Kenya Medical Research Institute

Structural, psychological, and clinical barriers to HIV care engagement among adolescents and young adults living with HIV (AYAH) persist globally despite gains in HIV epidemic control. Phone-based peer navigation may provide critical peer support, increase delivery flexibility, and require fewer resources. Prior studies show that phone-based navigation and automated text messaging interventions improve HIV care engagement, adherence, and retention among AYAH. However, little is known about AYAH experiences utilizing electronic phone-based peer navigation and automated text messaging (E-NAV). We assessed the experiences of AYAH receiving phone-based peer navigation to address barriers to HIV care engagement and viral suppression. We purposefully selected participants randomized to E-NAV within the Adapt for Adolescents in Kisumu, Kenya, and conducted 20 in-depth interviews. Interviews were conducted by a trained qualitative researcher between October and December 2021 and explored topics such as health-seeking and care experiences, E-NAV acceptability and benefits, and the client-navigator relationship. The interviews were audio-recorded and transcribed. We then applied inductive and deductive coding, followed by thematic analysis. Overall, participants found E-NAV acceptable in regard to content and frequency–particularly the opportunity to select a preferred time for calls/text messages, including evenings and weekends. They found the tone of navigator calls and messages friendly, supporting relationship building. Further, AYAH-navigator relationships were described as fraternal, client-focused, and confidential, which supported a personal connection and trust. Reported E-NAV benefits included adherence and appointment reminders, increased knowledge about HIV care, and strategies to address HIV stigma. Electronic navigation is a promising method for youth peer navigation because it optimizes reach (both in time and space) for youth that have severe constraints on both while preserving the ability to create a rapport and a relationship with patients.

Antibiotics can trigger antimicrobial resistance and microbiome alterations. Reducing pathogen exposure and undernutrition can reduce infections and antibiotic use. We assess effects of water, sanitation, handwashing (WSH) and nutrition interventions on caregiver-reported antibiotic use in Bangladesh and Kenya, longitudinally measured at three timepoints among birth cohorts (ages 3–28 months) in a cluster-randomized trial. Over 50% of children used antibiotics at least once in the 90 days preceding data collection. In Bangladesh, the prevalence of antibiotic use was 10–14% lower in groups receiving WSH (prevalence ratio [PR] = 0.90 (0.82–0.99)), nutrition (PR = 0.86 (0.78–0.94)), and nutrition+WSH (PR = 0.86 (0.79–0.93)) interventions. The prevalence of using antibiotics multiple times was 26–35% lower in intervention arms. Reductions were largest when the birth cohort was younger. In Kenya, interventions did not affect antibiotic use. In this work, we show that improving WSH and nutrition can reduce antibiotic use. Studies should assess whether such reductions translate to reduced antimicrobial resistance.

Background Increased risk of HIV acquisition during pregnancy and lactation among women is evident, necessitating their inclusion in the evaluation of new HIV prevention interventions. Pregnant and postpartum women specifically face challenges with oral PrEP associated with stigma, and the burden of using other tablets. Long-acting products may address challenges related to oral PrEP, however, there is limited data on product-specific preferences and acceptability among pregnant and lactating women. Methods We conducted a mixed-method study to assess the preferences and acceptability of long-acting PrEP modalities either under development or already established among pregnant and lactating women. We conducted quantitative surveys (n = 434) and in-depth interviews (n = 80) in central and western Kenya. We used descriptive statistics and categorical variables to summarize frequencies and proportions. Inductive and deductive content analytic approaches were used for in-depth interviews. Results The median age of respondents was 25 years (IQR 19.3–31.0). Majority were married (263/434, 61%), had completed high school (222/434, 51%), with no condoms use in the prior 3 months (348/434, 80%). The most preferred PrEP formulations were injectable (251/434, 57%) and implantable (175/434, 40%) options. Participants who preferred injectable PrEP had 8.56 times higher odds of considering ease of use as a reason. (aOR = 8.56, 95% CI [3.81–20.48]) and 3.71 odds of choosing perceived discreteness (aOR = 3.71, 95% CI (1.57–9.97)) as their preference reasons. Participants who preferred Implant for HIV prevention had 2.31 odds of considering it due to perceived effectiveness in preventing HIV as a preference reason (aOR = 2.31, 95% CI (1.21—4.66)) and 2.53-fold of considering discreteness as a preference reason (aOR = 2.53, 95% CI (1.46—4.59)). From the in-depth interviews, women reported prospective acceptability due to the perceived convenience of LA products, perceived effectiveness, reduced cost, improved privacy, and reduced stigma. Women had concerns regarding the safety and efficacy of the products during pregnancy and lactation. Conclusion Acceptability of LA products underscores the importance of considering the unique needs of pregnant and breastfeeding women in the development of future prevention interventions. Aligning preferences and needs would enhance the uptake and adherence outcomes of HIV prevention products.

