ratios (AHR) 0.59, 95% CI 0.39-0.90); not being on antiretroviral therapy; and non-disclosure of HIV infection status (AHR 1.43, 95% CI 1.10-1.89). The clinic of enrolment, age, marital status, employment status, WHO clinical disease stage and education level were not associated with LTFU. 

Interventions to identify and enrol youth into care earlier, support disclosure, and initiate ART earlier may improve retention of youth and need further investigation. Further research is also needed to explore the reasons for LTFU from care among HIV-infected youth and the true outcomes of these patients.

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By:  Ojwang' VO1, Penner J1,2, Blat C1,3, Agot K4, Bukusi EA1, Cohen CR1,3.

• 1 Family AIDS Care & Education Services (FACES) , Centre for Microbiology Research (CMR), Kenya Medical Research Institute (KEMRI) , Nairobi , Kenya.
• 2 Department of Family Practice , University of British Columbia , Vancouver , Canada.
• 3 Department of Obstetrics, Gynaecology & Reproductive Sciences , University of California , San Francisco , CA , USA.
• 4 Impact Research and Development Organization , Kisumu , Kenya. 
• AIDS Care. 2016 Apr;28(4):500-7. doi: 10.1080/09540121.2015.1110234. Epub 2015 Nov 12.

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Molecular Epidemiology and Transmission Dynamics of Recent and Long-Term HIV-1 Infections in Rural Western Kenya

Objective

To identify unique characteristics of recent versus established HIV infections and describe sexual transmission networks, we characterized circulating HIV-1 strains from two randomly selected populations of ART-naïve participants in rural western Kenya.

Methods

Recent HIV infections were identified by the HIV-1 subtype B, E and D, immunoglobulin G capture immunoassay (IgG BED-CEIA) and BioRad avidity assays. Genotypic and phylogenetic analyses were performed on the pol gene to identify transmitted drug resistance (TDR) mutations, characterize HIV subtypes and potential transmission clusters. Factors associated with recent infection and clustering were assessed by logistic regression.

Results

Of the 320 specimens, 40 (12.5%) were concordantly identified by the two assays as recent infections. Factors independently associated with being recently infected were age ≤19 years (P = 0.001) and history of sexually transmitted infections (STIs) in the past six months (P = 0.004). HIV subtype distribution differed in recently versus chronically infected participants, with subtype A observed among 53% recent vs. 68% chronic infections (p = 0.04) and subtype D among 26% recent vs. 12% chronic infections (p = 0.012). Overall, the prevalence of primary drug resistance was 1.16%. Of the 258 sequences, 11.2% were in monophyletic clusters of between 2–4 individuals. In multivariate analysis factors associated with clustering included having recent HIV infection P = 0.043 and being from Gem region P = 0.002.

Conclusions

Recent HIV-1 infection was more frequent among 13–19 year olds compared with older age groups, underscoring the ongoing risk and susceptibility of younger persons for acquiring HIV infection. Our findings also provide evidence of sexual networks. The association of recent infections with clustering suggests that early infections may be contributing significant proportions of onward transmission highlighting the need for early diagnosis and treatment as prevention for ongoing prevention. Larger studies are needed to better understand the structure of these networks and subsequently implement and evaluate targeted interventions.

Below: Distribution of HIV-1 subtypes among participants, by recency of infection, Western Kenya, October 2003-May 2005

Full article at:   http://goo.gl/B0sgNH

By:  

Clement Zeh, Pauli N. Amornkul, Lisa A. Mills

US Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention (CDC), Kisumu, Kenya

Seth C. Inzaule, Lillian G. Nafisa, Alex Kasembeli, Fredrick Otieno, Lisa A. Mills

Kenya Medical Research Institute (KEMRI)/CDC Research and Public Health Collaboration, Kisumu Field Research Station, Kisumu, Kenya

Seth C. Inzaule, Pascale Ondoa

Amsterdam Institute of Global Health and Development (AIGHD), Department of Global Health of the Academic Medical Center, Amsterdam, The Netherlands

Hilde Vandenhoudt

Institute of Tropical Medicine (ITM), Antwerp, Belgium

John N. Nkengasong

Division of Global HIV and Tuberculosis, Center for Global Health, CDC Atlanta, Georgia, United States of America

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An Ethnographic Exploration of Drug Markets in Kisumu, Kenya

Highlights

• Drug markets are expanding throughout sub-Saharan Africa.
• Emergent drug markets in Kisumu, Kenya, are dynamic and fueling injection drug use.
• Injectors report availability of heroin and cocaine in Kisumu.
• Availability of cocaine is pharmacologically unconfirmed, but opens up questions about the social meanings of drug markets.
• Drug surveillance, education, and further ethnographic inquiry are needed in emergent drug markets in sub-Saharan Africa.

