Empowering peer outreach workers in an HIV prevention and care program for Kenyan gay, bisexual, and other men who have sex with men: challenges and opportunities in the Anza Mapema Study

Gay, bisexual, and other men who have sex with men (MSM) are at high risk for human immunodeficiency virus (HIV) infection. In rights-constrained settings with pervasive stigma, peer outreach workers play a key role in recruitment and retention of MSM in HIV research, prevention, and treatment programs. We explored factors affecting the empowerment of peers in an HIV prevention and care study for MSM in Kisumu, Kenya, with the goal of improving program services and supporting good participatory practice. The Anza Mapema study, conducted from 8/2015-10/2017, aimed to enroll 700 MSM in a comprehensive package of find, test, link and retain in HIV prevention and care interventions, with quarterly follow-up over 12 months. Seventeen mostly heterosexual salaried staff implemented the clinical and research components of the study, while 13 gay and bisexual peers facilitated recruitment, retention, and participant education, supported by a monthly stipend. A community advisory board provided feedback on program methods and performance. In-depth interviews with peers and staff at two timepoints were used to obtain feedback and make program improvements. Thematic analysis was conducted, and results were presented to peers and staff for discussion and triangulation. Despite mutual appreciation of peers’ contributions to the project, peers and staff had different goals and vision for Anza Mapema. While staff focused on implementing the study protocol, peers envisioned broader programming including community-building activities, advocacy, mental health and substance use services, and economic empowerment. From the outset, power disparities and power struggles between peers and staff favored the staff, as peers were younger, less educated, and had lower compensation for their time. While peers appreciated the opportunity to help their community and the free health services provided by the project, they voiced concerns about stigmatizing attitudes from some staff, insufficient training, exclusion from decision-making, minimal representation on the study team, and lack of opportunities for advancement. Staff were supportive of peer’s requests but felt constrained by limited funding and rigid study timelines. Peers’ concerns were addressed at least in part through monthly team meetings with program leadership, weekly meetings with outreach coordinators, additional training, the promotion of one peer to a salaried position, and the development of community-building activities and a support group for participants who struggled with alcohol and drugs. Integration of gay and bisexual peers into HIV research and programming is critical in rights-constrained settings but challenged by disparities in power between peers and staff. Empowerment of peers is an important component of good participatory practice, and requires attention to training, inclusion in decision-making, opportunities for advancement, and support for community-building. Future studies that rely on peers for participant recruitment and retention should address these issues and make peer empowerment an overt component of the program.&nbsp

Empowering peer outreach workers in an HIV prevention and care program for Kenyan gay, bisexual, and other men who have sex with men: challenges and opportunities in the Anza Mapema Study

Gay, bisexual, and other men who have sex with men (MSM) are at high risk for human immunodeficiency virus (HIV) infection. In rights-constrained settings with pervasive stigma, peer outreach workers play a key role in recruitment and retention of MSM in HIV research, prevention, and treatment programs. We explored factors affecting the empowerment of peers in an HIV prevention and care study for MSM in Kisumu, Kenya, with the goal of improving program services and supporting good participatory practice. The Anza Mapema study, conducted from 8/2015-10/2017, aimed to enroll 700 MSM in a comprehensive package of find, test, link and retain in HIV prevention and care interventions, with quarterly follow-up over 12 months. Seventeen mostly heterosexual salaried staff implemented the clinical and research components of the study, while 13 gay and bisexual peers facilitated recruitment, retention, and participant education, supported by a monthly stipend. A community advisory board provided feedback on program methods and performance. In-depth interviews with peers and staff at two timepoints were used to obtain feedback and make program improvements. Thematic analysis was conducted, and results were presented to peers and staff for discussion and triangulation. Despite mutual appreciation of peers’ contributions to the project, peers and staff had different goals and vision for Anza Mapema. While staff focused on implementing the study protocol, peers envisioned broader programming including community-building activities, advocacy, mental health and substance use services, and economic empowerment. From the outset, power disparities and power struggles between peers and staff favored the staff, as peers were younger, less educated, and had lower compensation for their time. While peers appreciated the opportunity to help their community and the free health services provided by the project, they voiced concerns about stigmatizing attitudes from some staff, insufficient training, exclusion from decision-making, minimal representation on the study team, and lack of opportunities for advancement. Staff were supportive of peer’s requests but felt constrained by limited funding and rigid study timelines. Peers’ concerns were addressed at least in part through monthly team meetings with program leadership, weekly meetings with outreach coordinators, additional training, the promotion of one peer to a salaried position, and the development of community-building activities and a support group for participants who struggled with alcohol and drugs. Integration of gay and bisexual peers into HIV research and programming is critical in rights-constrained settings but challenged by disparities in power between peers and staff. Empowerment of peers is an important component of good participatory practice, and requires attention to training, inclusion in decision-making, opportunities for advancement, and support for community-building. Future studies that rely on peers for participant recruitment and retention should address these issues and make peer empowerment an overt component of the program.&nbsp

