Publications by authors named "Pamela Kohler"

44 Publications

Improving quality of PrEP counseling for adolescent girls and young women in Kenya with standardized patient actors: a dose-response analysis.

J Acquir Immune Defic Syndr 2021 Sep 23. Epub 2021 Sep 23.

Department of Global Health, University of Washington, Seattle, WA, USA Department of Epidemiology, University of Washington, Seattle, WA, USA Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya Policy Development & Evaluation Unit, Public Health Seattle/King County, Seattle, WA, USA Howard University, Washington, DC, USA Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA Department of Biostatistics, University of Washington, Seattle, WA, USA Department of Medicine, University of Washington, Seattle, WA, USA Department of Pediatrics, University of Washington, Seattle, WA, USA Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, USA.

Background: Health care worker (HCW) training using standardized patient actors (SPs) is an evidence-based approach for improving patient-provider interactions. We evaluated whether SP training among HCWs in Western Kenya improved quality of PrEP counseling for adolescent girls and young women (AGYW).

Methods: We conducted a 2-day SP training intervention among HCWs providing PrEP counseling for AGYW. Six trained SPs role-played one encounter each with HCWs following scripts depicting common PrEP-seeking scenarios. SPs used checklists to report and discuss domains of adherence to national PrEP guidelines, communication, and interpersonal skills using validated scales after each encounter. HCWs presented to each case in random order. Overall and domain-specific mean score percentages were compared between the first and subsequent case encounters using generalized linear models, clustering by HCW.

Results: During 564 training cases among 94 HCW, the overall mean quality of PrEP counseling score was 83.1 (standard deviation [SD]:10.1); scores improved over the course of the 6 encounters (p<0.001). Compared to the first case encounter, mean scores for the fourth were significantly higher (79.1 vs. 85.9, p<0.001). Mean scores plateaued from the fourth to the sixth case (85.2). While HCWs demonstrated high baseline communication (95.3) and interpersonal skills (83.7), adherence to PrEP guidelines at baseline was suboptimal (57.6). By the 4th case, scores increased significantly (p<0.001) for all domains.

Conclusions: SP training improved PrEP counseling overall and in domains of interpersonal skills, use of guidelines, and communication with AGYW and could be useful in efforts to improve quality of PrEP counseling for AGYW.
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http://dx.doi.org/10.1097/QAI.0000000000002814DOI Listing
September 2021

Key influences on the decision to initiate PrEP among adolescent girls and young women within routine maternal child health and family planning clinics in Western Kenya.

AIDS Care 2021 Sep 20:1-8. Epub 2021 Sep 20.

Department of Global Health, University of Washington, Seattle, WA, USA.

We sought to understand influences on PrEP uptake among Kenyan adolescent girls and young women (AGYW) whose decision on PrEP use was misaligned with their risk for HIV acquisition. In-depth interviews were conducted with 47 Kenyan HIV-negative AGYW aged 15-24 years who were offered PrEP during routine maternal and child health and family planning services. AGYW were sampled from two groups (1) declined PrEP and had ≥1 sexual partner(s) of unknown HIV status and (2) initiated PrEP and reported having one HIV-negative partner. AGYW with HIV-negative partners initiated PrEP due to known or suspected infidelity. AGYW with partners of unknown HIV status recognized PrEP as a helpful HIV prevention tool, yet worried about partner reactions and prioritized avoiding uncomfortable or unsafe situations over PrEP. Among pregnant AGYW, the responsibility of motherhood and providing a future for one's family, through staying healthy and remaining HIV-free, was a strong PrEP use motivator. Among AGYW who desired future motherhood, fears that PrEP could negatively impact fertility or reduce contraceptive effectiveness led to declining PrEP. Peers positively influenced PrEP decision-making, especially personally knowing a PrEP user. Strategies are needed to enhance messaging and delivery approaches that are tailored to AGYW, including peer-led strategies.
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http://dx.doi.org/10.1080/09540121.2021.1981217DOI Listing
September 2021

High Acceptance and Completion of HIV Self-testing Among Diverse Populations of Young People in Kenya Using a Community-Based Distribution Strategy.

AIDS Behav 2021 Sep 1. Epub 2021 Sep 1.

Department of Global Health, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359931, Seattle, WA, 98104, USA.

Oral HIV self-testing (HIVST) may expand access to testing among hard-to-reach reach adolescents and young adults (AYA). We evaluated community-based HIVST services for AYA in an urban settlement in Kenya. Peer-mobilizers recruited AYA ages 15-24 through homes, bars/clubs, and pharmacies. Participants were offered oral HIVST, optional assistance and post-test counseling. Outcomes were HIVST acceptance and completion (self-report and returned kits). Surveys were given at enrollment, post-testing, and 4 months. Log-binomial regression evaluated HIVST preferences by venue. Among 315 reached, 87% enrolled. HIVST acceptance was higher in bars/clubs (94%) than homes (86%) or pharmacies (75%). HIVST completion was 97%, with one confirmed positive result. Participants wanted future HIVST at multiple locations, include PrEP, and cost ≤ $5USD. Participants from bars/clubs and pharmacies were more likely to prefer unassisted testing and peer-distributers compared to participants from homes. This differentiated community-based HIVST strategy could facilitate engagement in HIV testing and prevention among AYA.
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http://dx.doi.org/10.1007/s10461-021-03451-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8409270PMC
September 2021

"What is this PrEP?"- Sources and accuracy of HIV Pre-Exposure Prophylaxis (PrEP) awareness among adolescent girls and young women attending family planning and maternal child health clinics in Western Kenya.

J Acquir Immune Defic Syndr 2021 Aug 9. Epub 2021 Aug 9.

University of Washington, Department of Global Health, Seattle, WA, USA University of Washington, Department of Biobehavioral Nursing and Health Informatics, Seattle, WA, USA Kenya Medical Research Institute, Nairobi, Kenya Kenyatta National Hospital, Nairobi, Kenya University of Washington, Child, Family, and Population Health, Seattle, WA, USA University of Washington, Department of Epidemiology, Seattle, WA, USA University of Washington, Department of Medicine, Seattle, WA, USA.

Background: PrEP delivery to adolescent girls and young women (AGYW) is scaling-up in sub-Saharan African countries. Understanding how AGYW learn about PrEP is needed to inform programs seeking to reach AGYW with HIV prevention tools.

Methods: AGYW (ages 15-24), attending routine family planning and maternal child health clinics in Kisumu, Kenya, participated in in-depth interviews (IDIs). AGYW were recruited if they either declined or accepted PrEP when offered that day in clinic, or were currently or previously on PrEP. Thematic analysis was used to identify key themes related to the type and quality of knowledge sources from which AGYW first became aware of PrEP.

