Stakeholders perception of HIV sero-discordant couples in western Kenya

Objective: To describe the perceptions of key stakeholders regarding the counselling needs of HI V sero-discordant couples as part of preparation for a clinical trial involving HIV sero-discordant couples. Design: Qualitative study using key informant and couple interviews. Setting: Moi Teaching and Referral Hospital (MTRH). Subjects: A purposive sample of nine key informants and 31 couple interviews totaling 71 participants. The couple interviews consisted of HI V untested, HI V concordant (positive and negative) and discordant couples. Results: Seventy one individuals participated in nine key informant and 31 couple interviews. The responses identified the following as key issues in counselling HIV discordant couples: The need for education on the meaning of HI V sero-discordancy including potential sources of infection; assistance in disclosing HIV test results to one\'s partner; discussion of the stigma surrounding formula feeding. Overall, the participants supported safer sexual practices in discordant partnerships. Conclusions: Psychosocial support of HI V sero-discordant couples should include messages about the meaning, mechanisms and implications of sero-discordancy. Culturally appropriate HI Vdisclosure and safer sex messages are also needed to support these partnerships. East African Medical Journal Vol. 85 (7) 2008: pp. 326-33

Determinants In HIV Counselling And Testing In Couples In North Rift Kenya

Background: Voluntary HIV counselling and testing (VCT) has been shown to be an acceptable and effective tool in the fight against HIV/AIDS. Couple HIV Counselling and Testing (CHCT) however, is a relatively new concept whose acceptance and efficacy is yet to be determined.Objective: To describe factors that motivate couples to attend VCT as a couple. Design: A cross sectional qualitative study.Setting: Moi Teaching and Referral Hospital and Moi University, School of Medicine, Eldoret, KenyaSubjects: Seventy one individuals were interviewed during KII (9) and dyad interviews (31 couples). Ten FGDs involving a total of 109 individuals were held. Results: Cultural practices, lack of CHCT awareness, stigma and fear of results deter CHCT utilisation. Location of centre where it is unlikely to be associated with HIV testing, qualified professional staff and minimal waiting times would enhance CHCT utilisation.Conclusions: CHCT as a tool in the fight against HIV/AIDS in this region of Kenya is feasible as the factors that would deter couples are not insurmountable

A Needs Assessment to Build International Research Ethics Capacity at Moi University

International Research Ethics Partnership. This online version is the post-print version (final, peer-reviewed and accepted for publication version) of the published article. For the published version, refer to the article citation within the item record.International collaborators in biomedical sciences face ethical challenges in the design,review, and conduct of research. Challenges include differences in research ethics capacity, cultural differences in interpretation and application of ethical principles, and cooperation between ethics review boards at collaborating institutions. Indiana University School of Medicine (Indianapolis, USA) and Moi University Faculty of Health Sciences (Eldoret, Kenya)developed a Memorandum of Understanding (MOU) to establish greater cooperation between their ethics review boards, followed by a joint needs assessment to assess barriers to implementing the MOU. Focus groups and interviews at each institution revealed that while each side verbalized understanding and respect for the other's culture, there were misunderstandings deeply rooted in each culture that could potentially derail the collaboration. Although the participants at each university agreed on the major principles and issues in research ethics and on the importance attributed to them, a more in-depth evaluation of the responses revealed important differences. Methods to address these misunderstandings are outlined in the recommended Best Practices.Fogarty International Center at the NIH, Indiana University Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indiana University International Development Fund, Indiana Genomics Initiative, Lilly Endowment, Inc

Admission Characteristics, Diagnoses And Outcomes Of HIV-Infected Patients Registered In An Ambulatory HIV-Care Programme In Western Kenya

