The gender-based violence and recovery centre at Coast Provincial General Hospital, Mombasa, Kenya: An integrated care model for survivors of sexual violence

Sexual violence (SV) is highly prevalent and a major public health problem globally. In Kenya, an estimated 32% of females and 18% of males were reported to have experienced SV before the age of 18 years. This paper presents a data set collected between 2007 and 2018 and describes the gender-based violence and recovery centre (GBVRC) model under which survivors of SV were cared for at a 24-hour public hospital in Mombasa, Kenya—including its development, implementation, achievements, and challenges. The GBVRC model is a partnership that provides (in addition to emergency healthcare) mental health support, paralegal services, and integrated cooperation with police, judiciary, local leaders, and the wider community. The Mombasa GBVRC has provided post-SV care to 6,575 people reporting SV, of whom 88% were female and over 50% were younger than 16 years. Over 90% of the perpetrators were family, neighbours, community members, or in some other way known to the survivors. The low rate (19%) of attendance by survivors for the second counselling visit suggests a more robust strategy is needed for follow-up—for example, by referring people back to smaller, closer health facilities. A second limitation was a lack of trained staff, although this is an expected issue in sub-Saharan Africa. There was also a low rate of legal resolution to the cases. This may be due to the need for education about the standard of evidence required by courts. The experiences of successful and sustainable implementation of the GBVRC model should strengthen arguments for service delivery for people experiencing SV in this and similar settings

Association of HIV infection with distribution and viral load of HPV types in Kenya: a survey with 820 female sex workers

<p>Abstract</p> <p>Background</p> <p>Human papillomavirus (HPV) and HIV are each responsible for a considerable burden of disease. Interactions between these infections pose substantial public health challenges, especially where HIV prevalence is high and HPV vaccine coverage low.</p> <p>Methods</p> <p>Between July 2005 and January 2006, a cross-sectional community-based survey in Mombasa, Kenya, enrolled female sex workers using snowball sampling. After interview and a gynaecological examination, blood and cervical cytology samples were taken. Quantitative real-time PCR detected HPV types and viral load measures. Prevalence of high-risk HPV was compared between HIV-infected and -uninfected women, and in women with abnormal cervical cytology, measured using conventional Pap smears.</p> <p>Results</p> <p>Median age of the 820 participants was 28 years (inter-quartile range [IQR] = 24-36 years). One third of women were HIV infected (283/803; 35.2%) and these women were y more likely to have abnormal cervical cytology than HIV-negative women (27%, 73/269, versus 8%, 42/503; <it>P </it>< 0.001). Of HIV-infected women, 73.3% had high-risk HPV (200/273) and 35.5% had HPV 16 and/or 18 (97/273). Corresponding figures for HIV-negative women were 45.5% (229/503) and 15.7% (79/503). After adjusting for age, number of children and condom use, high-risk HPV was 3.6 fold more common in HIV-infected women (95%CI = 2.6-5.1). Prevalence of all 15 of the high-risk HPV types measured was higher among HIV-infected women, between 1.4 and 5.5 fold. Median total HPV viral load was 881 copies/cell in HIV-infected women (IQR = 33-12,110 copies/cell) and 48 copies/cell in HIV-uninfected women (IQR = 6-756 copies/cell; <it>P </it>< 0.001). HPV 16 and/or HPV 18 were identified in 42.7% of LSIL (32/75) and 42.3% of HSIL (11/26) lesions (<it>P </it>= 0.98). High-risk HPV types other than 16 and 18 were common in LSIL (74.7%; 56/75) and HSIL (84.6%; 22/26); even higher among HIV-infected women.</p> <p>Conclusions</p> <p>HIV-infected sex workers had almost four-fold higher prevalence of high-risk HPV, raised viral load and more precancerous lesions. HPV 16 and HPV 18, preventable with current vaccines, were associated with cervical disease, though other high-risk types were commoner. HIV-infected sex workers likely contribute disproportionately to HPV transmission dynamics in the general population. Current efforts to prevent HIV and HPV are inadequate. New interventions are required and improved implementation of existing strategies.</p

Preference of specimen collection methods for human papillomavirus detection for cervical cancer screening: a cross-sectional study of high-risk women in Mombasa, Kenya

Abstract Objectives Self-collection of genital specimens for high-risk types of human papillomavirus (hrHPV) detection may increase cervical cancer screening uptake. We hypothesized that women would prefer self-collection to clinician-collection of genital specimens. To test this hypothesis, and women’s preference between two different self-collection approaches, a total of 199 women were enrolled in a cross-sectional study in Mombasa, Kenya. Materials and methods Participants provided self-collected specimens using the Evalyn cytobrush (Rovers) stored in a dry tube and the Viba cytobrush (Rovers) stored in wet Aptima media (Hologic). A clinician also collected cervical specimens for hrHPV testing and for cytology, and performed visual inspection using acetic acid. A post-examination questionnaire assessed preferences for the different methods of specimen collection. To test the difference in proportions for each collection method, we performed an exact binomial probability test, under the null hypothesis that women would prefer each specimen-collection method equally. Results Most women preferred clinician-collection over self-collection (68% versus 32%, p < 0.01). For self-collection, dry-self collection with the Evalyn brush was preferred over the wet-selection with the Viba brush (53% versus 27%, p < 0.01). There was no association between preference for self-collection and preference for a particular self-collection cytobrush. Conclusion Further research to understand and address obstacles to self-collection of genital specimens may be needed to improve the uptake of self-collection for cervical cancer screening, especially in settings with poor access to trained healthcare providers

Decrease in HIV-1 RNA in blood and semen during the first month of antiretroviral therapy.