Results: Overall, 140 IDIs were conducted with AGYW. The median age was 21.5 years (IQR: 20.0, 23.0), 65% of participants were married, and almost half (45.7%) were currently taking PrEP. Participants reported learning about PrEP from three primary sources: 1) clinic-based education, 2) friends, family, or other PrEP users, and 3) media and community outreach. Participants who reported learning about PrEP from friends or family were highly enthusiastic about PrEP. The accuracy and completeness of knowledge varied with most inaccuracies around the cost, dosing, and who benefits from PrEP. Community outreach campaigns provided fewer details, resulting in more inaccurate information and distrust of information received.

Conclusion: PrEP information reaches AGYW through many sources with variable accuracy and completeness. Training providers and peer leaders to disseminate thorough and accurate PrEP information when counselling AGYW could positively impact acceptance and proper use.
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http://dx.doi.org/10.1097/QAI.0000000000002782DOI Listing
August 2021

Contraceptive counseling experiences among women attending HIV care and treatment centers: A national survey in Kenya.

Contraception 2021 08 22;104(2):139-146. Epub 2021 Apr 22.

Department of Child, Family, and Population Health Nursing and Department of Global Health, University of Washington, Seattle, WA, United States. Electronic address:

Objectives: To characterize contraceptive counseling experiences among women living with HIV (WLWH) receiving HIV care in Kenya.

Study Design: Sexually active, WLWH aged 15 to 49 years were purposively sampled from 109 high-volume HIV Care and Treatment Centers in Kenya between June and September 2016. Cross-sectional surveys were administered to enroll women on a tablet using Open Data Kit. Poisson generalized linear regression models adjusted for facility-level clustering were used to examine cofactors for receiving family planning (FP) counseling with a provider.

Results: Overall, 4805 WLWH were enrolled, 60% reported they received FP counseling during the last year, 72% of whom reported they were counseled about benefits of birth spacing and limiting. Most women who received FP counseling were married (64%) and discussed FP with their partner (78%). Use of FP in the last month (adjusted Prevalence Ratio [aPR] = 1.74, 95% confidence interval [CI]: 1.41-2.15, p < 0.001), desire for children in >2 years (aPR = 1.18, 95% CI: 1.09-1.28, p < 0.001), and concern about contraceptive side-effects (aPR = 1.13, 95% CI 1.02-1.25, p < 0.05) were significantly higher among WLWH who received FP counseling compared to those that did not.

Conclusions: Over one-third of WLWH did not receiving FP counseling with an HIV care provider during the last year, and counseling was more commonly reported among women who were using FP or desired children in >2 years.

Implications: There are missed opportunities for FP counseling in HIV care. FP integration in HIV care could improve FP access and birth spacing or limiting among WLWH.
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http://dx.doi.org/10.1016/j.contraception.2021.04.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8286320PMC
August 2021

Evaluation of a New Field Epidemiology Training Program Intermediate Course to Strengthen Public Health Workforce Capacity in Tanzania.

Public Health Rep 2021 Sep-Oct;136(5):575-583. Epub 2021 Feb 4.

7284 Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA, USA.

Objectives: Sub-Saharan Africa faces a shortage of skilled epidemiologists to prevent, detect, and respond to health threats. Tanzania has implemented one of the first Centers for Disease Control and Prevention Field Epidemiology Training Program (FETP) Intermediate courses in Africa. This course aims to strengthen health workforce capacity in surveillance system assessment, outbreak investigation, and evaluation, prioritizing HIV control. We conducted an outcome evaluation of this new course.

Methods: We used a pre/post evaluation design using data from 4 cohorts of trainees who took the FETP Intermediate course from 2017 to 2020. We conducted knowledge assessments before and after each cohort and combined those results. Outcomes included knowledge and self-rated competency and trends in integrated disease surveillance and response (IDSR) data. We collected data through tests, field assignments, exit interviews, and data audits. We compared the mean change in pre-/posttest scores using linear regression and 95% CIs. We used content analysis to summarize exit interviews.

Results: Fifty-three FETP trainees from 10 regions enrolled in the FETP Intermediate course, and 52 (99.0%) completed the course. We found substantial increases in mean knowledge (44.0 to 68.0 points) and self-rated competency (4.14 to 4.43) scores before and after the course. Trainees evaluated 52 surveillance systems and 52 district HIV care programs, and 39 (75.0%) trainees participated in outbreak investigations. From before to after cohort 1, timeliness and completeness of IDSR reports increased from 4.2% to 52.1% and from 27.4% to 76.5%, respectively. Course strengths were quality of instruction, individualized mentoring, and practical skills gained. Challenges were mentor availability, limited time for data analysis practice, and balancing work and field assignments.

Conclusions: The Tanzania FETP Intermediate course substantially improved trainee knowledge and helped to improve local data quality and reporting. This course is a promising model to strengthen subnational capacity to prevent, detect, and respond to public health threats in Africa.
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http://dx.doi.org/10.1177/0033354920974663DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8361556PMC
October 2021

Adolescent participation in HIV research: consortium experience in low and middle-income countries and scoping review.

Lancet HIV 2020 12;7(12):e844-e852

Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Faculty of Infectious Diseases, London School of Hygiene & Tropical Medicine.

Adolescents in low and middle-income countries (LMICs) have a high prevalence of HIV, therefore, it is important that they are included in HIV research. However, ethical challenges regarding consent can hinder adolescent research participation. We examined examples from the Prevention and Treatment Through a Comprehensive Care Continuum for HIV-affected Adolescents in Resource Constrained Settings (PATC3H) research consortium, which investigates adolescent HIV prevention and treatment in seven LMICs: Brazil, Kenya, Mozambique, Nigeria, South Africa, Uganda, and Zambia. PATC3H researchers were asked to identify ethical and practical challenges of adolescent consent to research participation in these countries. We also did a scoping review of strategies that could improve adolescent participation in LMIC HIV studies. Examples from PATC3H research highlighted many ethical challenges that affect adolescent participation, including inconsistent or absent consent guidance, guidelines that fail to account for the full array of adolescents' lives, and variation in how ethical review committees assess adolescent studies. Our scoping review identified three consent-related strategies to expand adolescent inclusion: waiving parental consent requirements, allowing adolescents to independently consent, and implementing surrogate decision making. Our analyses suggest that these strategies should be further explored and incorporated into ethical and legal research guidance to increase adolescent inclusion in LMIC HIV research.
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http://dx.doi.org/10.1016/S2352-3018(20)30269-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8491773PMC
December 2020

Influences on Early Discontinuation and Persistence of Daily Oral PrEP Use Among Kenyan Adolescent Girls and Young Women: A Qualitative Evaluation From a PrEP Implementation Program.