Antimicrobial resistance (AMR) poses a great challenge to health systems all over the world. It is exacerbated by the abuse, misuse and overuse of antimicrobials in humans, animals, plants and the environment. This viewpoint emphasizes the critical need to address the challenges of AMR through an integrated, long-term approach that focuses on education, advocacy and collective action. This article stresses that the fight against AMR is not a battle for governments and scientists alone but requires engagement at every level. The article concludes that we can reduce the spread of AMR by exploring the potential of education, advocacy and collective action.

Background Despite their ubiquity across sub-Saharan Africa, private pharmacies are underutilized for HIV service delivery beyond the sale of HIV self-test kits. To understand what uptake of HIV prevention and treatment services might look like if private pharmacies offered clients free HIV self-testing and referral to clinic-based HIV services, we conducted a pilot study in Kenya. Methods At 20 private pharmacies in Kisumu County, Kenya, pharmacy clients (≥ 18 years) purchasing sexual health-related products (e.g., contraception) were offered free HIV testing. Based on their test result and recent self-reported behaviors associated with HIV risk, clients were encouraged to consider pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), or antiretroviral therapy (ART) initiation, informed where they could access free services, and issued a referral. We called clients three months after study completion to see if they had initiated the recommended service. Among clients who reported PrEP referral, we used Poisson regression models to examine characteristics associated with PrEP initiation and calculated adjusted prevalence ratios (aPRs). Results From March to June 2022, 1500 pharmacy clients completed HIV testing and were referred to clinic-based HIV services; in October 2022, 1178 (79%) were reached and meet our criteria for follow-up. Among those reached, the majority (63%, 742/1178) were women, the median age was 26 years (IQR 22–31), and few (4%, 51/1178) reported any prior PrEP use. At the pharmacy, most clients (96%, 1136/1178) tested HIV-negative and reported PrEP (95%, 1122/1178) or PEP (1%, 14/1178) referral; the remainder (4%, 42/1178) tested HIV-positive and reported ART referral. The uptake of ART (90%, 38/42) and PEP (86%, 12/14) among clients referred was high. The uptake of PrEP was only 9% (101/1122) among those referred and prior PrEP use was the only characteristic significantly associated with initiation (aPR 2.45, 95% confidence interval 1.19 to 5.07). Conclusions Although offering free HIV testing at private pharmacies led to the identification and referral of clients who could benefit from HIV services, additional interventions (e.g., incentives, patient navigators) may be needed to support PrEP referral follow-through. Alternatively, new delivery models that circumvent the need for referrals, such as same-day PrEP initiation at pharmacies, should be considered.