Background

Illegal drug markets are shaped by multiple forces, including local actors and broader economic, political, social, and criminal justice systems that intertwine to impact health and social wellbeing. Ethnographic analyses that interrogate multiple dimensions of drug markets may offer both applied and theoretical insights into drug use, particularly in developing nations where new markets and local patterns of use traditionally have not been well understood. This paper explores the emergent drug market in Kisumu, western Kenya, where our research team recently documented evidence of injection drug use.

Methods

Our exploratory study of injection drug use was conducted in Kisumu from 2013-2014. We draw on 151 surveys, 29 in-depth interviews, and 8 months of ethnographic fieldwork to describe the drug market from the perspective of injectors, focusing on their perceptions of the market and reports of drug use therein.

Results

Injectors described a dynamic market in which the availability of drugs and proliferation of injection drug use have taken on growing importance in Kisumu. In addition to reports of white and brown forms of heroin and concerns about drug adulteration in the market, we unexpectedly documented widespread perceptions of cocaine availability and injection in Kisumu. Examining price data and socio-pharmacological experiences of cocaine injection left us with unconfirmed evidence of its existence, but opened further possibilities about how the chaos of new drug markets and diffusion of injection-related beliefs and practices may lend insight into the sociopolitical context of western Kenya.

Conclusions

We suggest a need for expanded drug surveillance, education and programming responsive to local conditions, and further ethnographic inquiry into the social meanings of emergent drug markets in Kenya and across sub-Saharan Africa.

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By:  Jennifer L. Syvertsen, Spala Ohaga, Kawango Agot, Margarita Dimova, Andy Guise, Tim Rhodes, Karla D. Wagner

Affiliations

Department of Anthropology The Ohio State University 4046 Smith Laboratory 174 W. 18th Ave. Columbus, OH 43210-1106, USA

Correspondence

Corresponding author. Tel.: +1 614 247 6815; fax: +1 614 292 4155.

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Correlates pf Prevalent HIV Infection among Adults & Adolescents in Kisumu, Kenya

We estimated HIV prevalence and identified correlates of HIV infection among 1106 men and women aged 16–34 years residing in Kisumu, Kenya. Demographic, sexual, and other behavioural data were collected using audio computer-assisted self-interview in conjunction with a medical examination, real-time parallel rapid HIV testing, and laboratory testing for pregnancy, gonorrhoea, chlamydia, syphilis, and herpes simplex virus type 2. Multivariate logistic regression was used to identify variables associated with prevalent HIV infection by gender. 

• Overall HIV prevalence was 12.1%. 
• HIV prevalence among women (17.1%) was approximately two and one half times the prevalence among men (6.6%). 
• Odds of HIV infection in men 
• increased with age and 
• were greater among those who were uncircumcised 
• and those who had an herpes simplex virus type 2 positive test result. 
• Odds of prevalent HIV infection among women also 
• increased with age. 
• Women who tested herpes simplex virus type 2 positive had more than three times the odds of prevalent HIV infection compared with those who tested herpes simplex virus type 2 negative. 

Tailored sexual health interventions and programs may help mitigate HIV age and gender disparities.

Correlates of HIV infection among men, Kisumu Incidence Cohort Study, Kenya, 2007–2010.