J Acquir Immune Defic Syndr 2021 04;86(4):e83-e89

Global Health, University of Washington, Seattle, WA.

Background: Discontinuation of daily oral pre-exposure prophylaxis (PrEP) is frequent among adolescent girls and young women (AGYW) in African settings. We explored factors influencing early PrEP discontinuation and persistence among Kenyan AGYW who accepted PrEP within a programmatic setting.

Methods: We conducted in-depth interviews with AGYW (aged 15-24 years) who accepted PrEP from 4 maternal child health (MCH) and family planning (FP) clinics. AGYW were identified by nurses at routine clinic visits and purposively sampled based on 4 categories: (1) accepted PrEP pills, but never initiated PrEP use (eg, never swallowed PrEP pills), (2) discontinued PrEP <1 month after initiation, (3) discontinued PrEP within 1-3 months, and (4) persisted with PrEP use >3 months. Informed by the Stages of Change Model, thematic analysis characterized key influences on PrEP discontinuation/persistence.

Results: We conducted 93 in-depth interviews with AGYW who accepted pills. Median age was 22 years, 71% were married; 89% were from MCH, and 11% were from FP clinics. Early PrEP use was positively influenced by encouragement from close confidants and effective concealment of PrEP pill-taking when necessary to avoid stigma or negative reactions from partners. Pregnancy helped conceal PrEP use because pill-taking is normalized during pregnancy, but concealment became more difficult postpartum. AGYW found keeping up with daily PrEP pill-taking challenging, and many noted only episodic periods of the HIV risk. Frequently testing HIV-negative reassured AGYW that PrEP was working and motivated persistence.

Discussion: As PrEP programs scale-up in MCH/FP, it is increasingly important to enhance protection-effective PrEP use through approaches tailored to AGYW, with special considerations during pregnancy and postpartum.
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http://dx.doi.org/10.1097/QAI.0000000000002587DOI Listing
April 2021

Modeling the health impact and cost threshold of long-acting ART for adolescents and young adults in Kenya.

EClinicalMedicine 2020 Aug 16;25:100453. Epub 2020 Jul 16.

Department of Epidemiology,University of Washington, 1959 NE Pacific Street, Health Sciences Bldg, Box 357236, Seattle, WA, United States.

Background: Despite high efficacy of oral antiretroviral therapy (ART), viral suppression among adolescents and young adults (AYA) living with HIV in sub-Saharan Africa (SSA) remains low. Compared to daily oral ART, bimonthly long-acting injectable ART (LA-ART) may simplify adherence, improve clinical outcomes, and decrease HIV transmission in this priority population. However, LA-ART will likely cost more than oral ART and the cost threshold at which LA-ART will be cost effective in SSA has not been evaluated.

Methods: We adapted a mathematical model of HIV transmission and progression in Kenya to include HIV acquisition and viral suppression among AYA (age 10-24). We projected the population-level health and economic impact of providing LA-ART to AYA over a 10-year time horizon assuming oral ART costs of US$233 annually and a two-month duration of viral suppression per LA-ART injection. We calculated the maximum cost at which switching from oral to LA-ART would be considered cost-effective, using thresholds of $500 and $1,508 per disability-adjusted life year averted (WHO's threshold of HIV treatment interventions and Kenya's gross domestic product per capita).

Findings: Assuming 85% of AYA switch from oral to injectable formulations, LA-ART is estimated to prevent 40,540 infections and 20,480 deaths over 10 years. The maximum increase in the annual per-person cost of receiving LA-ART is estimated to be $89 and $236 for LA-ART to be cost-effective under the thresholds of $500 and $1,508 per DALY averted, respectively. The cost threshold was lower when non-adherent oral ART AYA users were assumed to be less likely to switch to LA-ART.

Interpretation: Providing LA-ART to AYA can be cost-effective in Kenya if it is less than twice the cost of oral ART. Long-acting injectable ART for priority populations with low viral suppression has the potential to cost-effectively avert disability and death.

Funding: National Institutes of Health (R01 HD085807; PI: Kohler).
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http://dx.doi.org/10.1016/j.eclinm.2020.100453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7486332PMC
August 2020

Brief Report: Time to Repeat Viral Load Testing Among Unsuppressed Adolescents and Young Adults Living With HIV in Kenya.

J Acquir Immune Defic Syndr 2020 12;85(5):606-611

Global Health, University of Washington, Seattle, WA.

Background: Repeat HIV viral load (VL) testing is required after unsuppressed VL to confirm treatment failure. We assessed proportion of adolescents and young adults living with HIV (AYALHIV) in Kenya with a confirmatory VL test and time to repeat testing.

Design: A retrospective analysis of longitudinal data abstracted from Kenya's national VL database.

Methods: VL data for AYALHIV who were 10-24 year old between April 2017 and May 2019 were abstracted from 117 HIV care clinics. Records were eligible if at least one VL test was performed ≥6 months after antiretroviral therapy (ART) initiation. The proportion of unsuppressed AYALHIV (≥1000 copies/mL) and time in months between first unsuppressed VL and repeat VL was determined.

Results: We abstracted 40,928 VL records for 23,969 AYALHIV; of whom, 17,092 (71%) were eligible for this analysis. Of these, 12,122 (71%) were women, median age of 19 years [interquartile range (IQR): 13-23], and median ART duration of 38 months (IQR: 16-76). Among eligible AYALHIV, 4010 (23%) had an unsuppressed VL at first eligible measurement. Only 316 (8%) of the unsuppressed AYALHIV had a repeat VL within 3 months and 1176 (29%) within 6 months. Among 2311 virally unsuppressed AYALHIV with a repeat VL, the median time between the first and the repeat VL was 6 months (IQR: 4-8), with 1330 (58%) having confirmed treatment failure.

Conclusions: One-quarter of AYALHIV on ART had unsuppressed VL, with less than a third receiving a repeat VL within 6 months. Strategies to improve VL testing practices are needed to improve AYALHIV's outcomes.
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http://dx.doi.org/10.1097/QAI.0000000000002498DOI Listing
December 2020

The Psychosocial Effects of the COVID-19 Pandemic on Youth Living with HIV in Western Kenya.

AIDS Behav 2021 Jan;25(1):68-72

Department of Child, Family, Population Health Nursing, University of Washington, Box 359932, Seattle, WA, 98104, USA.

