Perceived stigma among patients receiving antiretroviral treatment: a prospective randomised trial comparing an m-DOT strategy with standard-of-care in Kenya

HIV and AIDS remain highly stigmatised. Modified directly observed therapy (m-DOT) supports antiretroviral treatment (ART) adherence but little is known about its association with perceived stigma in resource-constrained settings. In 2003, 234 HIV-infected adults enrolled in a two-arm randomised trial comparing a health centre-based m-DOT strategy with standard self-administration of ART. Data on perceived stigma were collected using Berger\u27s HIV stigma scale prior to starting ART and after 12 months. This was a secondary analysis to examine whether perceived stigma was related to treatment delivery. Perceived stigma scores declined after 12 months of treatment from a mean of 44.9 (sd=7.6) to a mean of 41.4 (sd=7.7), (t=6.14,

Changes in stigma among a cohort of people on antiretroviral therapy: Findings from Mombasa, Kenya

Stigma has been a reality in the lives of people living with HIV (PLHIV) since the inception of the AIDS epidemic, and it can have profound implications for health, psychosocial well-being, and utilization of health services. In the industrialized world, the availability of antiretroviral therapy (ART) and a subsequent change in perception of AIDS as a chronic manageable disease has coincided with a decrease in stigma and discrimination directed toward PLHIV. However, little is known in developing countries about whether perceptions and experiences of stigma among PLHIV have changed following increased access to ART. The Horizons Program and the International Centre for Reproductive Health undertook an observational study in Mombasa, Kenya, to document changes in internalized and experienced stigma in a cohort of HIV-infected individuals over a 12-month period after initiating ART. As detailed in this brief, the study found that levels of internalized stigma decreased after 12 months on treatment. Participants also disclosed to a greater number of family members. Despite these positive changes, internalized stigma remains a problem for many respondents and warrants increased stigma-reduction activities in the community

Sexual risk behaviors of HIV-positive persons receiving ART in Mombasa, Kenya: Longitudinal study findings

As a result of the success of antiretroviral therapy (ART) in dramatically decreasing morbidity and mortality due to HIV, many HIV-infected individuals are now living longer, healthier, and more sexually active lives. However, unprotected sex by people living with HIV is an area of concern because of the risk of transmission to sero-discordant partners and reinfection with new, drug-resistant viral strains. There is evidence to suggest that some sero-positive individuals continue to engage in unprotected sex that places others at risk for infection and places themselves at risk for contracting secondary infections. To learn more about the impact of ART on sexual risk behavior in a developing country setting, researchers from the Horizons Program and the International Center for Reproductive Health followed a cohort of HIV-positive individuals receiving ART for 12 months in Mombasa, Kenya. The study revealed no increase in unsafe sex. However, there remained a risk of HIV transmission as a result of unprotected sex with an HIV-negative or unknown status partner. As indicated in this brief, safer-sex counseling needs special emphasis in ART programs

A prospective study of vaginal trichomoniasis and HIV-1 shedding in women on antiretroviral therapy

<p>Abstract</p> <p>Background</p> <p><it>Trichomonas vaginalis </it>has been associated with increased vaginal HIV-1 RNA shedding in antiretroviral therapy (ART)-naïve women. The effect of trichomoniasis on vaginal HIV-1 shedding in ART-treated women has not been characterized. We tested the hypothesis that <it>T. vaginalis </it>infection would increase vaginal HIV-1 RNA shedding in women on ART, and that successful treatment would reduce vaginal HIV-1 RNA levels.</p> <p>Methods</p> <p>We conducted a prospective cohort study including monthly follow-up of 147 women receiving ART in Mombasa, Kenya. Those with <it>T. vaginalis </it>infection, defined by the presence of motile trichomonads on vaginal saline wet mount, received treatment with single dose metronidazole (2 g). Test of cure was performed at the next monthly visit. Using the pre-infection visit as the reference category, we compared detection of vaginal HIV-1 RNA before versus during and after infection using generalized estimating equations. A cut-off of 100 HIV-1 RNA copies/swab was used as the lower limit for linear quantitation.</p> <p>Results</p> <p>Among 31 women treated for trichomoniasis, the concentration of vaginal HIV-1 RNA was above the limit for quantitation before, during, and after <it>T. vaginalis </it>infection in 4 (13% [95% CI 4% - 30%]), 4 (13% [95% CI 4% - 30%]), and 5 (16% [95% confidence interval {CI} 5% - 34%]) women respectively. After adjusting for potential confounding factors, we could detect no difference in the likelihood of detecting vaginal HIV-1 RNA before versus during infection (odds ratio [OR] 1.41, 95% CI 0.23 - 8.79, p = 0.7). In addition, detection of HIV-1 RNA was similar before infection versus after successful treatment (OR 0.68, 95% CI (0.13 - 3.45), p = 0.6).</p> <p>Conclusion</p> <p>Detection of vaginal HIV-1 RNA during ART was uncommon at visits before, during and after <it>T. vaginalis </it>infection.</p