Antimicrobial resistant pathogens are a leading cause of morbidity and mortality worldwide, with overuse and misuse of antimicrobials being key contributors. We aimed to identify factors associated with antibiotic prescriptions among patients presenting to clinics in Kenya. We performed a retrospective, descriptive cohort study of persons presenting to outpatient clinics in Western and Coastal Kenya, including symptoms, physical exams, clinician assessments, laboratory results and prescriptions. We reviewed 1,526 visits among 1,059 people who sought care from December 2019-February 2022. Median age was 16 (IQR 6–35) and 22% were under 5. 30% of malaria RDTs were positive and 3% of dengue RT-qPCRs were positive. Antibiotics were prescribed in 73% of encounters overall and in 84% among children under 5. In 48% of visits antibiotics were prescribed without a provisional bacterial diagnosis. In the multivariable model, factors associated with increased odds of an antibiotic prescription were the clinic in Western Kenya (OR 5.1, 95% CI 3.0–8.8), age less than or equal to 18 (OR 2.1, 95% CI 1.4–3.2), endorsement of cardiorespiratory symptoms (OR 5.2, 95% CI 3.2–8.3), a negative malaria RDT (OR 4.0, 95% CI 2.5–6.8), and a provisional diagnosis that could be bacterial in etiology (OR 5.9, 95% CI 3.5–10.3). High rates of antibiotic prescriptions are common even when associated diagnoses are not bacterial. Compared to our 2014–2017 cohort, we found higher rates of antibiotic prescriptions among children. Improved diagnostics to rule in alternative diagnoses as well as stewardship programs are needed.

Background Transactional sexual relations in the absence of condom use is a well-established behaviour that strongly contributes to HIV transmission if the infected person is not virally suppressed. In this study, we determined the trends and factors associated with VLNS among treatment-experienced FSWs in Kenya. Methods This retrospective cohort study used data collected from 7-sex workers outreach clinics between 2015 and 2022. VLNS trends were determined using the Modified Mann-Kendall test, and the effects of covariates on VLNS odds were examined using generalized estimating equations (GEE) with a logit link. Results 12,117 viral load tests were performed on samples collected from 1,947 FSWs. The prevalence of VLNS decreased from 25.5% (95%CI 17.6–34.6) in 2016 to 4.3% (95%CI 2.5–6.7) in 2021. The odds of VLNS decreased by 9% per year during the study period in the multivariable GEE analysis adjusted for covariates (regimen, age, and sex worker outreach program (SWOP) clinic), (OR 0.91, 95%CI 0.84–0.98; P = 0.005). Age was a significant factor associated with VLNS, with younger women (18–24 years) having 2.2 times higher odds of VLNS (OR 2.15 95%CI 1.10–4.20; P = 0.025) than those aged >55 years (reference). Subjects on dolutegravir (DTG)-based cART regimen had 64% lower odds of VLNS (OR 0.36, 95%CI 0.25–0.52; P < 0.001) compared to those on PI-based regimen. Conclusions There is a strong evidence of decreasing population level viremia among FSWs during the study period. To maintain the trend, it is necessary to continue supporting SWOP clinics in order to provide HIV treatment services to this key population.

Exposure to pulmonary tuberculosis (PTB) culminates in heterogeneous outcomes, including variation in Mtb antigen-specific interferon-gamma (IFN-γ) T-cell responses. IFN-γ-independent cytokines, including tumor necrosis factor (TNF) and interleukin (IL-2), offer potential diagnostic improvements and insights into pathogenesis. We hypothesized that ESAT6/CFP10 TNF and IL-2 responses improve Mtb infection detection among exposed household contacts (HHCs) and are associated with index case Mtb aerosolization (i.e., cough aerosol culture positive for Mtb growth, CAC+) and HIV co-infection. We enrolled individuals with PTB and their HHCs in a longitudinal study in Nairobi, Kenya. We measured TNF and IL-2 in HHCs from QuantiFERON-TB Plus TB1 tube supernatants. An additional 9.2% (25) HHCs beyond the 58.6% (129) with an IFN-γ response demonstrated an antigen-specific increase in IL-2 and TNF. HHCs of CAC + participants were more likely to have positive IL-2 (84.6% vs. 53.8%, p = 0.02) and IFN-γ (88.0% vs. 54.9%, p = 0.01), but not TNF responses, compared to CAC-negative individuals. While HIV co-infection in the index was negatively associated with IFN-γ responses in HHCs (35.7% vs. 62.3%, p = 0.03), IL-2 and TNF responses did not differ. Antigen-specific ESAT6/CFP10 IL-2 and TNF may increase rates of Mtb infection detection and provide insights into Mtb transmission and pathogenesis.