The objective of this study was to assess psychosocial effects of COVID-19 among adolescents living with HIV (ALHIV) in Kenya and to assess the feasibility of conducting behavioral surveys by phone. We adapted our protocol to administer telephone rather than in-person follow-up surveys and included questions about COVID-19. The majority of participants (99%) reported having heard of COVID-19; 23% reported no longer being able to go outside, 17% reported that they could no longer go to their regular clinic for medical care, and 3% reported that they could no longer get medication refills. PHQ-9 screening identified 9% (n = 45) with mild depression symptoms, and 1% (n = 3) with moderate-to-severe depression symptoms. Young adults 20-24 years old had more mild to severe depressive symptoms than the younger age groups (p < 0.001). Offering remote peer-support or mental health care, continuing to offer differentiated care services, and considering financial support will support the health and well-being of ALHIV.
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http://dx.doi.org/10.1007/s10461-020-03005-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7438976PMC
January 2021

High Awareness, Yet Low Uptake, of Pre-Exposure Prophylaxis Among Adolescent Girls and Young Women Within Family Planning Clinics in Kenya.

AIDS Patient Care STDS 2020 08;34(8):336-343

Department of Global Health, University of Washington, Seattle, Washington, USA.

Adolescent girls and young women (AGYW) are a priority population for HIV prevention in high-burden settings. We evaluated psychosocial characteristics, behavioral risk factors for HIV, and pre-exposure prophylaxis (PrEP) awareness and uptake among AGYW seeking contraceptive services at four public sector family planning (FP) clinics offering integrated PrEP delivery in Kisumu, Kenya. From October 2018 to June 2019, we approached all AGYW (aged 15-24 years) seeking contraception to participate in a survey following receipt of FP services and PrEP screening. Overall, 470 AGYW were screened for PrEP at their FP visit by facility staff and subsequently enrolled in the survey. Median age was 22 years (interquartile range 20-23), 22% of AGYW were in school, and 55% were married. The most frequent forms of contraception were implants and injectables (41% each). Over a third of AGYW (36%) reported low social support, 13% had symptoms of moderate to severe depression, and 3% reported intimate partner violence. Three-quarters (75%) of AGYW reported recent condomless sex and 42% suspected that their primary partner had other sexual partners. Most AGYW (89%) had previously heard of PrEP; 76% had at least one PrEP eligibility criterion as per national guidelines; however, only 4% initiated PrEP at their current FP visit. PrEP initiators more frequently had high HIV risk perception than noninitiators (85% vs. 10%,  < 0.001). Low perceived HIV risk (76%) and pill burden (51%) were common reasons for declining PrEP among AGYW with HIV behavioral risk factors. PrEP counseling should be tailored to AGYW to guide appropriate PrEP decision-making in this important population.
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http://dx.doi.org/10.1089/apc.2020.0037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7415219PMC
August 2020

Training Exposure and Self-Rated Competence among HIV Care Providers Working with Adolescents in Kenya.

J Int Assoc Provid AIDS Care 2020 Jan-Dec;19:2325958220935264

Department of Global Health, University of Washington, Seattle, WA, USA.

Lack of health care worker (HCW) training is a barrier to implementing youth-friendly services. We examined training coverage and self-reported competence, defined as knowledge, abilities, and attitudes, of HCWs caring for adolescents living with HIV (ALWH) in Kenya. Surveys were conducted with 24 managers and 142 HCWs. Competence measures were guided by expert input and Kalamazoo II Consensus items. Health care workers had a median of 3 (interquartile range [IQR]: 1-6) years of experience working with ALWH, and 40.1% reported exposure to any ALWH training. Median overall competence was 78.1% (IQR: 68.8-84.4). In multivariable linear regression analyses, more years caring for ALWH and any prior training in adolescent HIV care were associated with significantly higher self-rated competence. Training coverage for adolescent HIV care remains suboptimal. Targeting HCWs with less work experience and training exposure may be a useful and efficient approach to improve quality of youth-friendly HIV services.
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http://dx.doi.org/10.1177/2325958220935264DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322818PMC
May 2021

Standardised patient encounters to improve quality of counselling for pre-exposure prophylaxis (PrEP) in adolescent girls and young women (AGYW) in Kenya: study protocol of a cluster randomised controlled trial.

BMJ Open 2020 06 21;10(6):e035689. Epub 2020 Jun 21.

Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, Washington, USA.

Introduction: Adolescent girls and young women (AGYW) in sub-Saharan Africa are at high risk of HIV acquisition. Pre-exposure prophylaxis (PrEP) demonstration projects observe that AGYW uptake and adherence to PrEP during risk periods is suboptimal. Judgemental interactions with healthcare workers (HCW) and inadequate counselling can be barriers to PrEP use among AGYW. Improving HCW competency and communication to support PrEP delivery to AGYW requires new strategies.

Methods And Analysis: PrEP Implementation for Young Women and Adolescents Program-standardised patient (PrIYA-SP) is a cluster randomised trial of a standardised patient actor (SP) training intervention designed to improve HCW adherence to PrEP guidelines and communication skills. We purposively selected 24 clinics offering PrEP services under fully programmatic conditions in Kisumu County, Kenya. At baseline, unannounced SP 'mystery shoppers' present to clinics portraying AGYW in common PrEP scenarios for a cross-sectional assessment of PrEP delivery. Twelve facilities will be randomised to receive a 2-day training intervention, consisting of lectures, role-playing with SPs and group debriefing. Unannounced SPs will repeat the assessment in all 24 sites following the intervention. The primary outcome is quality of PrEP counselling, including adherence to national guidelines and communication skills, scored on a checklist by SPs blinded to intervention assignment. An intention-to-treat (ITT) analysis will evaluate whether the intervention resulted in higher scores within intervention compared with control facilities, adjusted for baseline SP scores and accounting for clustering by facility. We hypothesise that the intervention will improve quality of PrEP counselling compared with standard of care. Results from this study will inform guidelines for PrEP delivery to AGYW in low-resource settings and offer a potentially scalable strategy to improve service delivery for this high-risk group.

Ethics And Dissemination: The protocol was approved by institutional review boards at Kenyatta National Hospital and University of Washington. An external advisory committee monitors social harms. Results will be disseminated through peer-reviewed journals and presentations.

Trial Registration Number: NCT03875950.
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http://dx.doi.org/10.1136/bmjopen-2019-035689DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7311012PMC
June 2020

Depression and HIV risk behaviors among adolescent girls and young women seeking family planning services in Western Kenya.

Int J STD AIDS 2020 06;31(7):652-664

Department of Global Health, University of Washington, Seattle, WA, USA.