Objective: To determine admissions diagnosis and outcomes of HIV-infected patients attending AMPATH ambulatory HIV-care clinics. Design: Prospective cohort study. Setting: Academic Model for Prevention and Treatment of HIV/ AIDS (AMPATH) ambulatory HIV-care clinic in western Kenya. Results: Between January 2005 and December 2006, 495 HIV-infected patients enrolled in AMPATH were admitted. Median age at admission was 38 years (range: 19 - 74), 62% females, 375 (76%) initiated cART a median 56 days (range: 1- 1288) before admission. Majority (53%) had pre-admission CD4 counts 200 cells/ml. Common admissions diagnoses were: tuberculosis (27%); pneumonia (15%); meningitis (11%); diarrhoea (11%); malaria (6%); severe anaemia (4%); and toxoplasmosis (3%). Deaths occurred in 147 (30%) patients who enrolled at AMPATH a median 44 days (range: 1 - 711) before admission and died a median 41 days (range: 1 -713) after initiating cART. Tuberculosis (27%) and meningitis (14%) were the most common diagnoses in the deceased. Median admission duration was six days (range: 1 - 30) for deceased patients and eight days (range: I - 44) for survivors (P=0.0024). Deceased patients enrolled in AMPATH or initiated cART more recently, had lower CD4 counts and were more frequently lost to follow-up than survivors (

Reduced renal function is associated with progression to AIDS but not with overall mortality in HIV-infected kenyan adults not initially requiring combination antiretroviral therapy

<p>Abstract</p> <p>Background</p> <p>The World Health Organization (WHO) has recently recommended that antiretrovirals be initiated in all individuals with CD4 counts of less than 350 cells/mm³. For countries with resources too limited to expand care to all such patients, it would be of value to able to identify and target populations at highest risk of HIV progression. Renal disease has been identified as a risk factor for disease progression or death in some populations.</p> <p>Methods</p> <p>Times to meeting combination antiretroviral therapy (cART) initiation criteria (developing either a CD4 count < 200 cells/mm³or WHO stage 3 or 4 disease) and overall mortality were evaluated in cART-naïve, HIV-infected Kenyan adults with CD4 cell counts ≥200/mm³and with WHO stage 1 or 2 disease. Cox proportional hazard regression models were used to evaluate the associations between renal function and these endpoints.</p> <p>Results</p> <p>We analyzed data of 7383 subjects with a median follow-up time of 59 (interquartile range, 27-97) weeks. In Cox regression analyses adjusted for age, sex, WHO disease stage, CD4 cell count and haemoglobin, estimated creatinine clearance (CrCl) < 60 mL/min was significantly associated with shorter times to meeting cART initiation criteria (HR 1.34; 95% CI, 1.23-1.52) and overall mortality (HR 1.73; 95% CI, 1.19-2.51) compared with CrCl ≥60 mL/min. Estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m²was associated with shorter times to meeting cART initiation criteria (HR 1.39; 95% CI, 1.22-1.58), but not with overall mortality. CrCl and eGFR remained associated with shorter times to cART initiation criteria, but neither was associated with mortality, in weight-adjusted analyses.</p> <p>Conclusions</p> <p>In this large natural history study, reduced renal function was strongly associated with faster HIV disease progression in adult Kenyans not initially meeting cART initiation criteria. As such, renal function measurement in resource-limited settings may be an inexpensive method to identify those most in need of cART to prevent progression to AIDS. The initial association between reduced CrCl, but not reduced eGFR, and greater mortality was explained by the low weights in this population.</p

A semiparametric method for the analysis of outcomes during a gap in HIV care under incomplete outcome ascertainment