Determinants of insulin-related knowledge among healthcare providers at a county referral hospital in Kenya

Background: Insulin is a high alert medication with potential to cause hypoglycaemia if used incorrectly. Inadequate healthcare provider knowledge regarding insulin contributes to errors in its use that may cause patient harm. Objective: To identify the determinants of healthcare provider knowledge regarding insulin use in type 2 diabetes. Methodology: A cross-sectional study was conducted at Thika Level V Hospital in March 2015. A 20-item questionnaire was used to assess insulin knowledge in pharmaceutical, nursing and medical staff working in the outpatient department and the medical wards. The outcomes of interest were the scores on types, prescribing, administration and monitoring of insulin. Descriptive and regression data analyses were performed using IBM SPSS Statistics Version 20. Results: The participants’ mean (±SD) age was 32.6±10.2 years. The mean (±SD) duration of clinical practice was 8.3±9.03 years. Nurses formed the largest (36, 40%) cadre in the study. Determinants of the overall score in the insulin knowledge test were professional cadre (p<0.0001), in-patient care (p=0.044) and reading of journals (p=0.005). Insulin pharmacology scores were correlated with younger age (21-30 years, (p=0.02), clinical experience of <5 years, (p=0.013), use of information from drug representatives (p=0.023) and being a pharmacist intern or medical officer (p=0.002). Good prescribing scores were found among the medical officers, consultants and the clinical pharmacist (p=0.035). Conclusion: Several factors account for the differences in insulin-related knowledge among the healthcare providers evaluated in this study. Interventions are required to address these variations and equip the health workers with knowledge on all areas related to insulin use. Such interventions should include development of a curriculum on certified diabetes education, improved access to journals, collaboration with pharmaceutical companies in provision of drug-related information, continuing medical education and staff duty rotation to ensure that the healthcare providers gain experience in in-patient diabetes care. Keywords: diabetes, healthcare provider, insulin-related knowledg

Building capacity in implementation science research training at the University of Nairobi.

BACKGROUND: Health care systems in sub-Saharan Africa, and globally, grapple with the problem of closing the gap between evidence-based health interventions and actual practice in health service settings. It is essential for health care systems, especially in low-resource settings, to increase capacity to implement evidence-based practices, by training professionals in implementation science. With support from the Medical Education Partnership Initiative, the University of Nairobi has developed a training program to build local capacity for implementation science. METHODS: This paper describes how the University of Nairobi leveraged resources from the Medical Education Partnership to develop an institutional program that provides training and mentoring in implementation science, builds relationships between researchers and implementers, and identifies local research priorities for implementation science. RESULTS: The curriculum content includes core material in implementation science theory, methods, and experiences. The program adopts a team mentoring and supervision approach, in which fellows are matched with mentors at the University of Nairobi and partnering institutions: University of Washington, Seattle, and University of Maryland, Baltimore. A survey of program participants showed a high degree satisfaction with most aspects of the program, including the content, duration, and attachment sites. A key strength of the fellowship program is the partnership approach, which leverages innovative use of information technology to offer diverse perspectives, and a team model for mentorship and supervision. CONCLUSIONS: As health care systems and training institutions seek new approaches to increase capacity in implementation science, the University of Nairobi Implementation Science Fellowship program can be a model for health educators and administrators who wish to develop their program and curricula

