STI's HIV and AIDS

STIs, HIV and AIDS: 2005 - 2008
HIV testing and counselling for women attending child health clinics:
An opportunity for entry to prevent mother-to-child transmission and
HIV treatment.
Author: Chersich MF; Luchters SM; Othigo MJ; Yard E; Mandaliya K
Source: International Journal of STD and AIDS. 2008 Jan;19(1):42-46.
Abstract: This study assessed the potential for HIV testing at child health clinics to increase
knowledge of HIV status, and entry to infant feeding counselling and HIV
treatment. At a provincial hospital in Mombasa, Kenya, HIV testing and
counselling were offered to women bringing their child for immunization or
acute care services. Most women said HIV testing should be offered in these
clinics (472/493, 95.7%), with many citing the benefits of regular testing and
entry to prevent mother-to-child transmission. Of 500 women, 416 (83.4%)
received test results, 97.6% on the same day. After 50 participants, point-of-care
testing replaced laboratory-based rapid testing. Uptake increased 2.6 times with
point-of-care testing (95% confidence interval = 1.4-5.1; P = 0.003). Of 124 women
who had not accessed HIV testing during pregnancy, 98 tested in the study
(79.0%). Measured by uptake and attitudes, HIV testing in child health clinics is
acceptable. This could optimize entry into HIV treatment, infant feeding
counselling and family planning services. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | SURVEYS | MOTHERS | INFANT |

PREVENTION OF MOTHER-TO-CHILD TRANSMISSION | HIV TESTING
| COUNSELING | CHILD HEALTH SERVICES | HIV INFECTIONS |
TREATMENT | BREASTFEEDING | DEVELOPING COUNTRIES |
AFRICA, EASTERN | AFRICA, SUB SAHARAN | AFRICA | SAMPLING
STUDIES | STUDIES | RESEARCH METHODOLOGY | PARENTS |
FAMILY RELATIONSHIPS | FAMILY CHARACTERISTICS | FAMILY AND
HOUSEHOLD | SOCIOCULTURAL FACTORS | YOUTH | AGE FACTORS
| POPULATION CHARACTERISTICS | DEMOGRAPHIC FACTORS |
POPULATION | DISEASE TRANSMISSION CONTROL | PREVENTION
AND CONTROL | DISEASES | LABORATORY EXAMINATIONS AND
DIAGNOSES | EXAMINATIONS AND DIAGNOSES | MEDICAL
PROCEDURES | MEDICINE | HEALTH SERVICES | DELIVERY OF
HEALTH CARE | HEALTH | CLINIC ACTIVITIES | PROGRAM
ACTIVITIES | PROGRAMS | ORGANIZATION AND ADMINISTRATION
| MATERNAL-CHILD HEALTH SERVICES | PRIMARY HEALTH CARE |
VIRAL DISEASES | INFANT NUTRITION | NUTRITION
Document Number: 324667
1
Morbidity in the first year postpartum among HIV-infected women in

Kenya.
Author: Chersich MF; Luchters SM; Yard E; Othigo JM; Kley N
Source: International Journal of Gynecology and Obstetrics. 2008 Jan;100(1):45-51.
Abstract: The objective was to assess the effects of HIV infection on morbidity and the
needs of infected women for services in the first year postpartum. A cross-
sectional study with 500 women attending a child-health clinic in Mombasa,
Kenya. Postpartum duration was a median of 3.3 months (interquartile range,
1.9-6.1 months). The 54 HIV-infected women had a lower income and less
financial support than the uninfected women, and they were more likely to
experience fever, dyspnea, and dysuria, and to have genital warts (odds ratio
[OR], 9.6; 95% confidence interval [CI], 2.6-35.6; P less than 0.001), candidiasis
(OR, 2.9; 95% CI, 1.2-6.8; P=0.012), and bacterial vaginosis (OR, 1.8; 95% CI, 0.95-
3.3; P=0.066). Six (nearly 15%) of the HIV-infected women had low- or high-
grade squamous intraepithelial lesions, and 21 (42%) had an unmet need for
contraception. More than half of all women were anemic, and normocytic anemia
was predominant among the HIV infected. Compared with uninfected women,
morbidity was increased for HIV-infected women during the year following
delivery. This period could be used to offer these, and all-women, family
planning services, cervical cancer screening, and treatment for anemia and
reproductive tract infections. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | CROSS SECTIONAL ANALYSIS |

POSTPARTUM WOMEN | PERSONS LIVING WITH HIV/AIDS |
MORBIDITY | ANEMIA | POSTPARTUM PROGRAMS | DEVELOPING
COUNTRIES | AFRICA, EASTERN | AFRICA, SUB SAHARAN | AFRICA |
RESEARCH METHODOLOGY | PUERPERIUM | REPRODUCTION | HIV
INFECTIONS | VIRAL DISEASES | DISEASES | FAMILY PLANNING
PROGRAMS | FAMILY PLANNING
HIV, hepatitis B and hepatitis C coinfection in Kenya.
Author: Harania RS; Karuru J; Nelson M; Stebbing J
Source: AIDS. 2008 Jun 19;22(10):1221-1222.
Abstract: There are few data regarding hepatitis and HIV coinfection in Africa. In 378 HIV
seropositive individuals in Nairobi, 23 (6%) were hepatitis B virus (HBV) and
2
HIV coinfected, four (1%) were hepatitis C virus (HCV) and HIV coinfected and
one patient was infected with all three viruses. Coinfected individuals were more
likely to be men and older; a lack of HBV vaccination was a risk factor for
HIV/HBV coinfection (P = 0.001) and tenofovir containing regimens appeared
most effective at reducing HBV viral load. (excerpt)
Language: English
Keywords: KENYA | RESEARCH REPORT | CLINICAL RESEARCH |

EPIDEMIOLOGIC METHODS | HIV POSITIVE PERSONS | HIV
INFECTIONS | HEPATITIS | COMPLICATIONS | SEX FACTORS | AGE
FACTORS | IMMUNIZATION | ANTIBIOTICS | PREVALENCE |
DEVELOPING COUNTRIES | AFRICA, EASTERN | AFRICA, SUB
SAHARAN | AFRICA | RESEARCH METHODOLOGY | PERSONS LIVING
WITH HIV/AIDS | VIRAL DISEASES | DISEASES | POPULATION
CHARACTERISTICS | DEMOGRAPHIC FACTORS | POPULATION |
PRIMARY HEALTH CARE | HEALTH SERVICES | DELIVERY OF HEALTH
CARE | HEALTH | DRUGS | TREATMENT | MEDICAL PROCEDURES |
MEDICINE | MEASUREMENT
HIV-neutralizing immunoglobulin A and HIV-specific proliferation are

independently associated with reduced HIV acquisition in Kenyan sex
workers.
Author: Hirbod T; Kaul R; Reichard C; Kimani J; Ngugi E
Source: AIDS. 2008 Mar 30;22(6):727-735.
Abstract: HIV-neutralizing immunoglobulin A (IgA) and HIV-specific cellular immunity

have been described in highly exposed, persistently seronegative (HEPS)
individuals, but well controlled studies have not been performed. We performed
a prospective, nested case-control study to examine the association of genital IgA
and systemic cellular immune responses with subsequent HIV acquisition in
high-risk Kenyan female sex workers (FSWs). A randomized trial of monthly
antibiotic prophylaxis to prevent sexually transmitted disease/HIV infection was
performed from 1998 to 2002 in HIV-uninfected Kenyan FSWs. After the
completion of trial, FSWs who had acquired HIV (cases) were matched 1 : 4 with
persistently uninfected controls based on study arm, duration of HIV-
seronegative follow-up, and time of cohort enrolment. Blinded investigators
assayed the ability at enrolment of genital IgA to neutralize primary HIV isolates
as well as systemic HIV-specific cellular IFNy-modified enzyme-linked
immunospot and proliferativeresponses. The study cohort comprised 113 FSWs:
24 cases who acquired HIV and 89 matched controls. Genital HIV-neutralizing
3
IgA was associated with reduced HIV acquisition (P = 0.003), as was HIV-specific
proliferation (P = 0.002), and these associations were additive. HIV-specific IFNg
production did not differ between case and control groups. In multivariable
analysis, HIV-neutralizing IgA and HIV-specific proliferation each remained
independently associated with lack of HIV acquisition. Genital herpes (HSV2)
was associated with increased HIV risk and with reduced detection of HIV-
neutralizing IgA. Genital HIV-neutralizing IgA and systemic HIV-specific
proliferative responses, assayed by blinded investigators, were prospectively
associated with HIV nonacquisition. The induction of these immune responses
may be an important goal for HIV vaccines. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | PROSPECTIVE STUDIES | SEX

WORKERS | HIV | BLOOD | LABORATORY PROCEDURES | EXPOSURE
| AUTOIMMUNE RESPONSE | DEVELOPING COUNTRIES | AFRICA,
EASTERN | AFRICA, SUB SAHARAN | AFRICA | STUDIES | RESEARCH
METHODOLOGY | SEX BEHAVIOR | BEHAVIOR | HIV INFECTIONS |
VIRAL DISEASES | DISEASES | HEMIC SYSTEM | PHYSIOLOGY |
BIOLOGY | LABORATORY EXAMINATIONS AND DIAGNOSES |
EXAMINATIONS AND DIAGNOSES | MEDICAL PROCEDURES |
MEDICINE | HEALTH SERVICES | DELIVERY OF HEALTH CARE |
HEALTH | RISK FACTORS | ANTIBODIES | IMMUNOLOGIC FACTORS
| IMMUNITY | IMMUNE SYSTEM
Engendering health sector responses to sexual violence and HIV in

Kenya: Results of a qualitative study.
Author: Kilonzo N; Taegtmeyer M; Molyneux C; Kibaru J; Kimonji V
Source: AIDS Care. 2008 Feb;20(2):188-190.
Abstract: In Kenya many people who have been affected by sexual violence turn to the
health sector for clinical treatment and preventive therapies. This interface
provides a vital opportunity to impact on
the dual epidemics of HIV and sexual violence. Despite this, the uptake of post-
rape care services in health facilities as low and health care providers felt ill-
prepared to deal with the consequences of sexual violence. A qualitative study
was conducted to better understand the reasons for the low uptake of services
and to establish perceptions of sexual violence in Kenya. Thirty-four key
informants were interviewed and sixteen focus group discussions with women
and men were held in three districts in Kenya. Blurred boundaries between
forced and consensual sex emerged. Important implications for the delivery of
4
HIV post exposure prophylaxis (PEP) after sexual violence include the need for
gender-aware patient-centred training for health providers and for HIV PEP
interventions to strengthen on-going HIV-prevention counselling efforts. Further
research needs to determine the feasibility of on-going risk reduction measures
in the context of PEP delivery. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | QUALITATIVE RESEARCH |