We assessed prevalence of human immunodeficiency virus (HIV) risk behaviors and depressive symptoms among adolescent girls and young women (AGYW) aged 15-24 years attending four public family planning clinics in Western Kenya from January to June 2019. Moderate-to-severe depression (MSD) was defined as a Center for Epidemiologic Studies Depression Scale (CESD-10) score ≥10. Among 487 AGYW, the median age was 22 years (interquartile range 20-23), and 59 (12%) AGYW reported MSD. MSD was more prevalent among AGYW without a current partner (p = 0.001) and associated with HIV risk factors including partner ≥10 years older, recent transactional sex, forced sex, intimate partner violence, and alcohol use (each p ≤ 0.005). Thirty-four percent of AGYW with MSD had a high HIV risk score corresponding to 5 to 15 incident HIV cases per 100 person-years. Overlapping high prevalence of depression and HIV risk among AGYW underscores the need for integrated mental health and HIV services in family planning clinics.
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http://dx.doi.org/10.1177/0956462420920423DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7520985PMC
June 2020

A systematic review and meta-analysis of postpartum contraceptive use among women in low- and middle-income countries.

Reprod Health 2019 Oct 29;16(1):154. Epub 2019 Oct 29.

Department of Global Health, University of Washington, Seattle, WA, USA.

Background: Short birth intervals increase risk for adverse maternal and infant outcomes including preterm birth, low birth weight (LBW), and infant mortality. Although postpartum family planning (PPFP) is an increasingly high priority for many countries, uptake and need for PPFP varies in low- and middle-income countries (LMIC). We performed a systematic review and meta-analysis to characterize postpartum contraceptive use, and predictors and barriers to use, among postpartum women in LMIC.

Methods: PubMed, EMBASE, CINAHL, PsycINFO, Scopus, Web of Science, and Global Health databases were searched for articles and abstracts published between January 1997 and May 2018. Studies with data on contraceptive uptake through 12 months postpartum in low- and middle-income countries were included. We used random-effects models to compute pooled estimates and confidence intervals of modern contraceptive prevalence rates (mCPR), fertility intentions (birth spacing and birth limiting), and unmet need for contraception in the postpartum period.

Results: Among 669 studies identified, 90 were selected for full-text review, and 35 met inclusion criteria. The majority of studies were from East Africa, West Africa, and South Asia/South East Asia. The overall pooled mCPR during the postpartum period across all regions was 41.2% (95% CI: 15.7-69.1%), with lower pooled mCPR in West Africa (36.3%; 95% CI: 27.0-45.5%). The pooled prevalence of unmet need was 48.5% (95% CI: 19.1-78.0%) across all regions, and highest in South Asia/South East Asia (59.4, 95% CI: 53.4-65.4%). Perceptions of low pregnancy risk due to breastfeeding and postpartum amenorrhea were commonly associated with lack of contraceptive use and use of male condoms, withdrawal, and abstinence. Women who were not using contraception were also less likely to utilize maternal and child health (MCH) services and reside in urban settings, and be more likely to have a fear of method side effects and receive inadequate FP counseling. In contrast, women who received FP counseling in antenatal and/or postnatal care were more likely to use PPFP.

Conclusions: PPFP use is low and unmet need for contraception following pregnancy in LMIC is high. Tailored counseling approaches may help overcome misconceptions and meet heterogeneous needs for PPFP.
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http://dx.doi.org/10.1186/s12978-019-0824-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6819406PMC
October 2019

Acceptability, feasibility and utility of a Mobile health family planning decision aid for postpartum women in Kenya.

Reprod Health 2019 Jul 8;16(1):97. Epub 2019 Jul 8.

Department of Global Health, University of Washington, Seattle, WA, USA.

Background: Unmet need for contraception is high during the postpartum period, increasing the risk of unintended subsequent pregnancy. We developed a client facing mobile phone-based family planning (FP) decision aid and assessed acceptability, feasibility, and utility of the tool among health care providers and postpartum women.

Methods: Semi-structured in-depth interviews (IDIs) were conducted among postpartum women (n = 25) and FP providers (n = 17) at 4 Kenyan maternal and child health clinics, 2 in the Nyanza region (Kisumu and Siaya Counties) and 2 in Nairobi. Stratified purposive sampling was used to enroll postpartum women and FP providers. Data were analyzed using an inductive content analysis approach by 3 independent coders, with consensual validation.

Results: FP providers stated that the Interactive Mobile Application for Contraceptive Choice (iMACC) tool contained the necessary information about contraceptive methods for postpartum women and believed that it would be a useful tool to help women make informed, voluntary decisions. Most women valued the decision aid content, and described it as being useful in helping to dispel myths and misconceptions, setting realistic expectations about potential side effects and maintaining confidentiality. Both women and providers expressed concerns about literacy and lack of familiarity with smart phones or tablets and suggested inclusion of interactive multimedia such as audio or videos to optimize the effectiveness of the tool.

Conclusions: The iMACC decision aid was perceived to be an acceptable tool to deliver client-centered FP counseling by both women and providers. Counseling tools that can support FP providers to help postpartum women make informed and individualized FP decisions in resource-limited settings may help improve FP counseling and contraceptive use in the postpartum period.
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http://dx.doi.org/10.1186/s12978-019-0767-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6615081PMC
July 2019

Health provider training is associated with improved engagement in HIV care among adolescents and young adults in Kenya.

AIDS 2019 07;33(9):1501-1510

Department of Global Health, University of Washington, Seattle, Washington, USA.

Objectives: Adolescents and young adults (AYA) have poorer retention, viral suppression, and survival than other age groups. We evaluated correlates of initial AYA engagement in HIV care at facilities participating in a randomized trial in Kenya.

Design: Retrospective cohort study.

Methods: Electronic medical records from AYA ages 10-24 attending 24 HIV care facilities in Kenya were abstracted. Facility surveys assessed provider trainings and services. HIV provider surveys assessed AYA training and work experience. Engagement in care was defined as return for first follow-up visit within 3 months among newly enrolled or recently re-engaged (returning after >3 months out of care) AYA. Multilevel regression estimated risk ratios and 95% confidence intervals (CIs), accounting for clustering by facility. Final models adjusted for AYA individual age and median AYA age and number enrolled per facility.

Results: Among 3662 AYA records at first eligible visit, most were female (75.1%), older (20-24 years: 54.5%), and on antiretroviral therapy (79.5%). Overall, 2639 AYA returned for care (72.1%) after enrollment or re-engagement visit. Engagement in care among AYA was significantly higher at facilities offering provider training in adolescent-friendly care (85.5 vs. 67.7%; adjusted risk ratio (aRR) 1.11, 95% CI: 1.01-1.22) and that used the Kenyan government's AYA care checklist (88.9 vs. 69.2%; aRR 1.14, 95% CI: 1.06-1.23). Engagement was also significantly higher at facilities where providers reported being trained in AYA HIV care (aRR 1.56, 95% CI: 1.13-2.16).