Partnering with communities is a vital component of public health research. Terms such as community participation, community engagement, and citizen participation have been used to denote community partnerships that aim to re-distribute power through negotiation between citizens and researchers and enable co-creative processes that bring non-researchers in as core partners. These citizen-researcher partnerships go beyond informed consent, voluntary participation, and intervention adherence but instead constitute a means by which shared planning, design, implementation, dissemination, and decision-making take place. In this case study, we describe our intervention study in coastal Kenya that included homeowners, schools, schoolchildren, and other stakeholders to increase people’s awareness of vectors and vector-borne diseases and catalyze their participation in vector control. The partners for this work included researchers from local and international universities, social scientists, non-governmental organizations, officials from the ministries of health and education, and the community members themselves. We trialed new strategies to deeply engage adult and child community members to promote vector control activities at home and in the community. Strengthening community involvement and establishing prolonged interaction of community representatives with control services, municipalities, and other public actors were shown to be time-consuming and costly at the beginning but rewarding during the process and with excellent potential for sustainability. In this case study, we also investigate the concepts of gender norms and patriarchy and underscore how they interact with other forms of culture to impact decision-making processes, power imbalance and dominance, and vulnerability to ill health at our study site in Kenya. We highlight social science’s contribution to enhancing a deeper understanding of the social constructs that underlie power structures and concepts of disease and health in the Kenyan village, thus fostering successful partnerships with the community and enhancing research outcomes. The key tenets from this case study are relevant to community-based research conducted in similar contexts.

Background In western Kenya, a cluster-randomized trial is assessing the impact of attractive targeted sugar baits (ATSBs) on malaria in children enrolled in three consecutive cohorts. Here, characteristics of children and households at enrolment, and factors associated with baseline malaria prevalence are described. Methods Children aged 1 to < 15 years were randomly selected by cluster (n = 70) from a census database. Cohorts were enrolled in March–April 2022, September–October 2022, and March–April 2023. ATSBs were deployed in March 2022. At enrolment, all participants were tested for malaria by rapid diagnostic test (RDT). After enrolment a household survey was conducted. Household structures were classified as ‘improved’ (finished walls and roofs, and closed eaves) or ‘traditional’ (all other construction). A generalized linear mixed model was used to assess factors associated with malaria prevalence. Results Of 3705 children screened, 220 declined and 523 were excluded, due to plans to leave the study area (n = 392), ineligible age (n = 64) or other reason (n = 67). Overall, 2962 children were enrolled. Bed net use the previous night was more common in children aged 1–4 years (746/777 [96%]) than those aged 5–<15 years (1806/2157 [84%], p < 0.001). Of the 2644 households surveyed (for 2,886 participants), information on house construction was available for 2595. Of these, only 199 (8%) were categorized as ‘improved’, as most houses had open eaves. While 99% of households owned at least one bed net, only 51% were adequately covered (one net per two household residents). Among 999 children enrolled in the first cohort (baseline), 498 (50%) tested positive by RDT. In an adjusted multivariable analysis, factors associated with RDT positivity included sub-county (Alego-Usonga vs Rarieda, adjusted odds ratio [aOR] 4.81; 95% CI: 2.74–8.45; p < 0.001), house construction (traditional vs improved, aOR 2.80; 95% CI: 1.59–4.95; p < 0.001), and age (5–< 15 vs 1–4 years, aOR 1.64; 95% CI: 1.13–2.37; p = 0.009). Conclusions In western Kenya, the burden of malaria in children remains high. Most households owned a bed net, but coverage was inadequate. Residents of Alego-Usonga sub-county, those living in traditionally constructed households, and older children were more likely to test positive by RDT. Additional tools are needed to effectively control malaria in this area. Trial registration The ATSB trial is registered under Clinicaltrials.gov NCT05219565