	HIV Prevalence at Screening		Bivariate		Multiple Regression
	N	%	OR (95% CI)	p-value	aOR** (95% CI)	p-value
Age*			1.20 (1.11, 1.29)	<.0001	1.21 (1.07, 1.35)	.0017
Marital status				.0373		.2976
Single/never married	21	5.3	Ref		Ref
Married/living as married	12	9.8	1.95 (0.93, 4.08)		0.47 (0.14, 1.57)
Separated/divorced/widowed	2	25.0	6.00 (1.14, 31.54)		2.08 (0.24, 18.07)
Religion				.5776
Roman Catholic	11	5.2	Ref
Protestant or other Christian	15	6.8	1.32 (0.59, 2.94)
Muslim/Nomiya/Other	7	8.1	1.58 (0.59, 4.23)
No religion	2	13.3	2.78 (0.56, 13.90)
Highest education level				.0030		.2421
Never attended school	6	27.3	9.25 (2.67, 32.08)		4.47 (0.95, 21.06)
Primary school	12	7.6	2.01 (0.74, 5.51)		1.41 (0.42, 4.74)
Secondary school	11	5.7	1.48 (0.54, 4.10)		1.15 (0.38, 3.50)
Post-secondary schoola	6	3.9	Ref		Ref
Currently working				.8029
Yes	16	6.9	1.09 (0.55, 2.17)
No	19	6.4	ref
Lifetime number of sexual partnersb				.3646
1–2	2	4.4	Ref
3–4	7	4.7	1.09 (0.22, 5.41)
5 or more	25	7.9	1.88 (0.43, 8.20)
Ever had anal sex				.2108		.1577
Yes	3	3.4	0.46 (0.14, 1.55)		0.37 (0.09, 1.48)
No	31	7.0	Ref		Ref
Ever had oral sex				.9831
Yes	9	6.6	1.01 (0.46, 2.21)
No	26	6.6	Ref
Ever been forced into sex				.5502
Yes	6	8.2	1.32 (0.53, 3.30)
No	29	6.4	Ref
Number of sexual partners in the past three monthsb				.9009		.4761
0	5	14.3	Ref		Ref
1	5	4.4	0.27 (0.07, 1.00)		0.31 (0.06, 1.59)
2–3	13	6.1	0.39 (0.13, 1.18)		0.34 (0.08, 1.39)
4 or more	12	7.3	0.47 (0.16, 1.44)		0.42 (0.10, 1.74)
Any unprotected vaginal or anal sex in the past three months				.6114
Yes	3	4.4	1.38 (0.40, 4.70)
No	24	6.0	Ref
Sex during special occasions in the past three months				.6831
Yes	10	5.5	0.85 (0.39, 1.86)
No	20	6.4	Ref
STI history				<.0001		.0966
Never	19	4.3	Ref		Ref
Not recent	10	15.4	4.03 (1.78, 9.12)		2.09 (0.76, 5.78)
Recent (past three months)	6	24.0	7.00 (2.51, 19.53)		3.40 (0.99, 11.65)
HSV-2 results				<.0001		.0489
Positive	12	20.7	6.82 (3.04, 15.29)		3.13 (1.12, 8.73)
Indeterminate	7	16.7	5.23 (2.02, 13.55)		3.04 (0.95, 9.71)
Negative	16	3.7	Ref		Ref
Circumcision as confirmed by physical examination (men)				.0070		.0109
Uncircumcised	31	8.9	4.29 (1.49, 12.35)		4.42 (1.41, 13.89)
Circumcised	4	2.2	Ref		Ref

aPost-secondary education includes technical/vocational training, college, or university.

bPersons with whom the participant had vaginal or anal sex.

*Continuous variable.

**Odds ratios and confidence intervals adjusted for all variables listed in the column (i.e. all variables with p <.25 in bivariate models).

Correlates of HIV infection among women, Kisumu Incidence Cohort Study, Kenya, 2007–2010.