INTERVIEWS | FOCUS GROUPS | SEXUAL ABUSE | RAPE | GENDER
ISSUES | HIV | HEALTH PERSONNEL | HEALTH SERVICES |
AWARENESS | DEVELOPING COUNTRIES | AFRICA, EASTERN |
AFRICA, SUB SAHARAN | AFRICA | RESEARCH METHODOLOGY |
DATA COLLECTION | CRIME | SOCIAL PROBLEMS | SOCIOCULTURAL
FACTORS | HIV INFECTIONS | VIRAL DISEASES | DISEASES |
DELIVERY OF HEALTH CARE | HEALTH | KNOWLEDGE
Reduced rates of HIV acquisition during unprotected sex by Kenyan

female sex workers predating population declines in HIV prevalence.
Author: Kimani J; Kaul R; Nagelkerke NJ; Luo M; MacDonald KS
Source: AIDS. 2008 Jan 2;22(1):131-137.
Abstract: Female sex workers (FSWs) form a core group at high risk of both sexual HIV
acquisition and secondary transmission. The magnitude of these risks may vary
by sexual risk taking, partner HIV prevalence, host immune factors and genital
co-infections. We examined temporal trends in HIV prevalence and per-act
incidence, adjusted for behavioral and other variables, in FSWs from Nairobi,
Kenya. An open cohort of FSWs followed since 1985. Behavioral and clinical data
were collected six monthly from 1985 to 2005, and sexually transmitted infection
(STI) diagnostics and HIV serology performed. A Cox proportional hazards
model with time-dependent covariables was used to estimate infection risk as a
function of calendar time. HIV prevalence in new FSW enrollees peaked at 81%
in 1986, and was consistently below 50% after 1997. Initially uninfected FSWs
remained at high risk of acquiring HIV throughout the study period, but the rate
of HIV acquisition during unprotected sex with a casual client declined by
overfour-fold. This reduction correlated closely with decreases in gonorrhea
prevalence, and predated reductions in the Kenyan HIV population prevalence
by over a decade. The per-act rate of HIV acquisition in high-risk Nairobi FSWs
fell dramatically between 1985 and 2005. This decline may represent the impact
of improved STI prevention/therapy, immunogenetic shifts in at-risk women, or
changes in the proportion of HIV exposures occurring with clients who had
acute HIV infection. Declining HIV incidence in high-risk cohorts may predict
5
and/or be causally related to future reductions in population prevalence.

(author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | EPIDEMIOLOGIC METHODS | COHORT

ANALYSIS | MATHEMATICAL MODEL | LONGITUDINAL STUDIES |
SEX WORKERS | WOMEN IN DEVELOPMENT | HIV POSITIVE PERSONS
| HIV INFECTIONS | SEX BEHAVIOR | RISK BEHAVIOR | PREVALENCE
| Developing Countries | Africa, Eastern | Africa, Sub Saharan | Africa |
Research Methodology | Models, Theoretical | Studies | Behavior |
Economic Development | Economic Factors | Persons Living With HIV/AIDS
| Viral Diseases | Diseases | Measurement
Provider characteristics among staff providing care to sexually

transmitted infection self-medicating patients in retail pharmacies in
Kibera Slum, Nairobi, Kenya.
Author: Kwena Z; Sharma A; Wamae N; Muga C; Bukusi E
Source: Sexually Transmitted Diseases. 2008 May;35(5):480-483.
Abstract: The objectives were to evaluate the characteristics of providers in management of

STI self-medicating patients in retail pharmacies within the largest informal
settlement in Kenya. We collected sociodemographic, training, and work history
attributes among pharmacy staff from a convenience sample of 50 retail
pharmacies in Kibera slum using a self-administered questionnaire. We gathered
the required data in 8 weeks, collecting completed self-administered
questionnaires within 7 to 14 days after distribution. Two data collectors
subsequently presented at these pharmacies as mystery patients seeking care for
symptoms of genital ulcer disease and gonorrhea and completed a structured
observation form within 10 minutes of leaving the pharmacy. Approximately
half the respondents were men aged less than 28 years. Over 90% had 12 years of
formal education and an additional 3 years of medical professional training. Two
thirds (66%) had been trained in Government institutions. About 65% reported
that patients presented without prescriptions, and 45% noted that patients
requested specific medicines but were open to advice. One-third (36%) of the
patients used the pharmacy as their first point of care. Using mystery patients to
evaluate syndromic management of gonorrhea and genital ulcer disease, only
10% offered appropriate treatment per the Kenya Ministry of Health STI
syndromic management guidelines. Although the majority of the pharmacy staff
in this informal settlement have some medical training and some experience, a
very low proportion offered adequate treatment for 2 common STIs. (author's)
6
Language: English

QUESTIONNAIRES | PROVIDERS WITH CLIENTS | PHARMACIES |
TRAINING PROGRAMS | SEXUALLY TRANSMITTED DISEASES |
GONORRHEA | SIGNS AND SYMPTOMS | ANTIBIOTICS |
ADMINISTRATION AND DOSAGE | DEVELOPING COUNTRIES |
AFRICA, EASTERN | AFRICA, SUB SAHARAN | AFRICA | RESEARCH
METHODOLOGY | HEALTH SERVICES | DELIVERY OF HEALTH CARE |
HEALTH | HEALTH FACILITIES | EDUCATION | REPRODUCTIVE
TRACT INFECTIONS | INFECTIONS | DISEASES | DRUGS |
TREATMENT | MEDICAL PROCEDURES | MEDICINE
Associations of human leukocyte antigen DRB with resistance or

susceptibility to HIV-1 infection in the Pumwani Sex Worker Cohort.
Author: Lacap PA; Huntington JD; Luo M; Nagelkerke NJ; Bielawny T
Source: AIDS.2008;22(9):1029-1038.
Abstract: A group of commercial sex workers in the Pumwani Sex Worker Cohort,
established in 1985 in Nairobi, Kenya, remain HIV-1 uninfected despite heavy
exposure to HIV-1 through active sex work. Previous studies showed that this
resistance is associated with a strong CD4+ T-cell response, which suggested that
human leukocyte antigen class II antigens are important in
resistance/susceptibility to HIV-1 infection. DRB1 is the most polymorphic locus
among class II genes and forms haplotypes with DRB3, DRB4 and DRB5. The
aim of this study is to investigate the role of DRB alleles/haplotypes on
resistance/susceptibility to HIV-1 infection. In total, 1090 women enrolled in the
Pumwani cohort were genotyped for DRB1, DRB3, DRB4 and DRB5 using a
high-resolution sequence-based method. Allele/ haplotype frequencies were
compared between HIV-positive women and women who have remained HIV
negative for more than 3 years despite frequent exposure. Human leukocyte
antigen DRB genes were amplified, sequenced and genotyped using a two-step
sequence-based method. Allele/haplotype frequencies were determined using
PyPop32-0.6.0. Statistical analysis was conducted using SPSS 11.0 for Windows.
Three DRB1 alleles were associated with resistance: DRB1 010101 (P = 0.016; odd
ratio (OR): 2.55; 95% confidence interval (CI): 1.16-5.61), DRB1 010201 (P = 0.019;
OR: 1.86; 95% CI: 1.10-3.15), and DRB1 1102 (P = 0.025; OR: 1.72; 95% CI: 1.07-
2.78). DRB1 030201 (P = 0.038; OR: 0.48; 95% CI: 0.23-0.98), DRB1 070101 (P =
0.035; OR: 0.54; 95% CI: 0.30-0.97), DRB1 1503 (P = 0.0004; OR: 0.34; 95% CI: 0.19-
0.64), and DRB5 010101 (P = 0.001; OR: 0.37; 95% CI: 0.20-0.67) were associated
with susceptibility. The haplotype DRB1 1102-DRB3 020201 was associated with
7
HIV-1 resistance (P = 0.041; OR: 1.68; 95% CI: 1.02-2.78), whereas the haplotypes
DRB1 070101-DRB4 01010101 (P = 0.041; OR: 0.52; 95% CI: 0.28-0.98) and DRB1
1503-DRB5 01010101 (P = 0.0002; OR: 0.30; 95% CI: 0.15-0.58) were associated
with susceptibility. These associations with resistance/susceptibility to HIV-1
were independent of previously reported alleles HLA-DRB1 01 and HLA-A 2301.
Our findings indicate that human leukocyte antigen DRB-specific CD4+ T-cell
responses are an important factor in resistance/susceptibility to HIV-1 infection.
(author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | GENETIC TECHNICS | SEX WORKERS |

WOMEN | PERSONS LIVING WITH HIV/AIDS | IMMUNITY, NATURAL |
LABORATORY PROCEDURES | DEVELOPING COUNTRIES | AFRICA,
EASTERN | AFRICA, SUB SAHARAN | AFRICA | LABORATORY
EXAMINATIONS AND DIAGNOSES | EXAMINATIONS AND
DIAGNOSES | MEDICAL PROCEDURES | MEDICINE | HEALTH
SERVICES | DELIVERY OF HEALTH CARE | HEALTH | SEX BEHAVIOR |
BEHAVIOR | DEMOGRAPHIC FACTORS | POPULATION | HIV
INFECTIONS | VIRAL DISEASES | DISEASES | IMMUNITY | IMMUNE
SYSTEM | PHYSIOLOGY | BIOLOGY
Early effects of antiretroviral therapy on work performance: Preliminary

results from a cohort study of Kenyan agricultural workers.
Author: Larson BA; Fox MP; Rosen S; Bii M; Sigei C
Source: AIDS, 2008 Jan 30;22(3):421-425.
Abstract: This paper estimates the impact of antiretroviral therapy (ART) on days
harvesting tea per month for tea-estate workers in Kenya. Such information is
needed to assess the potential economic benefits of providing treatment to
working adults. Data for this analysis come from company payroll records for 59
HIV-infected workers and a comparison group of all workers assigned to the
same work teams (reference group, n = 1992) for a period covering 2 years before
and 1 year after initiating ART. Mean difference tests were used to obtain overall
trends in days harvesting tea by month. A difference in difference approach was
used to estimate the impact of HIV/AIDS on days working in the pre-ART
period. Information on likely trends in the absence of the therapy was used to
estimate the positive impacts on days harvesting tea over the initial 12 months on
ART. No significant difference existed in days plucking tea each month until the
ninth month before initiating ART, when workers worked -2.79 fewer days than
references (15% less). This difference grew to 5.09 fewer days (27% less) in the
8
final month before initiating ART. After 12 months on ART, we conservatively

estimate that workers worked at least twice as many days in the month than they
would have in the absence of ART. Treatment had a large, positive impact on the
ability of workers to undertake their primary work activity, harvesting tea, in the
first year on ART. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | COHORT ANALYSIS | AGRICULTURAL