Objective measures of oral PrEP adherence – especially point-of-care (POC) measures that enable real-time assessment, intervention, and feedback – have the potential to improve adherence. Our team previously developed and validated a novel urine-based POC metric of PrEP adherence. In this study, we sought to determine whether this assay is acceptable and feasible among women taking PrEP and PrEP providers in Kenya. We conducted a trial comparing PrEP adherence counseling using the assay (intervention) versus standard-of-care counseling. We conducted in-depth interviews (IDIs) with intervention-arm participants (n = 20), and focus group discussions (n = 18) after the final (12-month) follow-up visit. We also conducted IDIs with purposively-sampled healthcare providers (HCPs) (n = 8) who administered the assay. The assay was highly acceptable among participants and HCPs as it was perceived to be accurate, could provide evidence of adherence, provides real-time results, and improves participant and provider relationship. HCPs reported that the assay facilitated counseling, seemed to increase adherence, and would be feasible to implement in routine care settings. Both participants and HCPs reported concerns about the assay related to the fear of being stigmatized for negative results, and test accessibility. Future studies should evaluate the impact of this novel test on adherence patterns over time in diverse populations.

Objective To determine the safety, tolerance, and adherence to self‐administered intravaginal 5% fluorouracil (5FU) cream as adjuvant therapy following cervical intraepithelial neoplasia grade 2 or 3 (CIN2/3) treatment among women living with HIV (WLWH) in Kenya. Methods A phase I pilot trial was performed among 12 WLWH in Kenya, aged 18–49 years between March 2023 and February 2024 (ClinicalTrial.gov NCT05362955). Participants self‐administered 2 g of 5FU intravaginally every other week for eight applications. Safety was assessed using a standardized grading scale, and adherence was evaluated using self‐report, inspection of used applicators, and weighing of the study drug. Results The mean age and CD4 count were 43.9 years and 781 cells/mm³, respectively. Seven (58%) had an eighth‐grade education or less. All 12 reported at least one grade I adverse event (AE), one (8%) reported a grade 2 AE, no grade 3 or 4 AEs were reported. Increased vaginal discharge (n = 9, 75%) and irritation (n = 5, 42%), with a mean duration of 3.2 and 2.8 days, respectively, were the most commonly reported AEs. Provider‐observed AEs included grade 1 cervical erythema and superficial abrasions. All participants tolerated all eight 5FU doses, and 96% adherence was demonstrated. Conclusion Self‐administered 5FU following CIN2/3 treatment among WLWH in Kisumu, Kenya, was safe, tolerable, and associated with high adherence. Randomized trials are needed to investigate whether adjuvant 5FU can improve treatment outcomes or serve as primary cervical precancer treatment in sub‐Saharan Africa. A self‐administered therapy may be transformative in increasing access to treatment and, hence, secondary prevention of cervical cancer.

Background Despite the recognised links between food insecurity and parenting, few studies have evaluated the perceived impacts of livelihood or food security interventions on parental practices, intra-household functioning, adolescent behaviour and psychosocial outcomes in HIV-affected households in sub-Saharan Africa. Aims The study aimed to understand the perceived effects of food security on parenting practices and how this was experienced by both adolescent girls (aged 13–19 years) and their caregivers in rural Kenya. Method We conducted semi-structured, individual interviews with 62 caregiver–adolescent dyads who were participants in the adolescent Shamba Maisha (NCT03741634), a sub-study of adolescent girls and caregivers with a household member participating in the Shamba Maisha agricultural and finance intervention trial (NCT01548599). Data were analysed following the principles of thematic analysis. Results Compared to control households, the Shamba Maisha intervention households had improved food security and strengthened economic security, which, in turn, improved parenting practices. Intervention households described changes in parenting experiences, including decreased parental stress, reduced absenteeism and harsh parenting and improved caregiver– adolescent relationships. These positive caregiving practices, in turn, contributed to improved mental health and fewer behavioural problems among adolescent girls. Changes in the control households were less noticeable. Conclusion These findings demonstrate how an income-generating agricultural intervention may improve food security and positively affect parenting practices, intra-household dynamics and adolescent psychosocial well-being and behaviour. Further research is needed to explore how to harness the social benefits of agricultural interventions to best address the critical intersections among food insecurity, parenting practices and adolescent mental health.