	HIV Prevalence at Screening		Bivariate		Multiple Regression
	N	%	OR** (95% CI)	p-value	aOR** (95% CI)	p-value
Age*			1.17 (1.11, 1.23)	<.0001	1.16 (1.04, 1.29)	.0085
Marital status				<.0001		.9456
Single/never married	36	10.3	Ref		Ref
Married/living as married	44	24.2	2.76 (1.70, 4.48)		1.00 (0.34, 2.97)
Separated/divorced/widowed	16	41.0	6.03 (2.92, 12.45)		1.26 (0.29, 5.52)
Religion				.8482
Roman Catholic	48	17.3	Ref
Protestant or other Christian	28	15.3	0.87 (0.52, 1.44)
Muslim/Nomiya/Other	17	19.5	1.16 (0.63, 2.15)
No religion	4	18.2	1.07 (0.35, 3.29)
Highest education level				.0096		.3554
Never attended school	8	33.3	4.21 (1.53, 11.61)		4.77 (0.49, 46.07)
Primary school	48	21.2	2.26 (1.19, 4.28)		3.05 (0.84, 11.08)
Secondary school	27	14.4	1.42 (0.72, 2.83)		2.31 (0.66, 8.08)
Post-secondary schoola	14	10.6	Ref		Ref
Currently working				.0038		.6743
Yes	47	23.3	1.92 (1.24, 2.99)		0.83 (0.35, 1.96)
No	50	13.6	Ref		Ref
Lifetime number of sexual partnersb*				.0010		.2903
1–2	11	7.8	Ref		Ref
3–4	40	17.5	2.53 (1.25, 5.12)		2.52 (0.75, 8.47)
≥5	41	24.3	3.81 (1.88, 7.74)		1.68 (0.46, 6.16)
Ever had anal sex				.0940		.5813
Yes	19	12.5	0.63 (0.37, 1.08)		0.73 (0.24, 2.21)
No	76	18.5	Ref		Ref
Ever had oral sex				.5928
Yes	17	15.2	0.86 (0.48, 1.52)
No	78	17.3	Ref
Ever been forced into sex				.3499
Yes	29	19.5	1.26 (0.78, 2.04)
No	68	16.1	Ref
Number of sexual partners in the past three monthsb				.6828
0	6	17.1	Ref
1	51	15.6	0.89 (0.35, 2.27)Ref
2–3	28	18.0	1.06 (0.40, 2.79)
4 or more	14	19.4	1.17 (0.41, 3.35)
Any unprotected vaginal or anal sex in the past three months				.0725		.5167
Yes	70	18.1	1.96 (0.94, 4.10)		0.70 (0.24, 2.06)
No	9	10.1	Ref		Ref
Sex during special occasions in the past three months				.7423
Yes	19	17.9	1.10 (0.63, 1.92)
No	71	16.6	Ref
STI history				<.0001		.9115
Not recent	10	15.4	4.03 (1.78, 9.11)		1.38 (0.32, 5.90)
Recent (past three months)	6	24.0	7.00 (2.51, 19.53)		1.00 (0.08, 11.81)
Never	19	4.3	Ref		Ref
HSV-2 results				<.0001		.0114
Positive	76	35.5	12.92 (6.94, 24.06)		3.85 (1.38, 10.71)
Indeterminate	9	23.1	7.04 (2.78, 17.82)		0.88 (0.14, 5.59)
Negative	13	4.1	Ref		Ref
Pregnant as confirmed by lab test (women)				.0963		.9837
Yes	8	28.6	2.06 (0.88, 4.82)		0.98 (0.09, 10.66)
No	88	16.3	Ref		Ref
Used birth control pills to delay or avoid pregnancy in the past three months (women)				.0484		.5334
Yes	33	23.1	1.96 (1.01, 3.82)		1.38 (0.51, 3.74)
No	15	13.3	Ref		Ref
Used injections to delay or avoid pregnancy in the past three months (women)				.0355		.9940
Yes	33	24.1	2.02 (1.05, 3.90)		1.00 (0.38, 2.67)
No	16	13.6	Ref		Ref

aPost-secondary education includes technical/vocational training, college, or university.

bPersons with whom the participant had vaginal or anal sex.

*Continuous variable.

**Odds ratios and confidence intervals adjusted for all variables listed in the column (i.e. all variables with p <.25 in bivariate models).

Full article at:   http://goo.gl/NFjq0f

By:  Anne Gumbe,1 Eleanor McLellan-Lemal,2 Deborah A Gust,2 Sherri L Pals,2 Kristen Mahle Gray,2 Richard Ndivo,1Robert T Chen,2 Lisa A Mills,3 and Timothy K Thomas3, for the KICoS Study Team1

¹Kenya Medical Research Institute, Kisumu, Kenya

²Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, GA, USA

³Centers for Disease Control and Prevention, HIV-Research Branch, Kisumu, Kenya

Corresponding author: Anne Gumbe, International AIDS Vaccine Initiative, ABC Place (Building 2,3rd Fl) Waiyaki Way, PO Box 340 KNH, Nairobi, Kenya. Email: gro.ivai@ebmuga

Int J STD AIDS. 2015 Nov; 26(13): 929–940.

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