Risk‐based versus universal PrEP delivery during pregnancy: a cluster randomized trial in Western Kenya from 2018 to 2019

Abstract Introduction Integrating pre‐exposure prophylaxis (PrEP) delivery for pregnant and postpartum women within maternal and child health (MCH) clinics is feasible and acceptable. It is unknown whether a risk‐guided model would facilitate appropriate PrEP use among MCH attendees better than universally offering PrEP. Methods The PrEP Implementation for Mothers in Antenatal Care (PrIMA) study was a cluster randomized trial to assess two models for PrEP delivery among pregnant women seeking routine MCH care at 20 public clinics in Kenya between January 2018 and July 2019 (NCT03070600). In the Universal arm, all participants received PrEP counselling and self‐selected whether to initiate PrEP. In the Targeted arm, participants underwent an HIV risk assessment, including an objective risk‐scoring tool and an offer of HIV self‐tests for at‐home partner testing; those determined to be at high risk received a PrEP offer. Participants were followed through 9 months postpartum. Primary outcomes included incident HIV and appropriate PrEP use (defined as PrEP uptake among those at high risk and no PrEP uptake for those not at risk). Outcomes were compared using intention‐to‐treat analyses, adjusting for baseline HIV risk and marital status. Results Among 4447 women enrolled, the median age was 24.0 years (interquartile range [IQR]: 20.9, 28.3), and most were married (84.8%). The median gestational age at enrolment was 24 weeks (IQR: 20, 30). Women in the Targeted arm were more likely to be at high risk for HIV acquisition at baseline (51.6% vs. 33.3%). During 4638 person‐years (p‐yr) of follow‐up, there were 16 maternal HIV infections with no difference in maternal HIV incidence between arms: 0.31/100 p‐yr (95% CI: 0.15, 0.65) Targeted and 0.38/100p‐yr (95% CI: 0.20, 0.73) Universal (adjusted relative risk [aRR]: 0.85 [CI: 0.28, 2.55]). There was no significant difference in the frequency of appropriate PrEP use between the arms (68.2% vs. 59.1% in Targeted vs. Universal, respectively) (aRR: 1.03 [CI: 0.96, 1.10]). Conclusions Given comparable maternal HIV incidence and PrEP uptake in Universal and Targeted approaches, and the simplicity that universal PrEP offers, our findings suggest that universal PrEP counselling is optimal for integrating PrEP in MCH systems

Legacies of empire: state violence and collective punishment in Kenya's North Eastern Province, c. 1963-present

This article reflects on the dual historical evolution of the use of state violence and collective punishment in Kenya, with particular reference to the Somali inhabited North Eastern Province. The use of collective punishment began under British rule as a strategy designed to control its African population, and was central to British counterinsurgency during the 1950s Mau Mau Emergency. This system of government was then entrenched and expanded by the postcolonial elite as a means of dealing with a population that was perceived to be hostile to the interests of the state. The article provides evidence of both colonial continuities and discontinuities with regard to population control methods

Legacies of empire: state violence and collective punishment in Kenya's North Eastern Province, c. 1963-present

This article reflects on the dual historical evolution of the use of state violence and collective punishment in Kenya, with particular reference to the Somali inhabited North Eastern Province. The use of collective punishment began under British rule as a strategy designed to control its African population, and was central to British counterinsurgency during the 1950s Mau Mau Emergency. This system of government was then entrenched and expanded by the postcolonial elite as a means of dealing with a population that was perceived to be hostile to the interests of the state. The article provides evidence of both colonial continuities and discontinuities with regard to population control methods

Também somos paisagem : um estudo antropológico sobre o engajamento humano na natureza e a educação ambiental no Parque Estadual de Itapuã.

Este trabalho realiza um estudo no Parque Estadual de Itapuã, unidade de conservação localizada em Viamão/RS. Nesse universo, busca observar as experiências de interação humana com a natureza e como elas possibilitam as mudanças comportamentais idealizadas pelo discurso ecológico. Considera também o surgimento de novas sensibilidades em relação ao meio ambiente instigadas tanto pelas atividades de educação ambiental promovidas pelo parque quanto pelas atividades de lazer. Traz na sua base teórica a idéia de pertencimento humano à paisagem como geradora de percepções que regem a transformação da noção de uso da natureza para uma concepção mais holística da realidade.This report is a study on Parque Estadual de Itapuã, a conservation unit in Viamão /RS. In this place, this report observes the experiences of interaction among human beings and nature and how they make possible the behavioral changes idealized by the ecological thoughts. It also brings new sensibilities related to the environment which are instigated either for environmental education activities offered in the park or for entertainment activities. The theorical basis is the idea that the human being belongs to landscape, this idea generates the perceptions that rule the transformation of the idea of the use of the nature in an holistic conception

The politics of control in Kenya : understanding the bureaucratic-executive state, 1952–78

Colonial rule in Kenya witnessed the emergence of a profoundly unbalanced institutional landscape. With all capacity resided in a strong prefectural provincial administration, political parties remained underdeveloped. The co-option of sympathetic African elites during the colonial twilight into the bureaucracy, the legislature and the private property-based economy meant that the allies of colonialism and representatives of transnational capital were able to reap the benefits of independence. In the late colonial period these elites not only attained the means of production, they also assumed the political and institutional capacity to reproduce their dominance. The post-colonial state must therefore be seen as a representation of the interests protected and promoted during the latter years of colonial rule. Under Jomo Kenyatta, the post-colonial state represented a ‘pact-of-domination’ between transnational capital, the elite and the executive. The ability of this coalition to reproduce itself over time lay in its capacity to demobilise popular forces, especially those elements of the nationalist movement that questioned both the social and economic cleavages of the post-colonial state. Whilst Kenya may have experienced changes to both the executive and legislature, the structure of the state itself has demonstrated remarkable continuity