WORKERS | PERSONS LIVING WITH HIV/AIDS | ANTIRETROVIRAL
THERAPY | PERFORMANCE IMPROVEMENT | TREATMENT | COST
EFFECTIVENESS | DEVELOPING COUNTRIES | AFRICA, EASTERN |
AFRICA, SUB SAHARAN | AFRICA | RESEARCH METHODOLOGY |
LABOR FORCE | HUMAN RESOURCES | ECONOMIC FACTORS | HIV
INFECTIONS | VIRAL DISEASES | DISEASES | HIV | MANAGEMENT |
ORGANIZATION AND ADMINISTRATION | MEDICAL PROCEDURES |
HEALTH | EVALUATION INDEXES | QUANTITATIVE EVALUATION |
EVALUATION
HIV-1 persists in breast milk cells despite antiretroviral treatment to

prevent mother-to-child transmission.
Author: Lehman DA; Chung MH; John-Stewart GC; Richardson BA; Kiarie J
Source: AIDS. 2008 Jul;22(12):1475-1485.
Abstract: The effects of short-course antiretrovirals given to reduce mother-to-child

transmission (MTCT) on temporal patterns of cell-associated HIV-1 RNA and
DNA in breast milk are not well defined. Women in Kenya received short-course
zidovudine (ZDV), single-dose nevirapine (sdNVP), combination ZDV/sdNVP
or short-course highly active antiretroviral therapy (HAART). Breast milk
samples were collected two to three times weekly for 4-6 weeks. HIV-1 DNA was
quantified by real-time PCR. Cell-free and cellassociated RNA levels were
quantified by the Gen-Probe HIV-1 viral load assay. Cell-free HIV-1 RNA levels
in breast milk were significantly suppressed by sdNVP, ZDV/sdNVP or HAART
therapy compared with ZDV between day 3 and week 4 postpartum (P < or =
0.03). Breast milk HIV-1 DNA levels (infected cell levels) were not significantly
different between treatment arms at any timepoint during the 4-6-week follow-
up. At 3 weeks postpartum, when the difference in cell-free RNA levels was the
greatest comparing HAART directly with ZDV (P=0.0001), median log10 HIV-1
DNA copies per 1_106 cells were 2.78, 2.54, 2.69, and 2.31 in the ZDV, sdNVP,
ZDV/sdNVP and HAART arms, respectively (P=0.23). Cell-associated HIV-1
9
RNA levels were modestly suppressed in HAART versus ZDV/sdNVP during

week 3 (3.37 versus 4.02, P=0.04), as well as over time according to a linear
mixed-effects model. Cell-free and, to a lesser extent, cell-associated HIV-1 RNA
levels in breast milk were suppressed by antiretroviral regimens used to prevent
MTCT. However, even with HAART, there was no significant reduction in the
reservoir of infected cells, which could contribute to breast milk HIV-1
transmission. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | CLINICAL RESEARCH | MOTHERS |

PERSONS LIVING WITH HIV/AIDS | BREASTFEEDING | PREVENTION
OF MOTHER-TO-CHILD TRANSMISSION | ANTIRETROVIRAL
THERAPY | DEVELOPING COUNTRIES | AFRICA, EASTERN | AFRICA,
SUB SAHARAN | AFRICA | RESEARCH METHODOLOGY | PARENTS |
HOUSEHOLD | SOCIOCULTURAL FACTORS | HIV INFECTIONS |
VIRAL DISEASES | DISEASES | INFANT NUTRITION | NUTRITION |
HEALTH | DISEASE TRANSMISSION CONTROL | PREVENTION AND
CONTROL | HIV
Economic status, informal exchange, and sexual risk in Kisumu, Kenya.
Author: Luke N
Source: Economic Development and Cultural Change. 2008 Jan;56(2):375-396.
Abstract: Despite the escalating attention focused on the role of informal exchange in
fueling the HIV/AIDS epidemic in Africa, there has been no empirical
investigation of the connection between economic status, transfers, and sexual
risk behavior. One potential reason for the paucity of studies examining these
important linkages is the lack of quality data on economic status in African
populations and transfers within sexual partnerships. I overcome this
shortcoming by using survey data I collected in urban Kisumu that contain
information on the economic status of working-age men and sexual risk behavior
in their nonmarital partnerships. Mine is also one of the only existing surveys to
collect detailed data on men's involvement in informal exchange relationships
and the value of transfers given to their partners. In this article, I investigate
various mechanisms through which economic status is associated with sexual
risk behavior, as measured by the nonuse of condoms within sexual
partnerships, to shed light on the role that wealthy men play in spreading
infection in a high HIV/AIDS environment. (excerpt)
10
Language: English
Keywords: KENYA | RESEARCH REPORT | SURVEYS | MEN | INCOME | SEX

BEHAVIOR | RISK BEHAVIOR | CONDOM USE | HIV TRANSMISSION |
ECONOMIC FACTORS | SUGAR DADDIES | DEVELOPING COUNTRIES
| AFRICA, EASTERN | AFRICA, SUB SAHARAN | AFRICA | SAMPLING
STUDIES | STUDIES | RESEARCH METHODOLOGY | DEMOGRAPHIC
FACTORS | POPULATION | SOCIOECONOMIC FACTORS | BEHAVIOR
| RISK REDUCTION BEHAVIOR | HIV INFECTIONS | VIRAL DISEASES
| DISEASES
A prospective study of risk factors for bacterial vaginosis in HIV-1-

seronegative African women.
Author: McClelland RS; Richardson BA; Graham SM; Masese LN; Gitau R
Source: Sexually Transmitted Diseases. 2008 Jun;35(6):617-623.
Abstract: Bacterial vaginosis (BV) is common and has been associated with increased HIV-
1 susceptibility. The objective of this study was to identify risk factors for BV in
African women at high risk for acquiring HIV-1. We conducted a prospective
study among 151 HIV-1-seronegative Kenyan female sex workers. Nonpregnant
women were eligible if they did not have symptoms of abnormal vaginal itching
or discharge at the time of enrollment. At monthly follow-up, a vaginal
examination and laboratory testing for genital tract infections were performed.
Multivariate Andersen-Gill proportional hazards analysis was used to identify
correlates of BV. Participants completed a median of 378 (interquartile range 350-
412) days of follow-up. Compared with women reporting no vaginal washing,
those who reported vaginal washing 1 to 14 [adjusted hazard ratio (aHR) 1.29,
95% confidence interval (CI) 0.88-1.89], 15 to 28 (aHR 1.60, 95% CI 0.98 -2.61), and
greater than 28 times/wk (aHR 2.39, 95% CI 1.35-4.23) were at increased risk of
BV. Higher BV incidence was also associated with the use of cloth for
intravaginal cleansing (aHR 1.48, 95% CI 1.06 -2.08) and with recent unprotected
intercourse (aHR 1.75, 95% CI 1.47-2.08). Women using depot
medroxyprogesterone acetate contraception were at lower risk for BV (aHR 0.59,
95% CI 0.48-0.73). Vaginal washing and unprotected intercourse were associated
with increased risk of BV. These findings could help to inform the development
of novel vaginal health approaches for HIV-1 risk reduction in women. (author's)
Language: English

WORKERS | VAGINOSIS | RISK FACTORS | LABORATORY
EXAMINATIONS AND DIAGNOSES | SEX BEHAVIOR | HYGIENE |
11
DEPO-PROVERA | DEVELOPING COUNTRIES | AFRICA, EASTERN |

AFRICA, SUB SAHARAN | AFRICA | STUDIES | RESEARCH
METHODOLOGY | BEHAVIOR | VAGINAL ABNORMALITIES |
DISEASES | BIOLOGY | EXAMINATIONS AND DIAGNOSES | MEDICAL
HEALTH CARE | HEALTH | PUBLIC HEALTH |
MEDROXYPROGESTERONE ACETATE | CONTRACEPTIVE AGENTS,
PROGESTIN | CONTRACEPTIVE AGENTS, FEMALE | CONTRACEPTIVE
AGENTS | CONTRACEPTION | FAMILY PLANNING
An outcome assessment of an ABC-based HIV peer education intervention among Kenyan

university students.
Author: Miller AN; Mutungi M; Facchini E; Barasa B; Ondieki W
Source: Journal of Health Communication. 2008 Jun;13(4):345-356.
Abstract: This study reports an outcome assessment on an HIV peer education

intervention at the main campus of Kenyatta University in Nairobi, Kenya. A
quasiexperimental separate sample pretest-posttest design was used. Campus-
wide baseline and endline surveys were conducted with 632 and 746 students,
respectively, soliciting information on HIV-related knowledge, attitudes, and
behavior. After 2 years of on-campus intervention, no changes in behavior were
evident with respect to either abstinence or number of sexual partners. Small but
statistically significant changes were found in condom attitudes and behavior,
and a large increase in HIV testing was evident. It is recommended that future
research more specifically compare abstinence versus multiple option peer
education programs, giving special attention to the role of peer educators as
models. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | PRE-POST TESTS | STUDENTS | HIV

PREVENTION | PEER EDUCATORS | INTERVENTIONS | PROGRAM
EVALUATION | PROGRAM EFFECTIVENESS | HIV TESTING |
CONDOM USE | BEHAVIOR CHANGE | ABSTINENCE | MULTIPLE
PARTNERS | DEVELOPING COUNTRIES | AFRICA, EASTERN | AFRICA,
SUB SAHARAN | AFRICA | PROGRAMS | ORGANIZATION AND
ADMINISTRATION | EDUCATION | HIV INFECTIONS | VIRAL
DISEASES | DISEASES | LABORATORY EXAMINATIONS AND
HEALTH CARE | HEALTH | RISK REDUCTION BEHAVIOR | BEHAVIOR
| FAMILY PLANNING, BEHAVIORAL METHODS | FAMILY PLANNING |
12
SEXUAL PARTNERS | SEX BEHAVIOR
AIDS and kitchen gardens: insights from a village in western Kenya.
Author: Murphy LL
Source: Population and Environment. 2008 May;29(3-5):133-161.
Abstract: In rural Africa, indigenous farming and natural resource management systems
exemplified by kitchen gardens are being reshaped by the HIV/AIDS epidemic
and its negative impacts (illness, stigma and mortality, and economic costs) and
positive opportunities (organizational responses to the epidemic). Subtle changes
in crops and farm techniques can be traced to these diverse influences of HIV+
infection, illness, mortality, widowhood, foster child care, and AIDS support
groups, as well as the organizations, ideas, and flow of funding from outside.
These findings draw on original field data: a village census, in-depth interviews
with gardeners, and group discussions in a village in Bungoma District (in 2005
and 2007). This part of western Kenya is a typical small-farm zone that has faced
a moderate HIV/AIDS epidemic since the 1990s, following decades of
demographic, environmental, technological, and institutional changes.
Implications of this case study for further research on HIV/AIDS and on micro-
level population-environment change suggest that households are useful but
imperfect analytical units and are best seen as part of complex social networks,
shaping connections to markets. These important "mediating institutions" link
AIDS as a demographic and economic force with environmental outcomes in
cultivated landscapes. (Author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | INTERVIEWS | HIV INFECTIONS |

EPIDEMICS | RURAL POPULATION | AGRICULTURAL DEVELOPMENT
| LIVELIHOOD | HOUSEHOLDS | SOCIAL NETWORKS | AFRICA,
EASTERN | AFRICA, SUB SAHARAN | AFRICA | DEVELOPING
COUNTRIES | DATA COLLECTION | RESEARCH METHODOLOGY |
VIRAL DISEASES | DISEASES | POPULATION CHARACTERISTICS |
DEMOGRAPHIC FACTORS | POPULATION | RURAL DEVELOPMENT |
ECONOMIC FACTORS | RESOURCES | ORGANIZATION AND
ADMINISTRATION | FAMILY AND HOUSEHOLD | SOCIOCULTURAL
FACTORS | FRIENDS AND RELATIVES
13
Sexual risk behaviour and HAART: A comparative study of HIV-

infected persons on HAART and on preventive therapy in Kenya.
Author: Sarna A; Luchters SM; Geibel S; Kaai S; Munyao P
Source: International Journal of STD and AIDS. 2008 Feb;19(2):85-89.
Abstract: Unprotected sex (UPS) among persons receiving highly active antiretroviral
therapy (HAART) remains a concern because of the risk of HIV-transmission. A
cross-sectional study comparing the sexual risk behaviour of 179 people living
with HIV/AIDS (PLHA) receiving HAART with that of 143 PLHA receiving
preventive therapy (PT) with cotrimoxazole/isoniazid was conducted in
Mombasa, Kenya. Forty-five percent of all participants were sexually active in
the last six months. Participants receiving PT were more likely to report greater
than or equal to 2 partners (13% vs. 1%; P = 0.006). Participants receiving PT
reported more UPS with regular partners (odds ratio [OR]: 3.9; 95% confidence
interval [CI]: 1.8-8.4) and also more sexually transmitted infections (STI)
symptoms (OR: 1.7; 95% CI: 1.0-2.8; P = 0.059). More than 40% of all participants
did not know the HIV-status of regular partners. Therefore, HAART was not
associated with increased sexual risk behaviours though considerable risk of
HIV-transmission remains. HIV-care services need to emphasize partner testing
and consistent condom use with all partners. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | COMPARATIVE STUDIES | CROSS