Water, sanitation and hygiene at sex work venues to support menstrual needs

Introduction: Adequate menstrual health and hygiene (MHH) is necessary for women’s health and equity of all menstruators. Female sex workers (FSW) require good MHH to prevent discomfort and exposure to pathogens. No studies have evaluated water, sanitation, and hygiene (WASH) conditions of FSW. We report on a cross-sectional WASH assessment at FSW venues in Kisumu, western Kenya. Methods: Stakeholders identified 77 FSW venues in Kisumu, of which 47 were randomly sampled and visited between April-May 2023. A standardized structured survey of WASH conditions was deployed by trained research staff using Android tablets after proprietor’s consent. WASH scores ranging 0 – 3 were computed based on point each for direct observation of water available, soap available, and acceptable latrine. MHH scores ranging between 0-4 were computed (one point each) for direct observation of: currently available soap and water, locking door on a usable latrine, functional lighting, and a private area for changing clothes or menstrual materials, separate from the latrine(s). WASH and MHH scores were compared by venue type using non-parametric Kruskal-Wallis tests, and non-parametric Spearman rank tests. Results: Full WASH criteria was met by 29.8% of venues; 34.0% had no adequate WASH facilities; 46.8% had no female latrine, and 25.5% provided soap and water in private spaces for women. While 76.6% had menstrual waste disposal only 14 (29.8%) had covered bins. One in 10 venues provided adequate MHM facilities. Poorest WASH facilities were in brothels and in bars, and three-quarters of bars with accommodation had no MHH facilities. Discussion: WASH and MHH services were sub-optimal in the majority of FSW venues, preventing menstrual management safely, effectively, with dignity and privacy. This study highlights the unmet need for MHH support for this population. Poor MHH can deleteriously impact FSW health and wellbeing and compound the stigma and shame associated with their work and ability to stay clean. Acceptable and cost-effective solutions to sustainably improve WASH facilities for these populations are needed

High Prevalence of Lactobacillus crispatus Dominated Vaginal Microbiome Among Kenyan Secondary School Girls: Negative Effects of Poor Quality Menstrual Hygiene Management and Sexual Activity

The vaginal microbiome (VMB) impacts numerous health outcomes, but evaluation among adolescents is limited. We characterized the VMB via 16S rRNA gene amplicon sequencing, and its association with Bacterial vaginosis (BV) and sexually transmitted infections (STIs; chlamydia, gonorrhea, trichomoniasis) among 436 schoolgirls in Kenya, median age 16.9 years. BV and STI prevalence was 11.2% and 9.9%, respectively, with 17.6% of girls having any reproductive tract infection. Three community state types (CST) accounted for 95% of observations: CST-I L.crispatus-dominant (N=178, BV 0%, STI 2.8%, sexually active 21%); CST-III L.iners-dominant (N=152, BV 3.3%, STI 9.7%, sexually active 35%); CST-IV G.vaginalis-dominant (N=83, BV 51.8%, STI 25.3%, sexually active 43%). In multivariable adjusted analyses, sexually active girls had increased odds of CST-III and CST-IV, and use of cloth to manage menses had 1.72-fold increased odds of CST-IV vs. CST-I. The predominance of L.crispatus-dominated VMB, substantially higher than observed in prior studies of young adult and adult women in sub-Saharan Africa, indicates that non-optimal VMB can be an acquired state. Interventions to maintain or re-constitute L.crispatus dominance should be considered even in adolescents

Vaginal Microbial Network Analysis Reveals Novel Taxa Relationships among Adolescent and Young Women with Incident Sexually Transmitted Infection Compared with Those Remaining Persistently Negative Over a 30-Month Period

A non-optimal vaginal microbiome (VMB) is typically diverse with a paucity of Lactobacillus cris-patus, and is often associated with Bacterial vaginosis (BV) and sexually transmitted infections (STIs). Although compositional characterization of the VMB is well-characterized, especially for BV, knowledge remains limited on how different groups of bacteria relate to incident STIs, espe-cially among adolescents. In this study, we compared the VMB (measured via 16S ribosomal RNA gene amplicon sequencing) of Kenyan secondary school girls with incident STIs (composite of chlamydia, gonorrhea, trichomoniasis) to those who remained persistently negative for STIs and BV over 30 months of follow-up. We applied microbial network analysis to identify key taxa (i.e., those with greatest connectedness in terms of linkages to other taxa), as measured by betweenness and eigenvector centralities, and sub-groups of clustered taxa. VMB networks of those who re-mained persistently negative reflected greater connectedness compared to the VMB from partic-ipants with STI. Taxa with highest centralities were not correlated with relative abundance and differed between those with and without STI. Subject level analyses indicated that sociodemo-graphic (e.g., age, socioeconomic status) and behavioral (e.g., sexual activity) factors contribute to microbial network structure, and may be of relevance when designing interventions to improve VMB health