<p><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0043086#pone-0043086-g001" target="_blank">Figure 1a</a> presents results for blood plasma, and <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0043086#pone-0043086-g001" target="_blank">Figure 1b</a> presents results for seminal plasma. Open, connected circles represent included data points (see methods). The bold line represents the modeled estimate. Delta (δ) is the estimate for the initial, rapid phase of decay, and mu (μ) the estimate for the subsequent, slower phase of decay. The half-life in days for each phase is equal to ln(2) divided by the decay rate in log₁₀ virions/day. P values are presented for comparisons of the two decay rates in seminal plasma to those seen in blood plasma. NA = not applicable.</p

Median Log₁₀ HIV-1 RNA Level During the First Month of Antiretroviral Therapy among 13 Kenyan Men.

<p>P values given are for paired comparisons to baseline levels for each sample type.</p><p>IQR  =  Inter-quartile range.</p>*<p>Due to public holidays or other scheduling difficulties, eleven visits (15.9%) occurred one day before or one day after the scheduled visit date.</p>†<p>One day 7 visit was missed and two day 28 visits were missed. All semen samples were missing for one participant. Blood samples were missing on day 7 (2 samples) and day 14 (1 sample).</p

Protease Inhibitor Resistance in the First 3 Years of Second-Line Antiretroviral Therapy for HIV-1 in Sub-Saharan Africa

As antiretroviral therapy (ART) programs in sub-Saharan Africa mature, increasing numbers of persons with human immunodeficiency virus (HIV) infection will experience treatment failure, and require second- or third-line ART. Data on second-line failure and development of protease inhibitor (PI) resistance in sub-Saharan Africa are scarce. HIV-1-infected adults were included if they received >180 days of PI-based second-line ART. We assessed risk factors for having a detectable viral load (VL, ≥400 cps/mL) using Cox models. If VL was ≥1000 cps/mL, genotyping was performed. Of 227 included participants, 14.6%, 15.2% and 11.1% had VLs ≥400 cps/mL at 12, 24, and 36 months, respectively. Risk factors for a detectable VL were as follows: exposure to nonstandard nonnucleoside reverse-transcriptase inhibitor (NNRTI)-based (hazard ratio, 7.10; 95% confidence interval, 3.40-14.83; P < .001) or PI-based (7.59; 3.02-19.07; P = .001) first-line regimen compared with zidovudine/lamivudine/NNRTI, PI resistance at switch (6.69; 2.49-17.98; P < .001), and suboptimal adherence (3.05; 1.71-5.42; P = .025). Among participants with VLs ≥1000 cps/mL, 22 of 32 (69%) harbored drug resistance mutation(s), and 7 of 32 (22%) harbored PI resistance. Although VL suppression rates were high, PI resistance was detected in 22% of participants with VLs ≥1000 cps/mL. To ensure long-term ART success, intensified support for adherence, VL and drug resistance testing, and third-line drugs will be necessar

Suboptimal immune recovery during antiretroviral therapy with sustained HIV suppression in sub-Saharan Africa

OBJECTIVE: To assess incidence, determinants and clinical consequences of suboptimal immune recovery in HIV-1 infected adults in sub-Saharan Africa with sustained viral suppression on antiretroviral therapy (ART). DESIGN: Multicountry prospective cohort. METHODS: Suboptimal immune recovery was defined as proportions of participants who failed to attain clinically relevant CD4 cell count thresholds (>200, >350 and >500 cells/μl) despite sustained viral suppression on continuous first-line ART. Participants were censored at the earliest of death, loss to follow-up, last viral load less than 50 copies/ml, or database closure. Determinants of immune recovery were assessed using multivariable Cox regression. We estimated incidence rates of AIDS, pulmonary tuberculosis and all-cause mortality for CD4 strata. RESULTS: One thousand, five hundred and ninety-two participants were included; 60% were women, median age was 37 years (IQR 31-43) and median pre-ART CD4 cell count was 147 cells/μl (IQR 76-215). After 6 years of ART, suboptimal immune recovery at CD4 cell counts less than 200 cells/μl, less than 350  cells/μl, and less than 500 cells/μl occurred in 7, 27, and 57% of participants, respectively. Compared with participants with CD4 cell count greater than 500 cells/μl, on-ART incidence rates were 12.5, 4.1, 0.9 times higher for AIDS and 16.9, 3.5, and 2.3 times higher for pulmonary tuberculosis in participants with CD4 cell count less than 200, 200-349, and 350-499 cells/μl, respectively. All-cause mortality was highest in participants with CD4 cell count less than 200 cells/μl, and comparable across the higher CD4 strata. Older age, male sex, and lower pre-ART CD4 cell count were strongly associated with suboptimal immune recovery. CONCLUSION: These findings warrant close clinical and laboratory monitoring until adequate immune reconstitution is achieved and support early ART initiation before decline of CD4 cell count