Conclusion: Adolescent-specific health provider training and tools may improve quality of care and subsequent AYA engagement. Health provider interventions are needed to achieve the '95-95-95' targets for AYA.
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http://dx.doi.org/10.1097/QAD.0000000000002217DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6746576PMC
July 2019

Pilot evaluation of a standardized patient actor training intervention to improve HIV care for adolescents and young adults in Kenya.

AIDS Care 2019 10 27;31(10):1250-1254. Epub 2019 Feb 27.

b Department of Global Health, University of Washington , Seattle , WA , USA.

Poor retention in HIV care remains a major problem for Adolescents and Young Adults (AYA). A Standardized Patient (SP) clinical training intervention was developed to improve healthcare worker (HCW) "adolescent-friendly" competencies in Kenya. Professional actors were trained to portray HIV-infected AYA according to standardized scripts. HCWs completed a 2-day SP training that included didactic sessions, 7 video-recorded SP encounters, and group debriefing. AYA health experts rated HCWs by reviewing the video recordings. All HCWs (10/10) reported high satisfaction with the intervention and overall improvement in self-rated competency in caring for HIV-infected AYA. Cases were reported to be realistic and relevant by between 7 and 10 of 10 HCWs. The case on disclosure and adherence was rated as most challenging in communication and making medical decisions by HCWs. Areas identified by SPs for improvement by HCWs included allowing patients time to ask questions, and enabling SP to share sensitive information. The overall ICC by experts was low 0.27 (95% CI: -0.79 to 0.95), however, ICCs in assessment of HIV disclosure 0.78 (95% CI: 0.17-0.98), and sexual behavior 0.97 (95% CI: 0.89-0.99) were high. This intervention was acceptable for Kenyan HCWs and improved self-rated competency in caring for HIV-infected AYA.
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http://dx.doi.org/10.1080/09540121.2019.1587361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6663595PMC
October 2019

Distance to HIV and Antenatal Care: A Geospatial Analysis in Siaya County, Kenya.

J Assoc Nurses AIDS Care 2019 Sep-Oct;30(5):548-555

As maternal child health (MCH) programs expand in the setting of HIV, health systems are challenged to reach those most vulnerable and at the greatest need. Cross-sectional surveys of MCH clinics and recent mothers in the Siaya Health Demographic Surveillance System were conducted to assess correlates of accessing antenatal care and facility delivery. Of 376 recent mothers, 93.4% accessed antenatal care and 41.2% accessed facility delivery. Per-kilometer distance between maternal residence and the nearest facility offering delivery services was associated with 7% decreased probability of uptake of facility delivery. Compared with a reference of less than 1 km between home and clinic, a distance of more than 3 km to the nearest facility was associated with 25% decreased probability of uptake of facility delivery. Distance to care was a factor in accessing facility delivery services. Decentralization or transportation considerations may be useful to optimize MCH and HIV service impact in high-prevalence regions.
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http://dx.doi.org/10.1097/JNC.0000000000000050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6675674PMC
September 2020

Influence and involvement of support people in adolescent and young adult HIV testing.

AIDS Care 2019 01 27;31(1):105-112. Epub 2018 Sep 27.

a Department of Epidemiology , University of Washington , Seattle , WA , USA.

HIV incidence and mortality are high among adolescents and young adults (AYA) in sub-Saharan Africa, but testing rates are low. Understanding how support people (SP), such as peers, partners, or parents, influence AYA may improve HIV testing uptake. AYA aged 14-24 seeking HIV testing at a referral hospital in Nairobi, Kenya completed a post-test survey assessing the role of SP. Among 1062 AYA, median age was 21. Overall, 12% reported their decision to test was influenced by a parent, 20% by a partner, and 22% by a peer. Young adults (20-24 years old) were more likely than adolescents (14-19 years old) to be influenced to test by partners (23% vs. 12%, p < .001), and less likely by parents (6.6% vs. 27%, p < .001), healthcare workers (11% vs. 16%, p < .05), or counselors (9.4% vs. 19%, p < .001). Half of AYA were accompanied for testing (9.9% with parent, 10% partner, 23% peer, 4.3% others, and 2.1% multiple types). Young adults were more likely than adolescents to present alone (58% vs. 32%, p < .001) or with a partner (12% vs. 6.7%, p < .05), and less likely with a parent (1.6% vs. 31%, p < .001). Similar proportions of adolescents and young adults came with a peer or in a group. Correlates of presenting with SP included: younger age (aRR = 1.55 [95%CI = 1.30-1.85]), female sex (aRR = 1.45 [95%CI = 1.21-1.73]), and school enrollment (aRR = 1.41 [95%CI = 1.05-1.88]). SP play an important role in AYAs' HIV testing and varies with age. Leveraging SP may promote uptake of HIV testing and subsequent linkage care for AYA.
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http://dx.doi.org/10.1080/09540121.2018.1524563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6261297PMC
January 2019

Simulated patient encounters to improve adolescent retention in HIV care in Kenya: study protocol of a stepped-wedge randomized controlled trial.

Trials 2017 Dec 28;18(1):619. Epub 2017 Dec 28.

Department of Global Health, University of Washington, 325 9th Avenue, Box 359932, Seattle, WA, 98104, USA.

Background: Adolescent-friendly policies aim to tailor HIV services for adolescents and young adults aged 10-24 years (AYA) to promote health outcomes and improve retention in HIV care and treatment. However, few interventions focus on improving healthcare worker (HCW) competencies and skills for provision of high-quality adolescent care. Standardized patients (SPs) are trained actors who work with HCWs in mock clinical encounters to improve clinical assessment, communication, and empathy skills. This stepped-wedge randomized controlled trial will evaluate a clinical training intervention utilizing SPs to improve HCW skills in caring for HIV-positive AYA, resulting in increased retention in care.

Methods/design: The trial will utilize a stepped-wedge design to evaluate a training intervention using SPs to train HCWs in assessment, communication, and empathy skills for AYA HIV care. We will recruit 24 clinics in Kenya with an active electronic medical record (EMR) system and at least 40 adolescents enrolled in HIV care per site. Stratified randomization by county will be used to assign clinics to one of four waves - time periods when they receive the intervention - with each wave including six clinics. From each clinic, up to 10 HCWs will participate in the training intervention. SP training includes didactic sessions in adolescent health, current guidelines, communication skills, and motivational interviewing techniques. HCW participants will rotate through seven standardized SP scenarios, followed by SP feedback, group debriefing, and remote expert evaluation. AYA outcomes will be assessed using routine clinic data. The primary outcome is AYA retention in HIV care, defined as returning for first follow-up visit within 6 months of presenting to care, or returning for a first follow-up visit after re-engagement in care in AYA with a previous history of being lost to follow-up. Secondary outcomes include HCW competency scores, AYA satisfaction with care, and AYA clinical outcomes including CD4 and viral load. Additional analyses will determine cost-effectiveness of the intervention.