Investigation of HIV Incidence Rates in a High-Risk, High-Prevalence Kenyan Population: Potential Lessons for Intervention Trials and Programmatic Strategies

Abstract Cost-effective HIV prevention programs should target persons at high risk of HIV acquisition. We conducted an observational HIV incidence cohort study in Kisumu, Kenya, where HIV prevalence is triple that of the national rate. We used referral and venue-sampling approaches to enroll HIV-negative persons for a 12-month observational cohort, August 2010 to September 2011, collected data using computer-assisted interviews, and performed HIV testing quarterly. Among 1292 eligible persons, 648 (50%) were excluded for HIV positivity and other reasons. Of the 644 enrollees, 52% were women who were significantly older than men (P < .01). In all, 7 persons seroconverted (incidence rate [IR] per 100 person-years ¼ 1.11; 95% confidence interval [CI] 0.45-2.30), 6 were women; 5 (IR ¼ 3.14; 95% CI 1.02-7.34) of whom were 25 years. Most new infections occurred in young women, an observation consistent with other findings in sub-Saharan Africa that women aged 25 years are an important population for HIV intervention trials in Africa

What device would be best for early infant male circumcision in east and southern Africa? Provider experiences and opinions with three different devices in Kenya.

Voluntary medical male circumcision (VMMC) reduces risk of HIV acquisition in heterosexual men by approximately 60%. As some countries approach targets for proportions of adolescents and adults circumcised, some are considering early infant male circumcision (EIMC) as a means to achieve sustainability of VMMC for long term reduction of HIV incidence. Evaluations of specialized devices for EIMC are important to provide programs with information required to make informed decisions about how to design safe, effective EIMC programs. We provide assessments by 11 providers with experience in Kenya employing all three of the devices most likely to be considered by various EIMC programs in east and Southern Africa. There was no one device that was seen to be clearly superior to the others. Each had its own advantages and disadvantages. Provider preferences were situation-specific. Most preferred the Mogen Clamp if they themselves were performing the procedure. However, most were concerned that not everyone will have the skills necessary for optimal safety. If someone else were circumcising their son, most would opt for the AccuCirc because of the risk of severing the glans when using the Mogen. A minority preferred the PrePex, but only if the baby received local anesthesia, not EMLA cream (a eutectic mixture of lidocaine 2.5% and prilocaine 2.5%), as presently prescribed by the manufacturer. In the context of a national EIMC program, all participants agreed that AccuCirc would be the device they would recommend due to protection of the glans from laceration and to the provision of a pre-assembled sterile kit that overcomes the need for additional supplies or autoclaving. All agreed that scaling up EIMC, integrating it with existing maternal child health services, will face significant challenges, not least of which is persuading already over-burdened providers to take on additional workload. These results will be useful to programmers considering introduction of EIMC services in sub-Saharan African settings

Hydrothermal synthesis of zeolites using silica extracted from tropical volcanic ash

This study addresses the reliance on costly aluminosilicate sources for the synthesis of zeolites by exploring the use of silica extracted from tropical volcanic ash. The volcanic ash contained CaO, in the form of calcite polymorph of CaCO3, and silica at 47.09 wt% and 18.38 wt%, respectively. High purity silica was obtained by simply washing the volcanic ash with HCl to remove the calcite, and was then used, with additional commercial aluminate, in the synthesis of varieties of zeolites via the fusion method. The type of zeolite prepared, Na–X, Na–P or hydroxysodalite (Na-HS), was determined by the SiO2 : Al2O3 : Na2O : H2O molar ratios and in particular the amount of SiO2 and Na2O. The Na–X product had the highest surface area (766 m2 g−1), micropore surface area (644 m2 g−1) and pore volume (0.26 m3 g−1), and these textural values were comparable to those of commercial molecular sieve 13X. This work demonstrates that (i) high purity silica can be obtained from abundant and inexpensive volcanic ash by simple acid treatment, and (ii) the silica can be used in the production of high purity zeolites, whose quality is dependent on the hydrogel composition