Promoting adherence through a directly administered antiretroviral therapy strategy in Mombasa, Kenya

A principal concern of antiretroviral therapy (ART) programs is the ability of clients to maintain a high level of adherence to medication. Based on formative research conducted with HIV-infected clients and health workers in Mombasa, Kenya, and lessons learned from directly observed therapy strategies to encourage adherence to treatment for tuberculosis, a directly administered antiretroviral therapy (DAART) strategy to promote adherence to ART was developed. This study examines whether the intervention was more effective in fostering adherence to ART than standard follow-up among people living with HIV in Mombasa. Researchers from the Horizons Program and the International Centre for Reproductive Health conducted a randomized controlled two-arm study to determine the short- and longer-term effects of DAART compared to standard care. DAART was found to be more effective in promoting adherence during the 24-week intervention period than standard care, but the effect was not sustained postintervention. As noted in this brief, results suggest that DAART is effective for improving adherence in this setting, but the optimal length of the intervention for sustaining adherence and its transition to standard care may warrant further research

Higher pre-infection vitamin E levels are associated with higher mortality in HIV-1-infected Kenyan women: a prospective study

Background: Low vitamin E levels are often found in HIV-1 infection, and studies have suggested that higher levels may decrease the risk of disease progression. However, vitamin E supplementation has also been reported to increase CCR5 expression, which could increase HIV- 1 replication. We hypothesized that vitamin E levels at HIV-1 acquisition may influence disease progression. Methods: Vitamin E status was measured in stored samples from the last pre-infection visit for 67 Kenyan women with reliably estimated dates of HIV-1 acquisition. Regression analyses were used to estimate associations between pre-infection vitamin E and plasma viral load, time to CD4 count less than 200 cells/[micro]L, and mortality. Results: After controlling for potential confounding factors, each 1 mg/L increase in pre-infection vitamin E was associated with 0.08 log[sub]10 copies/mL (95% CI -0.01 to +0.17) higher set point viral load and 1.58-fold higher risk of mortality (95% CI 1.15�2.16). The association between higher preinfection vitamin E and mortality persisted after adjustment for set point viral load (HR 1.55, 95% CI 1.13�2.13). Conclusion: Higher pre-infection vitamin E levels were associated with increased mortality. Further research is needed to elucidate the role vitamin E plays in HIV-1 pathogenesis.This research was supported by National Institutes of Health grants AI-43844 and AI-38518 (all authors), and Fogarty International Center grant D43 TW000007 (SMG)

Impact of five years of peer-mediated interventions on sexual behavior and sexually transmitted infections among female sex workers in Mombasa, Kenya