SECTIONAL ANALYSIS | HIV POSITIVE PERSONS | SEX BEHAVIOR |
RISK BEHAVIOR | SEXUALLY TRANSMITTED DISEASES | HIV
INFECTIONS | ANTIRETROVIRAL THERAPY | TREATMENT | HIV
PREVENTION | DEVELOPING COUNTRIES | AFRICA, EASTERN |
METHODOLOGY | PERSONS LIVING WITH HIV/AIDS | VIRAL
DISEASES | DISEASES | BEHAVIOR | REPRODUCTIVE TRACT
INFECTIONS | INFECTIONS | HIV | MEDICAL PROCEDURES |
HEALTH
14
Sexual identity and risk of HIV / STI among men who have sex with men
in Nairobi.
Author: Sharma A; Bukusi E; Gorbach P; Cohen CR; Muga C
Source: Sexually Transmitted Diseases. 2008 Apr;35(4):352-354.
Abstract: Although there is great regional variation, a significant proportion of those with
human immunodeficiency virus (HIV/ AIDS) globally are men who have sex
with men (MSM) due to the high efficiency of transmission via anal intercourse.
This relatively small number of individuals may be disproportionately at risk of
HIV transmission vis-a-vis the wider population, particularly in countries where
social or legal retribution accompanies public disclosure. Recent short-term
estimates suggest that of the approximately 82,300 new HIV infections in Kenya
in 2005, 4.5% were in MSM. The incidence among these men may be even higher,
as the models assumed that only 1% of the male population had sex with men
and did not account for male sex workers in this population. The success of
HIV/sexually transmitted infections (STI) education, prevention and treatment
programs for MSM will depend on understanding the diversity of identities,
roles, and situations in this subpopulation. By the late 1990s, a growing body of
scientific literature revealed that some men in Africa had sexual intercourse with
men, that some of these men also had sex with women and that these men were
at significant risk for HIV/ STI. In Kenya, researchers lamented the lack of data
on MSM and suggested that in the absence of social sanction or legal rights,
MSM in Kenya would deny having male sexual partners, engage in clandestine
sex, and take social cover in marriage. (excerpt)
Language: English
Keywords: KENYA | RESEARCH REPORT | SAMPLING STUDIES | KAP SURVEYS |

EPIDEMIOLOGIC METHODS | MEN HAVING SEX WITH MEN | URBAN
POPULATION | SEXUALITY | ANAL SEX | HIV TRANSMISSION | RISK
BEHAVIOR | SEX BEHAVIOR | UTILIZATION OF HEALTH CARE |
SAHARAN | AFRICA | STUDIES | RESEARCH METHODOLOGY |
SURVEYS | BEHAVIOR | POPULATION CHARACTERISTICS |
DEMOGRAPHIC FACTORS | POPULATION | PERSONALITY |
PSYCHOLOGICAL FACTORS | HIV INFECTIONS | VIRAL DISEASES |
DISEASES | HEALTH SERVICES | DELIVERY OF HEALTH CARE |
HEALTH
15
Working with risk: Occupational safety issues among healthcare workers

in Kenya.
Author: Taegtmeyer M; Suckling RM; Nguku PM; Meredith C; Kibaru J
Source: AIDS Care. 2008 Mar;20(3):304-310.
Abstract: The objective of this study was to explore knowledge of, attitudes towards and
practice of post-exposure prophylaxis (PEP) among healthcare workers (HCWs)
in the Thika district, Kenya. We used site and population-based surveys,
qualitative interviews and operational research with 650 staff at risk of
needlestick injuries (NSIs). Research was conducted over a 5-year period in five
phases: (1) a bio-safety assessment; (2) a staff survey: serum drawn for
anonymous HIV testing; (3) interventions: biosafety measures, antiretrovirals for
PEP and hepatitis B vaccine; (4) a repeat survey to assess uptake and
acceptability of interventions; in-depth group and individual interviews were
conducted; and (5) health system monitoring outside a research setting. The main
outcome measures were bio-safety standards in clinical areas, knowledge,
attitudes and practice as regards to PEP, HIV-sero-prevalence in healthcare
workers, uptake of interventions, reasons for poor uptake elucidated and
sustainability indicators. Results showed that HCWs had the same HIV sero-
prevalence as the general population but were at risk from poor bio-safety. The
incidence of NSIs was 0.97 per healthcare worker per year. Twenty-one percent
had had an HIV test in the last year. After one year there was a significant drop
in the number of NSIs (OR: 0.4; CI: 0.3-0.6; p less than 0.001) and a significant
increase in the number of HCWs accessing HIV testing (OR: 1.55; CI: 1.2-2.1; p =
0.003). In comparison to uptake of hepatitis B vaccination (88% of those requiring
vaccine) the uptake of PEP was low (4% of those who had NSIs). In-depth
interviews revealed this was due to HCWs fear of HIV testing and their
perception of NSIs as low risk. We concluded that Bio-safety remains the most
significant intervention through reducing the number of NSIs. Post-exposure
prophylaxis can be made readily available in a Kenyan district. However, where
HIV testing remains stigmatised uptake will be limited*particularly in the initial
phases of a programme. (author's)
Language: English
Keywords: KENYA | ADMINISTRATIVE DISTRICTS | RESEARCH REPORT | KAP

SURVEYS | EPIDEMIOLOGIC METHODS | OPERATIONS RESEARCH |
FOCUS GROUPS | HEALTH PERSONNEL | OCCUPATIONAL HEALTH |
SAFETY | NEEDLE PIERCING | ACCIDENTS AND INJURIES | HIV
TESTING | HIV TRANSMISSION | PREVALENCE | DEVELOPING
GEOGRAPHIC FACTORS | POPULATION | SURVEYS | SAMPLING
STUDIES | STUDIES | RESEARCH METHODOLOGY | PROGRAM
EVALUATION | PROGRAMS | ORGANIZATION AND
ADMINISTRATION | DATA COLLECTION | DELIVERY OF HEALTH
16
CARE | HEALTH | PUBLIC HEALTH | RISK BEHAVIOR | BEHAVIOR |

LABORATORY EXAMINATIONS AND DIAGNOSES | EXAMINATIONS
AND DIAGNOSES | MEDICAL PROCEDURES | MEDICINE | HEALTH
SERVICES | HIV INFECTIONS | VIRAL DISEASES | DISEASES |
MEASUREMENT
Reasons for unsatisfactory acceptance of antiretroviral treatment in the

urban Kibera slum, Kenya.
Author: Unge C; Johansson A; Zachariah R; Some D; Van Engelgem I
Source: AIDS Care. 2008 Feb;20(2):146-149.
Abstract: The aim of this study was to explore why patients in the urban Kibera slum,
Nairobi, Kenya, offered free antiretroviral treatment (ART) at the Medecins Sans
Frontiers (MSF) clinic, choose not to be treated despite signs of AIDS. Qualitative
semi-structured interviews were conducted with 26 patients, 9 men and 17
women. Six main reasons emerged for not accepting ART: a) fear of taking
medication on an empty stomach due to lack of food; b) fear that side-effects
associated with ART would make one more ill; c) fear of disclosure and its
possible negative repercussions; d) concern for continuity of treatment and care;
e) conflicting information from religious leaders and community, and seeking
alternative care (e.g. traditional medicine); f) illiteracy making patients unable to
understand the information given by health workers. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | KAP SURVEYS | PERSONS LIVING

WITH HIV/AIDS | URBAN POPULATION | SLUMS | ANTIRETROVIRAL
THERAPY | USER COMPLIANCE | FEAR | SIDE EFFECTS | SOCIAL
DISCRIMINATION | RELIGIOUS ASPECTS | TRADITIONAL HEALTH
PRACTICES | ILLITERACY | BELIEFS | DEVELOPING COUNTRIES |
AFRICA, EASTERN | AFRICA, SUB SAHARAN | AFRICA | SURVEYS |
SAMPLING STUDIES | STUDIES | RESEARCH METHODOLOGY | HIV
INFECTIONS | VIRAL DISEASES | DISEASES | POPULATION
URBANIZATION | URBAN POPULATION DISTRIBUTION |
POPULATION DISTRIBUTION | GEOGRAPHIC FACTORS | HIV |
BEHAVIOR | EMOTIONS | PSYCHOLOGICAL FACTORS | TREATMENT
| MEDICAL PROCEDURES | MEDICINE | HEALTH SERVICES |
DELIVERY OF HEALTH CARE | HEALTH | SOCIAL PROBLEMS |
SOCIOCULTURAL FACTORS | RELIGION | CULTURE | EDUCATIONAL
STATUS | SOCIOECONOMIC STATUS | SOCIOECONOMIC FACTORS |
17
ECONOMIC FACTORS
HIV treatment.
Language: English

18

Author: Kimani J; Kaul R; Nagelkerke NJ; Luo M; MacDonald KS
Source: AIDS. 2008 Jan 2;22(1):131-137.
Abstract: Female sex workers (FSWs) form a core group at high risk of both sexual HIV
Kenya. An open cohort of FSWs followed since 1985. Behavioral and clinical data
were collected six monthly from 1985 to 2005, and sexually transmitted infection
(STI) diagnostics and HIV serology performed. A Cox proportional hazards
model with time-dependent covariables was used to estimate infection risk as a
function of calendar time. HIV prevalence in new FSW enrollees peaked at 81%
in 1986, and was consistently below 50% after 1997. Initially uninfected FSWs
remained at high risk of acquiring HIV throughout the study period, but the rate
of HIV acquisition during unprotected sex with a casual client declined by
overfour-fold. This reduction correlated closely with decreases in gonorrhea
prevalence, and predated reductions in the Kenyan HIV population prevalence
by over a decade. The per-act rate of HIV acquisition in high-risk Nairobi FSWs
fell dramatically between 1985 and 2005. This decline may represent the impact
of improved STI prevention/therapy, immunogenetic shifts in at-risk women, or
changes in the proportion of HIV exposures occurring with clients who had
acute HIV infection. Declining HIV incidence in high-risk cohorts may predict
and/or be causally related to future reductions in population prevalence.
(author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | EPIDEMIOLOGIC METHODS | COHORT

