A youth-centred approach to improving engagement in HIV services: Human-centred design methods and outcomes in a research trial in Kisumu County, Kenya

UNLABELLED: IntroductionInnovative interventions are needed to improve HIV outcomes among adolescents and young adults (AYAs) living with HIV. Engaging AYAs in intervention development could increase effectiveness and youth acceptance, yet research is limited. We applied human-centred design (HCD) to refine adherence-support interventions pretrial and assessed HCD workshop acceptability. METHODS: We applied an iterative, four-phased HCD process in Kenya that included: (1) systematic review of extant knowledge, (2) prioritisation of design challenges, (3) a co-creation workshop and (4) translation tables to pair insights with trial intervention adaptations. The co-creation workshop was co-led by youth facilitators employing participatory activities to inform intervention adaptations. Iterative data analysis included rapid thematic analysis of visualised workshop outputs and notes using affinity mapping and dialogue to identify key themes. We conducted a survey to assess workshop acceptability among participants. RESULTS: Twenty-two participants engaged in the 4-day workshop. Co-creation activities yielded recommendations for improving planned interventions (eg, message frequency and content; strategies to engage hard-to-reach participants), critical principles to employ across interventions (eg, personalisation, AYA empowerment) and identification of unanticipated AYA HIV treatment priorities (eg, drug holidays, transition from adolescent to adult services). We revised intervention content, peer navigator training materials and study inclusion criteria in response to findings. The youth-led HCD workshop was highly acceptable to participants. CONCLUSIONS: Research employing HCD among youth can improve interventions preimplementation through empathy, youth-led inquiry and real-time problem solving. Peer navigation may be most influential in improving retention when engagement with young people is based on mutual trust, respect, privacy and extends beyond HIV-specific support. Identifying opportunities for personalisation and adaptation within intervention delivery is important for AYAs. Patient engagement interventions that target young people should prioritise improved transition between youth and adult services, youth HIV status disclosure, AYA empowerment and healthcare worker responsiveness in interactions and episodic adherence interruptions

Adolescent and young adult preferences for financial incentives to support adherence to antiretroviral therapy in Kenya: A mixed methods study

INTRODUCTION: To develop a patient-centred financial incentive delivery strategy to improve antiretroviral treatment adherence in adolescents and young adults (AYA) living with HIV in Kisumu, Kenya, we conducted a mixed methods study exploring preferences. METHODS: A discrete choice experiment (DCE) and focus group discussion (FGD) were conducted simultaneously to identify preferences for five incentive delivery strategy features: value, eligibility, recipient, format and disbursement frequency. We used consecutive sampling to recruit AYA (14-24 years) living with HIV attending three health facilities in Kisumu, Kenya. We calculated mean preferences, willingness to trade, latent class membership and predictors of latent class membership. The FGD explored preferred incentive features, and, after deductive and inductive coding, qualitative findings were triangulated with DCE results. RESULTS: Two hundred and seven AYA living with HIV (46% 14-17 years, 54% 18-24 years; 33% male sex, 89% viral load \u3c50 copies/ml) were recruited to the study (28 October-16 November 2020). Two distinct preference phenotypes emerged from the DCE analysis (N = 199), 44.8% of the population fell into an immediate reward group, who wanted higher value cash or mobile money distributed at each clinic visit, and 55.2% fell into a moderate spender group, who were willing to accept lower value incentives in the form of cash or shopping vouchers, and accrued payments. The immediate reward group were willing to trade up to 200 Kenyan Shillings (KSH)-approximately 2 US dollars (USD)-of their 500 KSH (∼5 USD) incentive to get monthly as opposed to accrued yearly payments. The strongest predictor of latent class membership was age (RR 1.45; 95% CI: 1.08-1.95; p = 0.006). Qualitative data highlighted the unique needs of those attending boarding school and confirmed an overwhelming preference for cash incentives which appeared to provide the greatest versatility for use. CONCLUSIONS: Providing small financial incentives as cash was well-aligned with AYA preferences in this setting. AYA should additionally be offered a choice of other incentive delivery features (such as mobile money, recipient and disbursement frequency) to optimally align with the specific needs of their age group and life stage

Effect of pregnancy gestation on food insecurity in HIV-positive women from Kisumu and Migori Counties in Western Kenya