Objectives: Estimation of the cascade of HIV care is essential for evaluating care and treatment programs, informing policy makers and assessing targets such as 90-90-90. A challenge to estimating the cascade based on electronic health record concerns patients "churning" in and out of care. Correctly estimating this dynamic phenomenon in resource-limited settings, such as those found in sub-Saharan Africa, is challenging because of the significant death under-reporting. An approach to partially recover information on the unobserved deaths is a double-sampling design, where a small subset of individuals with a missed clinic visit is intensively outreached in the community to actively ascertain their vital status. This approach has been adopted in several programs within the East Africa regional IeDEA consortium, the context of our motivating study. The objective of this paper is to propose a semiparametric method for the analysis of competing risks data with incomplete outcome ascertainment. Methods: Based on data from double-sampling designs, we propose a semiparametric inverse probability weighted estimator of key outcomes during a gap in care, which are crucial pieces of the care cascade puzzle. Results: Simulation studies suggest that the proposed estimators provide valid estimates in settings with incomplete outcome ascertainment under a set of realistic assumptions. These studies also illustrate that a naïve complete-case analysis can provide seriously biased estimates. The methodology is applied to electronic health record data from the East Africa IeDEA Consortium to estimate death and return to care during a gap in care. Conclusions: The proposed methodology provides a robust approach for valid inferences about return to care and death during a gap in care, in settings with death under-reporting. Ultimately, the resulting estimates will have significant consequences on program construction, resource allocation, policy and decision making at the highest levels

How Many SARS-CoV-2–Infected People Require Hospitalization? Using Random Sample Testing to Better Inform Preparedness Efforts

Context: Existing hospitalization ratios for COVID-19 typically use case counts in the denominator, which problematically underestimates total infections because asymptomatic and mildly infected persons rarely get tested. As a result, surge models that rely on case counts to forecast hospital demand may be inaccurately influencing policy and decision-maker action. Objective: Based on SARS-CoV-2 prevalence data derived from a statewide random sample (as opposed to relying on reported case counts), we determine the infection-hospitalization ratio (IHR), defined as the percentage of infected individuals who are hospitalized, for various demographic groups in Indiana. Furthermore, for comparison, we show the extent to which case-based hospitalization ratios, compared with the IHR, overestimate the probability of hospitalization by demographic group. Design: Secondary analysis of statewide prevalence data from Indiana, COVID-19 hospitalization data extracted from a statewide health information exchange, and all reported COVID-19 cases to the state health department. Setting: State of Indiana as of April 30, 2020. Main Outcome Measure(s): Demographic-stratified IHRs and case-hospitalization ratios. Results: The overall IHR was 2.1% and varied more by age than by race or sex. Infection-hospitalization ratio estimates ranged from 0.4% for those younger than 40 years to 9.2% for those older than 60 years. Hospitalization rates based on case counts overestimated the IHR by a factor of 10, but this overestimation differed by demographic groups, especially age. Conclusions: In this first study of the IHR based on population prevalence, our results can improve forecasting models of hospital demand—especially in preparation for the upcoming winter period when an increase in SARS CoV-2 infections is expected

CD4 trajectory adjusting for dropout among HIV-positive patients receiving combination antiretroviral therapy in an East African HIV care centre

Objective: Estimates of CD4 response to antiretroviral therapy (ART) obtained by averaging data from patients in care, overestimate population CD4 response and treatment program effectiveness because they do not consider data from patients who are deceased or not in care. We use mathematical methods to assess and adjust for this bias based on patient characteristics. Design: We examined data from 25,261 HIV-positive patients from the East Africa IeDEA Consortium. Methods: We used inverse probability of censoring weighting (IPCW) to represent patients not in care by patients in care with similar characteristics. We address two questions: What would the median CD4 be “had everyone starting ART remained on observation?” and “were everyone starting ART maintained on treatment?” Results: Routine CD4 count estimates were higher than adjusted estimates even under the best-case scenario of maintaining all patients on treatment. Two years after starting ART, differences between estimates diverged from 30 cells/µL, assuming similar mortality and treatment access among dropouts as patients in care, to over 100 cells/µL assuming 20% lower survival and 50% lower treatment access among dropouts. When considering only patients in care, the proportion of patients with CD4 above 350 cells/µL was 50% adjusted to below 30% when accounting for patients not in care. One-year mortality diverged 6–14% from the naïve estimates depending on assumptions about access to care among lost patients. Conclusions: Ignoring mortality and loss to care results in over-estimation of ART response for patients starting treatment and exaggerates the efficacy of treatment programs administering it