ANALYSIS | MATHEMATICAL MODEL | LONGITUDINAL STUDIES |
SEX WORKERS | WOMEN IN DEVELOPMENT | HIV POSITIVE PERSONS
| HIV INFECTIONS | SEX BEHAVIOR | RISK BEHAVIOR | PREVALENCE
| DEVELOPING COUNTRIES | AFRICA, EASTERN | AFRICA, SUB
SAHARAN | AFRICA | RESEARCH METHODOLOGY | MODELS,
THEORETICAL | STUDIES | BEHAVIOR | ECONOMIC DEVELOPMENT |
ECONOMIC FACTORS | PERSONS LIVING WITH HIV/AIDS | VIRAL
19
DISEASES | DISEASES | MEASUREMENT
Lessons learned in the conduct, validation, and interpretation of national

population based HIV surveys.
Author: Garcia Calleja JM; Marum LH; Carcamo CP; Kaetano L; Muttunga J
Source: AIDS. 2005 May;19 Suppl 2:S9-S17.
Abstract: In the past few years several countries have conducted national population-
based HIV surveys. Survey methods, levels of participation bias from absence or
refusal and lessons learned conducting such surveys are compared in four
national population surveys: Mali, Kenya, Peru and Zambia. In Mali, Zambia,
and Kenya, HIV testing of adult women and men was included in the national-
level demographic and health surveys carried out regularly in these countries,
whereas in Peru the national HIV survey targeted young people in 24 cities with
populations over 50 000. The household response rate was above 90% in all
countries, but some individuals were absent for interviews. HIV testing rates
were between 70 and 79% of those eligible, with higher test rates for women.
Three critical questions in this type of survey need to be answered: who did the
surveys miss; how much it matters that they were missed; and what can be done
to increase the participation of respondents so the coverage rates are adequate.
The level of representativeness of the populations tested was adequate in each
survey to provide a reliable national estimate of HIV prevalence that
complements other methods of HIV surveillance. Different lessons were learned
from each survey. These population-based HIV seroprevalence surveys
demonstrate that reliable and useful results can be obtained, although they
require careful planning and increased financial and human resource investment
to maximize responses at the household and individual level, which are key
elements to validate survey results. This review was initiated through an
international meeting on 'New strategies for HIV/ AIDS Surveillance in
Resource-constrained Countries' held in Addis Ababa on 26--30 January 2004 to
share and develop recommendations to guide future surveys. (author's)
Language: English
Keywords: MALI | KENYA | PERU | ZAMBIA | METHODOLOGICAL STUDIES |

DEMOGRAPHIC AND HEALTH SURVEYS | EPIDEMIOLOGIC METHODS
| HOUSEHOLDS | HIV INFECTIONS | PREVALENCE | DATA QUALITY
| AFRICA, WESTERN | AFRICA SOUTH OF THE SAHARA | AFRICA |
DEVELOPING COUNTRIES | AFRICA, EASTERN | SOUTH AMERICA,
WESTERN | SOUTH AMERICA | LATIN AMERICA | AMERICAS |
AFRICA, SOUTHERN | DEMOGRAPHIC SURVEYS | POPULATION
DYNAMICS | DEMOGRAPHIC FACTORS | POPULATION | RESEARCH
METHODOLOGY | FAMILY AND HOUSEHOLD | SOCIOCULTURAL
20
FACTORS | VIRAL DISEASES | DISEASES | MEASUREMENT | DATA

ANALYSIS
Prevention of mother-to-child transmission and voluntary counseling

and testing programme data: What is their utility for HIV surveillance?
Author: Hladik W; Masupu K; Roels T; Plipat T; Kaharuza F
Abstract: Antenatal clinic (ANC)-based surveillance through unlinked anonymous testing

(UAT) for HIV without informed consent provides solid long-term trend data in
resource-constrained countries with generalized epidemics. The rapid expansion
of the prevention of mother-to-child transmission (PMTCT) and voluntary
counseling and testing (VCT) programmes prompts the question regarding their
utility for HIV surveillance and their potential to replace UAT-based ANC
surveillance. Four presentations on the use of PMTCT or VCT data for HIV
surveillance were presented at a recent international conference. The main
findings are presented in this paper, and the operational and epidemiological
aspects of using PMTCT or VCT data for surveillance are considered. VCT data
in Uganda confirm the falling trend in HIV prevalence observed in ANC
surveillance. Thailand, a country with nationwide PMTCT coverage and a very
high acceptance of HIV testing, has replaced UAT data in favor of PMTCT data
for surveillance. Studies from Botswana and Kenya showed that PMTCT-based
HIV prevalences was similar, but the quality and availability of the PMTCT data
varied. The strength of UAT lies in the absence of selection bias and the
availability of individual data. Conversely, the quantity of VCT and PMTCT
programme testing data often exceed those in UAT, but may be subject to bias
due to self-selection or test refusal. When using VCT or PMTCT data for
surveillance, investigators must consider these caveats, as well as their varying
data quality, accessibility, and availability of individual records. (author's)
Language: English
Keywords: UGANDA | THAILAND | BOTSWANA | KENYA | METHODOLOGICAL

STUDIES | EPIDEMIOLOGIC METHODS | MOTHERS | INFANT |
MOTHER-TO-CHILD TRANSMISSION | HIV PREVENTION | DATA
QUALITY | BIAS | VOLUNTARY COUNSELING AND TESTING |
ANTENATAL CARE | DEVELOPING COUNTRIES | AFRICA, EASTERN |
AFRICA SOUTH OF THE SAHARA | AFRICA | ASIA, SOUTHEASTERN |
ASIA | AFRICA, SOUTHERN | RESEARCH METHODOLOGY | PARENTS
| FAMILY RELATIONSHIPS | FAMILY CHARACTERISTICS | FAMILY
AND HOUSEHOLD | SOCIOCULTURAL FACTORS | YOUTH | AGE
21
FACTORS | POPULATION CHARACTERISTICS | DEMOGRAPHIC

FACTORS | POPULATION | TRANSMISSION | INFECTIONS |
DISEASES | HIV INFECTIONS | VIRAL DISEASES | DATA ANALYSIS |
ERROR SOURCES | MEASUREMENT | HIV TESTING | LABORATORY
SERVICES | DELIVERY OF HEALTH CARE | HEALTH | MATERNAL
HEALTH SERVICES | MATERNAL-CHILD HEALTH SERVICES |
PRIMARY HEALTH CARE
Prevalence of HCV and HCV / HIV co-infection among in-patients at the

Kenyatta National Hospital.
Author: Karuru JW; Lule GN; Joshi M; Anzala O
Source: East African Medical Journal. 2005 Apr;82(4):170-172.
Abstract: The objective was to determine the prevalence of HCV and HCV/HIV co-
infection among medical in-patients at the Kenyatta National Hospital. Design:
Prospective cross-sectional descriptive study. Setting: Kenyatta National
Hospital, a tertiary referral and teaching hospital, in-patient department Subjects:
HIV/AIDS and HIV negative in-patients at KNH medical wards. Among 458
HIV/AIDS medical in-patients, the prevalence of HCV was 3.7% while in the 518
HIV negative patients, it was 4.4%. The prevalence of co-infection with HCV and
HIV was 3.7%. The incidence of risk factors in persons with HCV and/ or HIV
infection(s) was low. This study found the prevalence of HCV infection among
medical in-patients to be similar in HIV positive and HIV negative group of
patients. The co-infection rates were low, as were the risk factors for transmission
of these infections. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | CLINICAL RESEARCH | CROSS

SECTIONAL ANALYSIS | CLIENTS | HOSPITALS | HEPATITIS | HIV
INFECTIONS | PREVALENCE | RISK FACTORS | AFRICA, EASTERN |
AFRICA SOUTH OF THE SAHARA | AFRICA | DEVELOPING
COUNTRIES | RESEARCH METHODOLOGY | PROGRAM ACTIVITIES |
PROGRAMS | ORGANIZATION AND ADMINISTRATION | HEALTH
FACILITIES | DELIVERY OF HEALTH CARE | HEALTH | VIRAL
DISEASES | DISEASES |
22
Prevalence of HCV and HIV / HCV co-infection among volunteer blood

donors and VCT clients.
Author: Karuru JW; Lule GN; Joshi M; Anzala O
Source: East African Medical Journal. 2005 Apr;82(4):166-169.
Abstract: The objective was to determine the prevalence of HCV infection and HCV/HIV
co-infection among voluntary blood donors at the National Blood Transfusion
Centre and clients at the Kenyatta National Hospital HIV-Voluntary Counselling
and Testing (VCT) Centre. Design: A prospective cross-sectional descriptive
study. Setting: Kenyatta National Hospital, a tertiary referral and teaching
hospital and the National Blood Transfusion Services Centre, Nairobi. Subjects:
Volunteer blood donors and VCT attendants. The prevalence of HCV/HIV co-
infection among 6154 blood donors in the NBTSC was very low, at 0.02. The HIV
prevalence among the 353 KNH HIV-VCT clients was 9.3%, none of the clients
tested positive for HCV. The incidence of risk factors in the persons with HCV
and/or HIV infection(s) was low. The prevalence of HCV infection among pre-
screened volunteer blood donors was low. However the current practice of
screening all donated blood for HCV remains indispensable to prevent its
Language: English
Keywords: KENYA | RESEARCH REPORT | PROSPECTIVE STUDIES | PREVALENCE

| INCIDENCE | HIV POSITIVE PERSONS | CLIENTS | BLOOD DONORS
| VOLUNTARY COUNSELING AND TESTING | HIV INFECTIONS |
AFRICA, EASTERN | AFRICA SOUTH OF THE SAHARA | AFRICA |
DEVELOPING COUNTRIES | STUDIES | RESEARCH METHODOLOGY |
MEASUREMENT | PERSONS LIVING WITH HIV/AIDS | VIRAL
DISEASES | DISEASES | PROGRAM ACTIVITIES | PROGRAMS |
ORGANIZATION AND ADMINISTRATION | BLOOD SUPPLY |
EQUIPMENT AND SUPPLIES | MEDICAL PROCEDURES | MEDICINE |
HEALTH SERVICES | DELIVERY OF HEALTH CARE | HEALTH | HIV
TESTING | LABORATORY EXAMINATIONS AND DIAGNOSES |
EXAMINATIONS AND DIAGNOSES
23
High probability of female-to-male HIV-1 transmission for

uncircumcised men with multiple partners.
Author: Crabb C
Source: AIDS. 2005;19(10):N1. Notes and Quotes
Abstract: Compared to circumcised men, uncircumcised men are more than twice as likely
to acquire HIV-1 each time they have unprotected sex with an infected woman,
according to a team of researchers in the US and Kenya. The study----the first to
measure infectivity, or the probability of HIV-1 transmission per sex act, in a
context of multiple partnerships----also found that infectivity among men,
whether circumcised or not, who have several female partners is many fold
higher than estimates based on monogamous HIV-1 discordant couples. Jared
Baeten of the University of Washington in Seattle and his colleagues calculated
infectivity from data collected during a 4-year prospective study of 745 male
employees of six trucking companies in Mombasa, Kenya. Ninety-five of the men
were uncircumcised. In quarterly check-ups at a mobile research clinic that
visited the companies on a weekly basis, each participant reported his sexual
behavior with wives, casual partners and prostitutes during the previous 3
months. (excerpt)
Language: English
Keywords: UNITED STATES | KENYA | RESEARCH REPORT | PROSPECTIVE