Thesis (Master's)--University of Washington, 2018Background: Food insecurity has been associated with adverse health outcomes among vulnerable populations including women, children, and persons infected with HIV. Little is known about the relationship between pregnancy and food insecurity among HIV-positive women. Methods: A cross-sectional analysis of data from HIV-infected women in Migori and Kisumu Counties in western Kenya was performed using univariate and multivariate linear regression to examine the association between pregnancy, modeled as gestational age (0->40 weeks), and food insecurity based on the Household Food Insecurity Access Scale (HFIAS). A subgroup analysis restricted to the pregnant women only was performed to examine this association. Results: A total of 1034 HIV-positive women were included in this study, of whom 106 (10.3%) were pregnant, and 928 (89.8%) were not pregnant at enrollment. Participants ranged in age from 18-49 years, with a median age of 30 years (inter-quartile range [IQR] 25-35) for non-pregnant women and 26 years (IQR 23-29) for pregnant women. The median gestational age among 106 pregnant women was 19 (IQR 13-27) weeks. Among all women, 227/1034 (23%) did not experience any food insecurity. The median food insecurity score was 6 for non-pregnant (IQR 2-12) and 6 for pregnant women (IQR 0-12). In unadjusted analysis, there was a weak negative association between gestational age and HFIAS score (β=-0.048, 95% confidence interval [CI] -0.096, 0.000, p=0.049) which was of borderline statistical significance This association was no longer present after adjusting for age, marital status, education, and CD4 count in (β=-0.016, 95% CI -0.064, 0.035, p=0.504). A number of covariates were significantly associated with HFIAS scores. These included age (β=0.131, 95%, CI, 0.089, 0.0175, p<0.001 , being married (β=-0.742, 95%, CI,-1.400,-0.085, p=0.027), and having secondary (β=-1.722, 95% CI -2.434,-1.010, p<0.001 or college/university (β=-3.833, 95% CI -5133,-2.533, p<0.001 education compared to primary education or less. Conclusions: In this population of HIV-positive women, there was no association between advancing gestational age and food insecurity Younger age, higher education, and being married were associated with less food insecurity, suggesting that social, cultural, and economic factors may be drivers of food insecurity in HIV-positive women

Google matrix

The Google matrix G of a directed network is a stochastic square matrix with nonnegative matrix elements and the sum of elements in each column being equal to unity. This matrix describes a Markov chain (Markov, 1906-a) of transitions of a random surfer performing jumps on a network of nodes connected by directed links. The network is characterized by an adjacency matrix Aij with elements Aij=1 if node j points to node i and zero otherwise. The matrix of Markov transitions Sij is constructed from the adjacency matrix Aij by normalization of the sum of column elements to unity and replacing columns with only zero elements (dangling nodes) with equal elements 1/N where N is the matrix size (number of nodes). Then the elements of the Google matrix are defined as Gij=αSij+(1−α)/NFil: Ermann, Leonardo. Comisión Nacional de Energía Atómica. Centro Atómico Constituyentes. Gerencia de Investigación y Aplicaciones; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Frahm, Klaus. Universitá Paul Sabatier; FranciaFil: Shepelyansky, Dima. Universitá Paul Sabatier; Franci

Text messaging for maternal and infant retention in prevention of mother-to-child HIV transmission services: A pragmatic stepped-wedge cluster-randomized trial in Kenya.

BackgroundTimely diagnosis of infant HIV infection is essential for antiretroviral therapy (ART) initiation. In a randomized controlled trial, we found the Texting Improves Testing (TextIT) intervention (a theory-based text messaging system) to be efficacious for improving infant HIV testing rates and maternal retention in prevention of mother-to-child HIV transmission (PMTCT) programs. Using an implementation science approach, we aimed to evaluate real-world effectiveness of the intervention.Methods and findingsIn a pragmatic, cluster-randomized, stepped-wedge trial with 2 time periods of observation, we randomly allocated 10 clinics to begin implementing the intervention immediately and 10 clinics to begin implementing 6 months later. To approximate real-world conditions, inclusion criteria were broad. Women at clinics implementing the intervention received up to 14 text messages during pregnancy and after delivery and had the option to respond to text messages, call, or send inquiry text messages to a designated clinic phone. The primary outcomes were infant HIV testing and maternal retention in care during the first 8 weeks after delivery. We used modified Poisson regression with robust variance estimation to estimate the relative risk and 95% confidence intervals (CIs). Generalized estimating equations were applied on individual-level data to account for clustering by site. Between February 2015 and December 2016, 4,681 women were assessed for study participation, and 2,515 were included. Participant characteristics at enrollment did not differ by study arm. Overall median age was 27 years (interquartile range [IQR] 23-30), median gestational age was 30 weeks (IQR 28-34), 99% were receiving ART, and 87% who enrolled during intervention phases owned a phone. Of 2,326 infants analyzed, 1,466 of 1,613 (90.9%) in the intervention group and 609 of 713 (85.4%) in the control group met the primary outcome of HIV virologic testing performed before 8 weeks after birth (adjusted relative risk [aRR] 1.03; 95% CI 0.97-1.10; P = 0.3). Of 2,472 women analyzed, 1,548 of 1,725 (90%) in the intervention group and 571 of 747 (76%) in the control group met the primary outcome of retention in care during the first 8 weeks after delivery (aRR 1.12; 95% CI 0.97-1.30; P = 0.1). This study had two main limitations. Staff at all facilities were aware of ongoing observation, which may have contributed to increased rates of infant HIV testing and maternal retention in care at both intervention and control facilities, and programmatic initiatives to improve maternal and infant retention in care were ongoing at all facilities at the time of this study, which likely limited the ability to demonstrate effectiveness of the trial intervention.ConclusionsIn this study, a larger proportion of infants in the intervention group received HIV testing compared with the control group, but the difference was small and not statistically significant. There was also a nonsignificant increase in maternal postpartum retention in the intervention periods. Despite the lack of a significant effect of the intervention, key lessons emerged, both for strengthening PMTCT and for implementation research in general. Perhaps most important, improving the implementation of usual care may have been sufficient to substantially improve infant HIV testing rates.Trial registrationClinicalTrials.gov Trial Number NCT02350140