<p>Abstract</p> <p>Background</p> <p>Since 2000, peer-mediated interventions among female sex workers (FSW) in Mombasa Kenya have promoted behavioural change through improving knowledge, attitudes and awareness of HIV serostatus, and aimed to prevent HIV and other sexually transmitted infection (STI) by facilitating early STI treatment. Impact of these interventions was evaluated among those who attended peer education and at the FSW population level.</p> <p>Methods</p> <p>A pre-intervention survey in 2000, recruited 503 FSW using snowball sampling. Thereafter, peer educators provided STI/HIV education, condoms, and facilitated HIV testing, treatment and care services. In 2005, data were collected using identical survey methods, allowing comparison with historical controls, and between FSW who had or had not received peer interventions.</p> <p>Results</p> <p>Over five years, sex work became predominately a full-time activity, with increased mean sexual partners (2.8 versus 4.9/week; <it>P </it>< 0.001). Consistent condom use with clients increased from 28.8% (145/503) to 70.4% (356/506; <it>P </it>< 0.001) as well as the likelihood of refusing clients who were unwilling to use condoms (OR = 4.9, 95%CI = 3.7–6.6). In 2005, FSW who received peer interventions (28.7%, 145/506), had more consistent condom use with clients compared with unexposed FSW (86.2% versus 64.0%; AOR = 3.6, 95%CI = 2.1–6.1). These differences were larger among FSW with greater peer-intervention exposure. HIV prevalence was 25% (17/69) in FSW attending ≥ 4 peer-education sessions, compared with 34% (25/73) in those attending 1–3 sessions (P = 0.21). Overall HIV prevalence was 30.6 (151/493) in 2000 and 33.3% (166/498) in 2005 (<it>P </it>= 0.36).</p> <p>Conclusion</p> <p>Peer-mediated interventions were associated with an increase in protected sex. Though peer-mediated interventions remain important, higher coverage is needed and more efficacious interventions to reduce overall vulnerability and risk.</p

Low serum albumin and the acute phase response predict low serum selenium in HIV-1 infected women

BACKGROUND: Low serum selenium has been associated with lower CD4 counts and greater mortality among HIV-1-seropositive individuals, but most studies have not controlled for serum albumin and the presence of an acute phase response. METHODS: A cross-sectional study was conducted to evaluate relationships between serum selenium concentrations and CD4 count, plasma viral load, serum albumin, and acute phase response markers among 400 HIV-1-seropositive women. RESULTS: In univariate analyses, lower CD4 count, higher plasma viral load, lower albumin, and the presence of an acute phase response were each significantly associated with lower serum selenium concentrations. In multivariate analyses including all four of these covariates, only albumin remained significantly associated with serum selenium. For each 0.1 g/dl increase in serum albumin, serum selenium increased by 0.8 μg/l (p < 0.001). Women with an acute phase response also had lower serum selenium (by 5.6 μg/l, p = 0.06). CONCLUSION: Serum selenium was independently associated with serum albumin, but not with CD4 count or plasma viral load, in HIV-1-seropositive women. Our findings suggest that associations between lower serum selenium, lower CD4 count, and higher plasma viral load may be related to the frequent occurrence of low serum albumin and the acute phase response among individuals with more advanced HIV-1 infection

Changes in sexual risk taking with antiretroviral treatment : influence of context and gender norms in Mombasa, Kenya

In-depth interviews were conducted with 23 sexually-active adults receiving antiretroviral treatment (ART) in Mombasa Kenya to understand changes in sexual behaviour after treatment initiation and factors influencing condom use. Advanced HIV disease had previously led to marked decreases in sexual desire and function. After HIV testing, numbers of partners reduced and monogamous relationships began to predominate. Receipt of ART strengthened these changes, while improving sexual health. However, concurrent sexual partnerships continue within polygamous marriage and unprotected sex occurs with regular partners, even those who are HIV-negative. Those who used condoms inconsistently prior to ART often remained inconsistent users thereafter. While disclosure of HIV status appeared to support condom use, this does not always predict protected sex. In addition to classic perceptions about condom's effect on intimacy and trust, traditional gender roles, misconceptions about potential harm from condoms and fertility desires hinder condom use

Vulnerability of women in an African setting: lessons for mother-to-child HIV transmission prevention programmes

After discussing advantages and risks, only a third of the 290 HIV-infected women included in an intervention study to reduce mother-to-child transmission of HIV in Mombasa, Kenya, informed their partners of their results. Despite careful counselling, 10% subsequently experienced violence or disruption of their relationship. To increase the uptake of interventions to reduce perinatal HIV transmission safely, we recommend the involvement of partners in HIV testing. In addition, the counselling of women has to address methods and skills to deal with violence