STUDIES | MEN | WOMEN | HIV TRANSMISSION | MALE
CIRCUMCISION | MULTIPLE PARTNERS | RISK FACTORS | CONDOM
USE | NORTH AMERICA | AMERICAS | DEVELOPED COUNTRIES |
AFRICA, EASTERN | AFRICA, SUB SAHARAN | AFRICA | DEVELOPING
COUNTRIES | STUDIES | RESEARCH METHODOLOGY |
DEMOGRAPHIC FACTORS | POPULATION | HIV INFECTIONS | VIRAL
DISEASES | DISEASES | MEDICAL PROCEDURES | MEDICINE |
HEALTH SERVICES | DELIVERY OF HEALTH CARE | HEALTH | SEXUAL
PARTNERS | SEX BEHAVIOR | BEHAVIOR | BIOLOGY | RISK
REDUCTION BEHAVIOR
Mortality among married men in rural Kenya and Malawi.
Author: Doctor HV; Weinreb AA
Source: African Population Studies/Etude de la Population Africaine. 2005;20(2):165-177.
24
Abstract: Using prospective longitudinal data, this article describes recent changes in the
levels of adult mortality among married men aged 20-59 in selected rural areas of
Malawi and Kenya, and in the age pattern of their mortality. Sampled areas have,
respectively, moderate and high HIV prevalence. The observed annual
probability of dying for males interviewed in an initial wave of each study and
then reported as deceased in follow-up interviews is 0.031 in Nyanza and 0.016
in Malawi. Compared to life table estimates for equivalent age groups generated
from Kenya's 1989 census and Malawi's 1987 census, these results represent a 3-
fold increase over 1980s census levels. These changes have reduced life
expectancy at age 20 by about 14 years in Nyanza and 7 years in Malawi.
Observed mortality is consistent with a younger age of HIV infection in Nyanza.
Sample characteristics suggest that these levels underestimate the total effect of
AIDS on mortality. (author's)
Language: English
Keywords: MALAWI | KENYA | RESEARCH REPORT | LONGITUDINAL STUDIES |

PROSPECTIVE STUDIES | MEN | RURAL POPULATION | CURRENTLY
MARRIED | MORTALITY | AGE SPECIFIC DEATH RATE | DEATH RATE
| LIFE EXPECTANCY | AIDS | AGE FACTORS | AFRICA, SOUTHERN |
AFRICA, SUB SAHARAN | AFRICA | DEVELOPING COUNTRIES |
AFRICA, EASTERN | STUDIES | RESEARCH METHODOLOGY |
DEMOGRAPHIC FACTORS | POPULATION | POPULATION
CHARACTERISTICS | MARITAL STATUS | NUPTIALITY | POPULATION
DYNAMICS | LENGTH OF LIFE | HIV INFECTIONS | VIRAL DISEASES |
DISEASES
Vitamin A, mastitis, and mother-to-child transmission of HIV-1 through

breast-feeding: current information and gaps in knowledge.
Author: Dorosko SM
Source: Nutrition Reviews. 2005 Oct;63(10):332-346.
Abstract: Mastitis has been implicated as a risk factor for mother-to-child transmission
(MTCT) of HIV-1 through breast-feeding. Maternal vitamin A deficiency is also
associated with increased MTCT, as well as with episodes of mastitis in lactating
animals. This review describes the complex interrelationship between vitamin A,
mastitis, and MTCT of HIV-1 via mothers' milk. Current gaps in knowledge, as
well as recommendations for future research efforts, are also discussed.
(author's)
25
Language: English
Keywords: DEVELOPING COUNTRIES | KENYA | RESEARCH REPORT | MOTHERS

| MOTHER-TO-CHILD TRANSMISSION | HIV INFECTIONS |
BREASTFEEDING | VITAMIN A | BREAST EXAM | MAMMARY GLAND
EFFECTS | AFRICA, EASTERN | AFRICA SOUTH OF THE SAHARA |
AFRICA | PARENTS | FAMILY RELATIONSHIPS | FAMILY
CHARACTERISTICS | FAMILY AND HOUSEHOLD | SOCIOCULTURAL
FACTORS | TRANSMISSION | INFECTIONS | DISEASES | VIRAL
DISEASES | INFANT NUTRITION | NUTRITION | HEALTH | VITAMINS
AND MINERALS | PHYSIOLOGY | BIOLOGY | PHYSICAL
SERVICES | DELIVERY OF HEALTH CARE

Author: Garcia Calleja JM; Marum LH; Carcamo CP; Kaetano L; Muttunga J
populations over 50 000. The household response rate was above 90% in all
from each survey. These population-based HIV seroprevalence surveys
elements to validate survey results. This review was initiated through an
26
international meeting on 'New strategies for HIV/ AIDS Surveillance in

Resource-constrained Countries' held in Addis Ababa on 26--30 January 2004 to
share and develop recommendations to guide future surveys. (author's)
Language: English
Keywords: MALI | KENYA | PERU | ZAMBIA | METHODOLOGICAL STUDIES |

DEMOGRAPHIC AND HEALTH SURVEYS | EPIDEMIOLOGIC METHODS
| HOUSEHOLDS | HIV INFECTIONS | PREVALENCE | DATA QUALITY
| AFRICA, WESTERN | AFRICA SOUTH OF THE SAHARA | AFRICA |
DEVELOPING COUNTRIES | AFRICA, EASTERN | SOUTH AMERICA,
WESTERN | SOUTH AMERICA | LATIN AMERICA | AMERICAS |
DYNAMICS | DEMOGRAPHIC FACTORS | POPULATION | RESEARCH
METHODOLOGY | FAMILY AND HOUSEHOLD | SOCIOCULTURAL
FACTORS | VIRAL DISEASES | DISEASES | MEASUREMENT | DATA
ANALYSIS
The HIV / AIDS epidemic in Kenya. HIV / AIDS policy fact sheet.
Author: Kates J; Leggoe AW
Source: Menlo Park, California, Henry J. Kaiser Family Foundation, 2005 Oct. [2] p.
(HIV / AIDS Policy Fact Sheet)
Abstract: Kenya has more than one million people estimated to be living with HIV/AIDS
(1.2 million as of the end of 2003). Kenya's HIV/AIDS prevalence rate (the
percent of people living with the disease) is just below that of the sub-Saharan
African region overall (6.7% compared to 7.5%). Recent data indicate that the
country's HIV prevalence rate may be on the decline in some areas. However, the
HIV/AIDS epidemic poses significant challenges to this low-income country.
The Government of Kenya first established a National AIDS Control Council
(NACC) in 1999, and has a National Strategic Framework for HIV/AIDS for
2005-2010. (excerpt)
Language: English
Keywords: KENYA | SUMMARY REPORT | PREVALENCE | PERSONS LIVING WITH

HIV/AIDS | YOUTH | HIV | AIDS | KNOWLEDGE | INTERNATIONAL
AGENCIES | INFORMATION SOURCES | FINANCIAL ACTIVITIES |
FOREIGN AID | ANTIRETROVIRAL THERAPY | GOVERNMENT
PROGRAMS | AFRICA, EASTERN | AFRICA SOUTH OF THE SAHARA |
AFRICA | DEVELOPING COUNTRIES | MEASUREMENT | RESEARCH
METHODOLOGY | HIV INFECTIONS | VIRAL DISEASES | DISEASES |
27
AGE FACTORS | POPULATION CHARACTERISTICS | DEMOGRAPHIC

FACTORS | POPULATION | SOCIOCULTURAL FACTORS |
ORGANIZATIONS | POLITICAL FACTORS | INFORMATION |
ECONOMIC FACTORS | PROGRAMS | ORGANIZATION AND
ADMINISTRATION
Prospects for financial sustainability of scaling up antiretroviral therapy

programs.
Author: Kyomuhangi L
Source: Health Policy and Development. 2005 Aug;3(2):154-164.
Abstract: The program costs of antiretroviral therapy (ART) were analyzed using the Cape
Town Antiretroviral Costing Model (Boulle, et al, (2004). The total ART costs by
end of 2008 for starting 18,500 patients in Senegal, 82,000 patients in Uganda and
165,000 in Kenya were estimated at US$ 20.5 million, US$ 68 million and US$ and
US$ 126 million respectively. The lifetime costs per patient on treatment were
estimated at US$ 5,015 for Uganda, US$ 5,782 for Senegal, and US$ 6,186 for
Kenya. The available funds for ART are about US$ 79 million for Senegal, US$ 74
million for Uganda and US$ 94 million for Kenya. Senegal has committed about
US$ 13.3 million from its domestic budget and acquired a loan of US$ 40 million
from the World Bank for ART services. Kenya has so far allocated only US$ 1.4
million from the national budget for its ART services. There are no funds from
the government budget directed for the ART program in Uganda. The three
countries are mainly depending on donor funding. The study concludedthat
ART services in Uganda and Kenya might not be financially sustainable whereas
Senegal may be able to financially its ART program if the current low prevalence
levels and political and financial commitment prevail. (author's)
Language: English
Keywords: SENEGAL | UGANDA | KENYA | CROSS SECTIONAL ANALYSIS | HIV

POSITIVE PERSONS | GOVERNMENT | ANTIRETROVIRAL THERAPY |
ECONOMIC FACTORS | CAPACITY BUILDING | PROGRAM
SUSTAINABILITY | DEVELOPING COUNTRIES | AFRICA, WESTERN |
AFRICA, SUB SAHARAN | AFRICA | AFRICA, EASTERN | RESEARCH
METHODOLOGY | PERSONS LIVING WITH HIV/AIDS | HIV
INFECTIONS | VIRAL DISEASES | DISEASES | POLITICAL FACTORS |
SOCIOCULTURAL FACTORS | HIV | PROGRAMS | ORGANIZATION
AND ADMINISTRATION
28
HIV / AIDS and sexually transmitted infection in Kenya. Behavioural

surveillance survey 2002.
Author: Kenya. Ministry of Health. National AIDS / STI Control Program
Source: Nairobi, Kenya, Ministry of Health, National AIDS / STI Control Program, 2005.
[65] p. (USAID Development Experience Clearinghouse DocID / Order No. PC-
AAB-540)
Abstract: The government of Kenya through the National AIDS/STI Control Program
(NASCOP) of the Ministry of Health in collaboration with Family Health
International (FHI), the Centers for Disease Control and Prevention (CDC), and
the Central Bureau of Statistics (CBS) conducted a national behavioural
surveillance survey of HIV/AIDS and sexually transmitted infection in Kenya in
late 2002 in order to understand the behaviour dynamics driving the HIV
epidemic. The behavioural surveillance survey is a monitoring and evaluation
tool to track trends in HIV/AIDS knowledge, attitudes and behaviour in
populations at particular risk of HIV infection, such as youth, female sex workers
and migrant men. It is envisaged that this survey will be repeated every two or
three years to monitor trends and changes in HIV and sexually transmitted
infection risky behaviour in the country. The populations selected to participate
in the first round of the national behavioural surveillance survey were out-of-
school youth, youth in school, female sex workers, women in low-income
settings, matatu or mini-van drivers and their touts or helpers, bodaboda or
bicycle taxi cyclists, policemen, and men in large worksites. Questionnaires were
developed in both English and Kiswahili. They were administered to
respondents in the selected groups by trained interviewers under close
supervision of a team of supervisors. High standards of conducting the survey
were adhered to in terms of a well-planned data collection strategy and a
commitment to establish high-quality data systems. EpiData software was used
for data entry and processing, and a statistical software package for social
sciences was used for data analysis. (excerpt)
Language: English
Keywords: KENYA | SUMMARY REPORT | INTERVIEWS | MULTIPLE PARTNERS |