Discussion: This trial will contribute valuable information to HIV programs in Kenya and other low-resource settings, providing a potentially scalable strategy to improve quality of care and retention in critical HIV services in this population.

Trial Registration: ClinicalTrials.gov, ID: NCT02928900. Registered 26 August 2016.
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http://dx.doi.org/10.1186/s13063-017-2266-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5745919PMC
December 2017

Continuous quality improvement intervention for adolescent and young adult HIV testing services in Kenya improves HIV knowledge.

AIDS 2017 07;31 Suppl 3:S243-S252

aDepartment of Global Health, University of Washington, Seattle, Washington, USA bDepartment of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya cInternational Training and Education Center for Health, University of Washington, Seattle, Washington, USA dVCT and HIV Prevention Unit/Youth Centre, Kenyatta National Hospital, Nairobi, Kenya eSchool of Medicine fDepartment of Epidemiology, University of Washington, Seattle, Washington, USA gResearch and Programs, Kenyatta National Hospital, Nairobi, Kenya hDepartment of Psychosocial and Community Health iDepartment of Pediatrics, University of Washington, Seattle, Washington, USA.

Objectives: To determine whether continuous quality improvement (CQI) improves quality of HIV testing services for adolescents and young adults (AYA).

Design: CQI was introduced at two HIV testing settings: Youth Centre and Voluntary Counseling and Testing (VCT) Center, at a national referral hospital in Nairobi, Kenya.

Methods: Primary outcomes were AYA satisfaction with HIV testing services, intent to return, and accurate HIV prevention and transmission knowledge. Healthcare worker (HCW) satisfaction assessed staff morale. T tests and interrupted time series analysis using Prais-Winsten regression and generalized estimating equations accounting for temporal trends and autocorrelation were conducted.

Results: There were 172 AYA (Youth Centre = 109, VCT = 63) during 6 baseline weeks and 702 (Youth Centre = 454, VCT = 248) during 24 intervention weeks. CQI was associated with an immediate increase in the proportion of AYA with accurate knowledge of HIV transmission at Youth Centre: 18 vs. 63% [adjusted risk difference (aRD) 0.42,95% confidence interval (CI) 0.21 to 0.63], and a trend at VCT: 38 vs. 72% (aRD 0.30, 95% CI -0.04 to 0.63). CQI was associated with an increase in the proportion of AYA with accurate HIV prevention knowledge in VCT: 46 vs. 61% (aRD 0.39, 95% CI 0.02-0.76), but not Youth Centre (P = 0.759). In VCT, CQI showed a trend towards increased intent to retest (4.0 vs. 4.3; aRD 0.78, 95% CI -0.11 to 1.67), but not at Youth Centre (P = 0.19). CQI was not associated with changes in AYA satisfaction, which was high during baseline and intervention at both clinics (P = 0.384, P = 0.755). HCW satisfaction remained high during intervention and baseline (P = 0.746).

Conclusion: CQI improved AYA knowledge and did not negatively impact HCW satisfaction. Quality improvement interventions may be useful to improve adolescent-friendly service delivery.
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http://dx.doi.org/10.1097/QAD.0000000000001531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5497779PMC
July 2017

"At our age, we would like to do things the way we want: " a qualitative study of adolescent HIV testing services in Kenya.

AIDS 2017 07;31 Suppl 3:S213-S220

aDepartment of Global Health, University of Washington, Seattle, Washington, USA bDepartment of Paediatrics and Child Health, University of Nairobi cVCT and HIV Prevention Unit/Youth Centre, Kenyatta National Hospital, Nairobi, Kenya dDepartment of Medicine eDepartment of Epidemiology fDepartment of Pediatrics gDepartment of Psychosocial and Community Health, University of Washington, Seattle, Washington, USA.

Objectives: Adolescents in Africa have low HIV testing rates. Better understanding of adolescent, provider, and caregiver experiences in high-burden countries such as Kenya could improve adolescent HIV testing programs.

Design: We conducted 16 qualitative interviews with HIV-positive and HIV-negative adolescents (13-18 years) and six focus group discussions with Healthcare workers (HCWs) and caregivers of adolescents in Nairobi, Kenya.

Methods: Semi-structured interviews and focus groups were recorded and transcribed. Analysis employed a modified constant comparative approach to triangulate findings and identify themes influencing testing experiences and practices.

Results: All groups identified that supportive interactions during testing were essential to the adolescent's positive testing experience. HCWs were a primary source of support during testing. HCWs who acted respectful and informed helped adolescents accept results, link to care, or return for repeat testing, whereas HCWs who acted dismissive or judgmental discouraged adolescent testing. Caregivers universally supported adolescent testing, including testing with the adolescent to demonstrate support. Caregivers relied on HCWs to inform and encourage adolescents. Although peers played less significant roles during testing, all groups agreed that school-based outreach could increase peer demand and counteract stigma. All groups recognized tensions around adolescent autonomy in the absence of clear consent guidelines. Adolescents valued support people during testing but wanted autonomy over testing and disclosure decisions. HCWs felt pressured to defer consent to caregivers. Caregivers wanted to know results regardless of adolescents' wishes.

Conclusion: Findings indicate that strengthening HCW, caregiver, and peer capacities to support adolescents while respecting their autonomy may facilitate attaining '90-90-90' targets for adolescents.
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http://dx.doi.org/10.1097/QAD.0000000000001513DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5497781PMC
July 2017

A national evaluation using standardised patient actors to assess STI services in public sector clinical sentinel surveillance facilities in South Africa.

Sex Transm Infect 2017 Jun 27;93(4):247-252. Epub 2017 Jan 27.

Department of Global Health, University of Washington, Seattle, Washington, USA.

Objectives: Quality concerns in STI service delivery and missed opportunities for integration with HIV testing and prevention services in South Africa have been well documented. This national evaluation aimed to evaluate current utilisation and adherence to national STI guidelines, including partner notification and integration with HIV services, for diagnosis and management of STIs.

Methods: Facility surveys assessed infrastructure and resource availability, and standardised patient (SP) assessments evaluated quality of STI care in 50 public clinics in nine provinces in South Africa. The primary outcome was the proportion of SPs receiving essential STI care, defined as: offered an HIV test, condoms, partner notification counselling and correct syndromic treatment. Weighted proportions were generated, and SP findings were compared by gender using χ tests with Rao-Scott correction.