Introduction Worldwide, 2.4 billion people rely on solid fuels such as wood or charcoal for cooking, leading to approximately 3.2 million deaths per year from illnesses attributable to household air pollution. Across Africa, household air pollution generated by solid fuel use accounts for nearly 700,000 deaths each year. Most studies to date have focused either household air pollution exposure, its impacts on particular health outcomes or on the efficacy of mitigation interventions. However, the economic, social, and cultural determinants of household air pollution in Africa are still poorly understood. The purpose of this study was to explore people’s experience of using solid fuels for cooking in two informal settlements, Ndirande in Malawi and Mukuru in Kenya, and the associated harms caused by household air pollution. Methods We adopted a community-based participatory method, photovoice, which was conducted with 9 participants in Ndirande and 10 participants in Mukuru. Participants took pictures reflecting their experiences and perceptions of household air pollution harms over a two-week period, and later discussed, sorted and analysed those in a series of meetings. Thematic analysis was used to analyse the data. Results With their pictures, participants described fuel stacking and switching behaviours in their communities. They described a mix of charcoal, firewood and other biomass fuels use. They also expressed their awareness and perceptions of the harms caused by smoke when cooking. Participants explained the simple behaviours used by residents to minimize the harms of household air pollution to themselves and within their own household. Other themes explored the roles and responsibilities for procuring fuels in the home, and the stated solutions required to address the issues and manage the transition to cleaner fuels in those informal settlements. Conclusion This study highlights not only the need to understand the daily life, priorities and concerns of those who use solid fuels on informal settlements, but also the urgency to place them and their experience at the heart of the solutions that will reduce the health harms of household air pollution.

Collaborative Filtering Recommender Systems predict user preferences for online information, products or services by learning from past user-item relationships. A predominant approach to Collaborative Filtering is Neighborhood-based, where a user-item preference rating is computed from ratings of similar items and/or users. This approach encounters data sparsity and scalability limitations as the volume of accessible information and the active users continue to grow leading to performance degradation, poor quality recommendations and inaccurate predictions. Despite these drawbacks, the problem of information overload has led to great interests in personalization techniques. The incorporation of context information and Matrix and Tensor Factorization techniques have proved to be a promising solution to some of these challenges. We conducted a focused review of literature in the areas of Context-aware Recommender Systems utilizing Matrix Factorization approaches. This survey paper presents a detailed literature review of Context-aware Recommender Systems and approaches to improving performance for large scale datasets and the impact of incorporating contextual information on the quality and accuracy of the recommendation. The results of this survey can be used as a basic reference for improving and optimizing existing Context-aware Collaborative Filtering based Recommender Systems. The main contribution of this paper is a survey of Matrix Factorization techniques for Context-aware Collaborative Filtering Recommender Systems.

The causal dose–response curve is commonly selected as the statistical parameter of interest in studies where the goal is to understand the effect of a continuous exposure on an outcome. Most of the available methodology for statistical inference on the dose-response function in the continuous exposure setting requires strong parametric assumptions on the probability distribution. Such parametric assumptions are typically untenable in practice and lead to invalid inference. It is often preferable to instead use nonparametric methods for inference, which only make mild assumptions about the data-generating mechanism. We propose a nonparametric test of the null hypothesis that the dose-response function is equal to a constant function. We argue that when the null hypothesis holds, the dose-response function has zero variance. Thus, one can test the null hypothesis by assessing whether there is sufficient evidence to claim that the variance is positive. We construct a novel estimator for the variance of the dose-response function, for which we can fully characterize the null limiting distribution and thus perform well-calibrated tests of the null hypothesis. We also present an approach for constructing simultaneous confidence bands for the dose-response function by inverting our proposed hypothesis test. We assess the validity of our proposal in a simulation study. In a data example, we study, in a population of patients who have initiated treatment for HIV, how the distance required to travel to an HIV clinic affects retention in care.