SEXUAL PARTNERS | SEX WORKERS | POLICE | YOUTH | HIV
INFECTIONS | AIDS | SEXUALLY TRANSMITTED DISEASES |
KNOWLEDGE | RISK BEHAVIOR | SEX BEHAVIOR | CONDOM |
BEHAVIOR CHANGE | AFRICA, EASTERN | AFRICA SOUTH OF THE
SAHARA | AFRICA | DEVELOPING COUNTRIES | DATA COLLECTION
| RESEARCH METHODOLOGY | BEHAVIOR | CORRECTIONS
OFFICERS | GOVERNMENT | POLITICAL FACTORS | SOCIOCULTURAL
FACTORS | AGE FACTORS | POPULATION CHARACTERISTICS |
DEMOGRAPHIC FACTORS | POPULATION | VIRAL DISEASES |
DISEASES | REPRODUCTIVE TRACT INFECTIONS | INFECTIONS |
29
BARRIER METHODS | CONTRACEPTIVE METHODS |

CONTRACEPTION | FAMILY PLANNING
Dual infection with HIV and malaria fuels the spread of both diseases in
sub-Saharan Africa.
Author: Abu-Raddad LJ
Source: Science. 2006 Dec 8;314(5805):1603-1606.
Abstract: Mounting evidence has revealed pathological interactions between HIV and
malaria in dually infected patients, but the public health implications of the
interplay have remained unclear. A transient almost one-log elevation in HIV
viral load occurs during febrile malaria episodes; in addition, susceptibility to
malaria is enhanced in HIV-infected patients. A mathematical model applied to a
setting in Kenya with an adult population of roughly 200,000 estimated that,
since 1980, the disease interaction may have been responsible for 8,500 excess
HIV infections and 980,000 excess malaria episodes. Co-infection might also have
facilitated the geographic expansion of malaria in areas where HIV prevalence is
high. Hence, transient and repeated increases in HIV viral load resulting from
recurrent co-infection with malaria may be an important factor in promoting the
spread of HIV in sub-Saharan Africa. (author's)
Language: English
Keywords: AFRICA SOUTH OF THE SAHARA | KENYA | RESEARCH REPORT |

EPIDEMIOLOGIC METHODS | MATHEMATICAL MODEL |
ESTIMATION TECHNICS | HIV POSITIVE PERSONS | MALARIA | HIV
INFECTIONS | COMPLICATIONS | FEVER | INCIDENCE | HUMAN
GEOGRAPHY | DEVELOPING COUNTRIES | AFRICA | AFRICA,
EASTERN | RESEARCH METHODOLOGY | MODELS, THEORETICAL |
PERSONS LIVING WITH HIV/AIDS | VIRAL DISEASES | DISEASES |
PARASITIC DISEASES | BODY TEMPERATURE | PHYSIOLOGY |
BIOLOGY | MEASUREMENT | GEOGRAPHY | SOCIAL SCIENCES |
SCIENCE | SOCIOCULTURAL FACTORS
Characteristics of HIV infected patients cared for at "academic model for

the prevention and treatment of HIV / AIDS" clinics in western Kenya.
30
Author: Diero LO; Shaffer D; Kimaiyo S; Siika AM; Rotich JK
Source: East African Medical Journal. 2006 Aug;83(8):424-433.
Abstract: With the new initiatives to treat large numbers of HIV infected individuals in
sub-Saharan Africa, policy makers require accurate estimates of the numbers and
characteristics of patients likely to seek treatment in these countries. The
objective was to describe characteristics of adults receiving care in two Kenyan
public HIV clinics. Design: Cross-sectional cohort analysis of data extracted from
an electronic medical records system. Setting: Academic Model for the
Prevention and Treatment of HIV/AIDS (AMPATH) HIV clinics in Kenya's
second national referral (urban) hospital and a nearby rural health center.
Subjects: Adult patients presenting for care at HIV clinics. Main outcome
measures: Gender and inter-clinic stratified comparisons of demographic,
clinical, and treatment data. In the first nineteen months, 790 adults visited the
urban clinic and 294 the rural clinic. Mean age was 36±9 (SD) years. Two-thirds
were women; a quarter had spouses who had died of acquired immune
deficiency syndrome (AIDS). HIV/AIDS behavioural risk factors (multiple
sexual partners, rare condom use) and constitutional symptoms (fatigue, weight
loss, cough, fever, chills) were common. Rural patients had more symptoms and
less prior and current tuberculosis. Men more commonly presented with
symptoms than women. The cohort CD4 count was low (223 ± 197mm3), with
men having significantly lower CD4 count than women (185 ± 175 vs 242 ± 205 p
= 0.0007). Eighteen percent had an infiltrate on chest radiograph. Five percent
(most often men) had received prior antiretroviral drug therapy, (7% in urban
and 1% in rural patients, p = 0.0006). Overall, 393 (36%) received antiretroviral
drugs, 89% the combination of lamivudine, stavudine, and nevirapine. Half
received prophylaxis for tuberculosis and Pneumocystis jirovecii. Men were
sicker and more often received antiretroviral drugs. Patients presenting to two
Kenyan HIV clinics were predominantly female, ill and naive to retroviral
therapy with substantial differences by clinic site and gender. Behavioural risk
factors for HIV/AIDS were common. A thorough understanding of clinical and
behavioural characteristics can help target prevention and treatment strategies.
(author's)
Language: English

COHORT ANALYSIS | PERSONS LIVING WITH HIV/AIDS | CLINICS |
RISK BEHAVIOR | SEX BEHAVIOR | ANTIRETROVIRAL THERAPY |
COUNTRIES | RESEARCH METHODOLOGY | HIV INFECTIONS | VIRAL
DISEASES | DISEASES | HEALTH FACILITIES | DELIVERY OF HEALTH
CARE | HEALTH | BEHAVIOR | HIV
31
Outcomes of HIV-infected orphaned and non-orphaned children on

antiretroviral therapy in western Kenya.
Author: Nyandiko WM; Ayaya S; Nabakwe E; Tenge C; Sidle JE
Source: JAIDS. Journal of Acquired Immune Deficiency Syndromes. 2006 Dec 1;43(4):418-
425.
Abstract: The objectives were to determine outcome differences between orphaned and
non-orphaned children receiving antiretroviral therapy (ART). Design:
Retrospective review of prospectively recorded electronic data. Setting: Nine
HIV clinics in western Kenya. Population: 279 children on ART enrolled between
August 2002 and February 2005. Main Measures: Orphan status, CD4%, sex- and
age-adjusted height (HAZ) and weight (WAZ) z scores, ART adherence,
mortality. Median follow-up was 34 months. Cohort included 51% males and
54% orphans. At ART initiation (baseline), 71% of children had CDC clinical
stage B or C disease. Median CD4% was 9% and increased dramatically the first
30 weeks of therapy, then leveled off. Parents and guardians reported perfect
adherence at every visit for 75% of children. Adherence and orphan status were
not significantly associated with CD4% response. Adjusted for baseline age,
follow-up was significantly shorter among orphaned children (median 33 vs. 41
weeks, P = 0.096). One-year mortality was 7.1% for orphaned and 6.6% for non-
orphaned children (P = 0.836). HAZ and WAZ were significantly below norm in
both groups. With ART, HAZ remained stable, while WAZ tended to increase
toward the norm, especially among non-orphans. Orphans showed identical
weight gains as non-orphans the first 70 weeks after start of ART but experienced
reductions afterwards. Good ART adherence is possible in western rural Kenya.
ART for HIV-infected children produced substantial and sustainable CD4%
improvement. Orphan status was not associated with worse short-term outcomes
but may be a factor for long-term therapy response. ART alone may not be
sufficient to reverse significant developmental lags in the HIV-positive pediatric
population. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | RETROSPECTIVE STUDIES | CHILD |

ORPHANS AND VULNERABLE CHILDREN | HIV POSITIVE PERSONS |
HIV | ANTIRETROVIRAL THERAPY | TREATMENT | AFRICA, EASTERN
| AFRICA SOUTH OF THE SAHARA | AFRICA | DEVELOPING
COUNTRIES | STUDIES | RESEARCH METHODOLOGY | YOUTH | AGE
FACTORS | POPULATION | PERSONS LIVING WITH HIV/AIDS | HIV
INFECTIONS | VIRAL DISEASES | DISEASES | MEDICAL PROCEDURES
| MEDICINE | HEALTH SERVICES | DELIVERY OF HEALTH CARE |
HEALTH | FAMILY AND HOUSEHOLD
32
Maternal knowledge on mother-to-child transmission of HIV and

breastmilk alternatives for HIV positive mothers in Homa Bay District
Hospital, Kenya.
Author: Omwega AM; Oguta TJ; Sehmi JK
Source: East African Medical Journal. 2006 Nov;83(11):610-618.
Abstract: Mother-to-Child Transmission (MTCT) of HIV is a relatively new concept in

rural populations and despite the huge amount of work that has been done on
the HIV/AIDS, there still remains a dearth of information in knowledge of
mothers on this concept especially in areas related to appropriate feeding
methods for infants born to mothers infected with the virus. The objectives were
to determine maternal knowledge on MTCT of HIV in the rural setting and to
examine viable breastmilk alternatives for mothers who would be HIV positive.
The design used was a cross-sectional study, supported by an observational
study. The setting was a rural district community and Homa-Bay District
Hospital in South Western Kenya. The subjects for the study were one-hundred
and twelve non-tested mothers having infants aged 0-12 months in the
community and a sub-group (10%) of HIV positive mothers from the District
Hospital. Maternal knowledge on MTCT of HIV was as low as 8.9% in the study
area. The MTCT knowledge was found to influence the alternative feeding choice
as mentioned by the non-tested mothers (p = 0.001; OR = l.41; 95%CI, 1.04-3.86).
Those with high MTCT knowledge tended to be more receptive and considered
feeding alternatives other than cowmilk like expressed breastmilk (p = 0.l 5),
formula (p = 0.036; OR = 2.44; 95%CI, 1.66-6.04) and milk from milk bank (p =
0.0l5; OR = l.34; 95%CI, 1.13-5.50) than their counterparts with low MTCT
knowledge. Cowmilk, formula and wet-nursing were the three feeding
alternatives that were viable with varying socio-cultural, economic and/or
nutritional constraints. Maternal MTCT knowledge influences the choice of
alternative infant feeding option but not breastfeeding practices. Cowmilk is the
most common, socio-culturally acceptable and accessible breastmilk alternative
in this community. It is recommended that in order to improve MTCT
knowledge, health education and nutrition counselling be intensified in PMTCT
programmes, VCT centers and ANC clinics. Concurrently, effort should be made
to increase the supply of cowmilk within the community so as to make it more
readily available and affordable. (author's)
Language: English

PERSONS LIVING WITH HIV/AIDS | WOMEN | INFANT | HIV
INFECTIONS | MOTHER-TO-CHILD TRANSMISSION | KNOWLEDGE |
33
HUMAN MILK | INFANT NUTRITION | SOCIOCULTURAL FACTORS |