Results: More than 80% of facilities reported medications in stock, with the exceptions of oral cefixime (48.3%), oral erythromycin (75.1%) and paediatric syrups. Among 195 SP encounters, 18.7% (95% CI 10.7% to 30.5%) received all hypothesised essential STI services: offered HIV test (67.1%), offered condoms (31.4%), partner notification counselling (70.2%) and recommended syndromic treatment (60.7%). Men were more likely than women to be offered all services (25.1% vs 12.3%, p=0.023), recommended treatment (70.7% vs 50.9%, p=0.013) and partner notification counselling (79.9% vs 60.6%, p=0.020). Only 6.3% of providers discussed male circumcision with male SPs, and 26.3% discussed family planning with female SPs.

Conclusions: This evaluation of STI services across South Africa found gaps in the availability of medications, adherence to STI guidelines, condom provision and prevention messaging. Limited integration with HIV services for this high-risk population was a missed opportunity. Quality of STI care should continue to be monitored, and interventions to improve quality should be prioritised as part of national strategic HIV and primary healthcare agendas.
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http://dx.doi.org/10.1136/sextrans-2016-052930DOI Listing
June 2017

A Risk Assessment Tool for Identifying Pregnant and Postpartum Women Who May Benefit From Preexposure Prophylaxis.

Clin Infect Dis 2017 03;64(6):751-758

Department of Global Health, University of Washington, Seattle, USA.

Background: A human immunodeficiency virus (HIV) risk assessment tool for pregnant women could identify women who would most benefit from preexposure prophylaxis (PrEP) while minimizing unnecessary PrEP exposure.

Methods: Data from a prospective study of incident HIV among pregnant/postpartum women in Kenya were randomly divided into derivation (n = 654) and validation (n = 650) cohorts. A risk score was derived using multivariate Cox proportional hazards models and standard clinical prediction rules. Ability of the tool to predict maternal HIV acquisition was assessed using the area under the curve (AUC) and Brier score.

Results: The final risk score included the following predictors: having a male partner with unknown HIV status, number of lifetime sexual partners, syphilis, bacterial vaginosis (BV), and vaginal candidiasis. In the derivation cohort, AUC was 0.84 (95% confidence interval [CI], .72-.95) and each point increment in score was associated with a 52% (hazard ratio [HR], 1.52 [95% CI, 1.32-1.76]; P < .001) increase in HIV risk; the Brier score was 0.11. In the validation cohort, the score had similar AUC, Brier score, and estimated HRs. A simplified score that excluded BV and candidiasis yielded an AUC of 0.76 (95% CI, .67-.85); HIV incidence was higher among women with risk scores >6 than with scores ≤6 (7.3 vs 1.1 per 100 person-years, respectively; P < .001). Women with simplified scores >6 accounted for 16% of the population but 56% of HIV acquisitions.

Conclusions: A combination of indicators routinely assessed in antenatal clinics was predictive of HIV risk and could be used to prioritize pregnant women for PrEP.
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http://dx.doi.org/10.1093/cid/ciw850DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6075205PMC
March 2017

Systems Mapping of Sexually Transmitted Infection Services at Three Clinical Sentinel Surveillance Sites in South Africa: Opportunities for Integrated Care.

J Assoc Nurses AIDS Care 2017 Jan - Feb;28(1):154-164. Epub 2016 Sep 17.

Sexually transmitted infection (STI) service delivery in the context of integrated care and the South African HIV epidemic is complex. We aimed to document STI care and HIV testing processes in public health clinics in South Africa, revealing bottlenecks to patient flow and identifying opportunities for improvement. Clinic mapping, with semi-structured interviews and clinic observation, was conducted with facility representatives at three clinical sentinel surveillance sites. Facility surveys assessed patient volume and staffing. Identified challenges were associated with staffing allocations, and disruptions in patient flow resulted from poor clinic layout, inadequate lighting, and limited allocation of space for HIV testing and physical examination. Recommendations include staffing adjustments, reorganization of space to allow for designated service and waiting areas, sufficient supplies, and improved lighting. The facility reorganization component of South Africa's Ideal Clinic initiative provides a key opportunity for enacting many of these recommendations.
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http://dx.doi.org/10.1016/j.jana.2016.09.004DOI Listing
January 2018

Safety, Feasibility, and Acceptability of the PrePex Device for Adult Male Circumcision in Malawi.

J Acquir Immune Defic Syndr 2016 Jun;72 Suppl 1:S49-55

*Department of Global Health, University of Washington, Seattle, WA; †Department of Psychosocial and Community Health, University of Washington, Seattle, WA; ‡Health Services, US Centers for Disease Control and Prevention, Lilongwe, Malawi; §Banja La Mtsogolo, Blantyre, Malawi; ‖Médecin Sans Frontières, Nsanje, Malawi; ¶International Training and Education Center for Health, Lilongwe, Malawi; #Malawi Ministry of Health, Lilongwe, Malawi; **US Centers for Disease Control and Prevention, Atlanta, Georgia; and ††Jhpiego, An affiliate of Johns Hopkins University, Washington, DC.

Introduction: Nonsurgical adult male circumcision devices present an alternative to surgery where health resources are limited. This study aimed to assess the safety, feasibility, and acceptability of the PrePex device for adult male circumcision in Malawi.

Methods: A prospective single-arm cohort study was conducted at 3 sites (1 urban static, 1 rural static, 1 rural tent) in Malawi. Adverse event (AE) outcomes were stratified to include/exclude pain, and confidence intervals (CIs) were corrected for clinic-level clustering.

Results: Among 935 men screened, 131 (14.0%) were not eligible, 13 (1.4%) withdrew before placement, and 791 (84.6%) received the device. Moderate and severe AEs totaled 7.1% including pain [95% CI: 3.4-14.7] and 4.0% excluding pain (95% CI: 2.6 to 6.4). Severe AEs included pain (n = 3), insufficient skin removal (n = 4), and early removal (n = 4). Among early removals, 1 had immediate surgical circumcision, 1 had surgery after 48 hours of observation, 1 declined surgery, and 1 did not return to our site although presented at a nearby clinic. More than half of men (51.9%) reported odor; however, few (2.2%) stated they would not recommend the device to others because of odor. Median levels of reported pain (scale, 1-10) were 2 (interquartile range, 2-4) during application and removal, and 0 (interquartile range, 0-2) at all other time points.

Conclusions: Severe AEs were rare and similar to other programs. Immediate provision of surgical services after displacement or early removal proved a challenge. Cases of insufficient skin removal were linked to poor technique, suggesting provider training requires reinforcement and supervision.
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http://dx.doi.org/10.1097/QAI.0000000000000774DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4936431PMC
June 2016
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