SAHARAN | AFRICA | RESEARCH METHODOLOGY | VIRAL DISEASES
| DISEASES | DEMOGRAPHIC FACTORS | POPULATION | YOUTH |
AGE FACTORS | POPULATION CHARACTERISTICS | TRANSMISSION |
INFECTIONS | LACTATION | MATERNAL PHYSIOLOGY |
PHYSIOLOGY | BIOLOGY | NUTRITION | HEALTH
Initial strategy for antiretroviral-naive patients.
Author: Abgrall S
Source: Lancet. 2006 Dec 16;368(9553):2107-2109.
Abstract: In today's Lancet, the CPCRA 058 FIRST trial is reported. Earlier this year, in The
Lancet, the INITIO trial was reported. Both trials attempted to define the best
antiretroviral strategy for drug-naive HIV-infected patients with moderate
immunosuppression, assessed clinically and immunologically in FIRST and
virologically in INITIO (table). The first question was: what is the best third drug
(protease inhibitor or non-nucleoside reversetranscriptase inhibitor [NNRTI]) to
add to two nucleoside reverse-transcriptase inhibitors (NRTI) in a two-class
initial antiretroviral regimen? The second question was: is there a three-class
(mainly four-drug) regimen more potent than the two-class and three-drug
standard one? Changes in CD4 cell counts best predict clinical outcome in the
short to mid term. Nevertheless, virological failure jeopardises further treatment
efficacy with acquisition of resistance mutations and compromises long-term
immunological and clinical outcome when prolonged. (excerpt)
Language: English
Keywords: DEVELOPING COUNTRIES | RECOMMENDATIONS | CLINICAL TRIALS

| PERSONS LIVING WITH HIV/AIDS | ANTIRETROVIRAL THERAPY |
USER COMPLIANCE | AIDS PREVENTION | IMMUNITY, CELLULAR |
ADMINISTRATION AND DOSAGE | CLINICAL RESEARCH | RESEARCH
METHODOLOGY | HIV INFECTIONS | VIRAL DISEASES | DISEASES |
HIV | BEHAVIOR | AIDS | IMMUNITY | IMMUNE SYSTEM |
PHYSIOLOGY | BIOLOGY | DRUGS | TREATMENT | MEDICAL
HEALTH CARE | HEALTH
34
The role of health care in the spread of HIV / AIDS in Africa: evidence
from Kenya.
Author: Deuchert E; Brody S
Source: International Journal of STD and AIDS. 2006 Nov;17(11):749-752.
Abstract: It is commonly asserted that the sub-Saharan African HIV/AIDS epidemic is

predominantly due to heterosexual transmission. However, recent reexamination
of the available evidence strongly suggests that unsafe health care is the more
likely vector. The present report adds to the evidence for health-care
transmission by showing that Kenyan women who received prophylactic tetanus
toxoid injections during pregnancy are 1.89 times (95% confidence interval [CI]:
1.03--3.47) more likely to be HIV-1 seropositive than women who did not receive
this vaccination. In contrast, recent sexual behaviour (condom use, number of
partners) was not related to HIV status. The findings are unconfounded by
reverse causality (all injections were purely prophylactic rather than for
treatment of any HIV-related illnesses, and none of the women reported
knowing that she was HIV seropositive). Focus on a specific injection may have
improved participant recall. The results are consistent with health care being a
very important vector for HIV in sub-Saharan Africa. It is recommended that
there be a reallocation of resources to address healthcare transmission of
HIV/AIDS. (author's)
Language: English

DEMOGRAPHIC AND HEALTH SURVEYS | PERSONS LIVING WITH
HIV/AIDS | PREGNANT WOMEN | HEALTH PERSONNEL | HIV
TRANSMISSION | NEEDLE PIERCING | VACCINATION | QUALITY OF
HEALTH CARE | SAFETY | AFRICA | DEVELOPING COUNTRIES |
AFRICA, EASTERN | DEMOGRAPHIC SURVEYS | POPULATION
DYNAMICS | DEMOGRAPHIC FACTORS | POPULATION | HIV
CHARACTERISTICS | DELIVERY OF HEALTH CARE | HEALTH | RISK
BEHAVIOR | BEHAVIOR | IMMUNIZATION | PRIMARY HEALTH CARE
| HEALTH SERVICES | HEALTH SERVICES EVALUATION | PROGRAM
ADMINISTRATION | PUBLIC HEALTH
Characteristics of HIV infected patients cared for at "academic model for

the prevention and treatment of HIV / AIDS" clinics in western Kenya.
35
Author: Diero LO; Shaffer D; Kimaiyo S; Siika AM; Rotich JK
Abstract: With the new initiatives to treat large numbers of HIV infected individuals in
sub-Saharan Africa, policy makers require accurate estimates of the numbers and
characteristics of patients likely to seek treatment in these countries. The
objective was to describe characteristics of adults receiving care in two Kenyan
public HIV clinics. Design: Cross-sectional cohort analysis of data extracted from
an electronic medical records system. Setting: Academic Model for the
Prevention and Treatment of HIV/AIDS (AMPATH) HIV clinics in Kenya's
second national referral (urban) hospital and a nearby rural health center.
Subjects: Adult patients presenting for care at HIV clinics. Main outcome
measures: Gender and inter-clinic stratified comparisons of demographic,
clinical, and treatment data. In the first nineteen months, 790 adults visited the
urban clinic and 294 the rural clinic. Mean age was 36±9 (SD) years. Two-thirds
were women; a quarter had spouses who had died of acquired immune
deficiency syndrome (AIDS). HIV/AIDS behavioural risk factors (multiple
sexual partners, rare condom use) and constitutional symptoms (fatigue, weight
loss, cough, fever, chills) were common. Rural patients had more symptoms and
less prior and current tuberculosis. Men more commonly presented with
symptoms than women. The cohort CD4 count was low (223 ± 197mm3), with
men having significantly lower CD4 count than women (185 ± 175 vs 242 ± 205 p
= 0.0007). Eighteen percent had an infiltrate on chest radiograph. Five percent
(most often men) had received prior antiretroviral drug therapy, (7% in urban
and 1% in rural patients, p = 0.0006). Overall, 393 (36%) received antiretroviral
drugs, 89% the combination of lamivudine, stavudine, and nevirapine. Half
received prophylaxis for tuberculosis and Pneumocystis jirovecii. Men were
sicker and more often received antiretroviral drugs. Patients presenting to two
Kenyan HIV clinics were predominantly female, ill and naive to retroviral
therapy with substantial differences by clinic site and gender. Behavioural risk
factors for HIV/AIDS were common. A thorough understanding of clinical and
behavioural characteristics can help target prevention and treatment strategies.
(author's)
Language: English

COHORT ANALYSIS | PERSONS LIVING WITH HIV/AIDS | CLINICS |
RISK BEHAVIOR | SEX BEHAVIOR | ANTIRETROVIRAL THERAPY |
COUNTRIES | RESEARCH METHODOLOGY | HIV INFECTIONS | VIRAL
DISEASES | DISEASES | HEALTH FACILITIES | DELIVERY OF HEALTH
CARE | HEALTH | BEHAVIOR | HIV
36
Absorptive capacity and disbursements by the Global Fund to Fight

AIDS, Tuberculosis and Malaria: analysis of grant implementation.
Author: Lu C; Michaud CM; Khan K; Murray CJ
Source: Lancet. 2006 Aug 5;368(9534):483-488.
Abstract: The Global Fund to Fight AIDS, Tuberculosis and Malaria was launched in 2002
to attract and rapidly disburse money to fight these diseases. However, some
commentators believe that poor countries cannot effectively use such resources
to increase delivery of their health programmes--referred to as a lack of
absorptive capacity. We aimed to investigate the major determinants of grant
implementation in developing countries. With information available publicly on
the Global Fund's website, we did random-effects analysis to investigate the
effect of grant characteristics, types of primary recipient and local fund agent,
and country attributes on disbursements that were made between 2003 and 2005
(phase one of Global Fund payments). To check the robustness of findings,
regression results from alternative estimation methods and model specifications
were also tested. Grant characteristics--such as size of commitment, lag time
between signature and first disbursement, and funding round--had significant
effects on grant implementation. Enhanced political stability was associated with
high use of grants. Low-income countries, and those with less-developed health
systems for a given level of income, were more likely to have a higher rate of
grant implementation than nations with higher incomes or more-developed
health systems. The higher rate of grant implementation seen in countries with
low income and low health-spending lends support to proponents of major
increases in health assistance for the poorest countries and argues that focusing
resources on low-income nations, particularly those with political stability, will
not create difficulties of absorptive capacity. Our analysis was restricted to grant
implementation, which is one part of the issue of absorptive capacity. In the
future, assessment of the effect of Global Fund grants on intervention coverage
will be vital. (author's)
Language: English
Keywords: DEVELOPING COUNTRIES | RESEARCH REPORT | EVALUATION |

NONGOVERNMENTAL ORGANIZATIONS | LOW INCOME
POPULATION | AIDS | TUBERCULOSIS | MALARIA | PREVENTION
AND CONTROL | GRANTS | DELIVERY OF HEALTH CARE | PROGRAM
EFFECTIVENESS | ORGANIZATIONS | POLITICAL FACTORS |
SOCIOCULTURAL FACTORS | SOCIAL CLASS | SOCIOECONOMIC
STATUS | SOCIOECONOMIC FACTORS | ECONOMIC FACTORS | HIV
INFECTIONS | VIRAL DISEASES | DISEASES | INFECTIONS |
PARASITIC DISEASES | FINANCIAL ACTIVITIES | HEALTH |
PROGRAM EVALUATION | PROGRAMS | ORGANIZATION AND
37
ADMINISTRATION
Sexual abstinence, contraception, and condom use by young African

women: a secondary analysis of survey data.
Author: Cleland J; Ali MM
Source: Lancet. 2006 Nov 18;368(9549):1788-1793.
Abstract: Drug therapy for people with AIDS is a humanitarian priority but prevention of
HIV infection remains essential. Focusing on young single African women, we
aimed to assess trends in a set of behaviours -- sexual abstinence, contraceptive
use, and condom use -- that are known to affect the rates of HIV transmission.
We did a secondary analysis of public-access data sets in 18 African countries
(132 800 women), and calculated changes in a set of behavioural indicators over
time. We standardised these trends from nationally representative surveys to
adjust for within-country changes in age, education, and type of residential
location. Between about 1993 and 2001, the percentage of women reporting no
sexual experience changed little. During the same period, the percentage of
sexually experienced women who reported no sexual intercourse in the previous
3 months (secondary abstinence) rose significantly in seven of 18 countries and
the median for all 18 countries increased from 43.8% to 49.2%. Use of condoms
for pregnancy prevention rose significantly in 13 of 18 countries and the median
proportion increased from 5.3% to 18.8%. The median rate of annual increase of
condom use was 1.41 percentage points (95% CI 1.12-2.25). In the 13 countries
with available data, condom use at most recent coitus rose from a median of
19.3% to 28.4%. Over half (58.5%) of condom users were motivated, at least in
part, by a wish to avoid pregnancy. Condom promotion campaigns in sub-
Saharan Africa have affected the behaviour of young single women; the pace of
change has matched the rise in contraceptive use by married couples in
developing countries over recent decades. Thus continuing efforts to promote
condom use with emphasis on pregnancy prevention are justified. (author's)
Language: English
Keywords: AFRICA | RESEARCH REPORT | DATA ANALYSIS | WOMEN | SEX

BEHAVIOR | ABSTINENCE, BE FAITHFUL, CONDOM USE | CONDOM
USE | CONTRACEPTIVE USAGE | CONDOM | PROMOTION |
CAMPAIGNS | HIV PREVENTION | PREGNANCY | PREVENTION AND
CONTROL | DEVELOPING COUNTRIES | RESEARCH METHODOLOGY
| DEMOGRAPHIC FACTORS | POPULATION | BEHAVIOR | RISK
REDUCTION BEHAVIOR | CONTRACEPTION | FAMILY PLANNING |
BARRIER METHODS | CONTRACEPTIVE METHODS | MARKETING |
38
ECONOMIC FACTORS | COMMUNICATION PROGRAMS |

COMMUNICATION | HIV INFECTIONS | VIRAL DISEASES | DISEASES
| REPRODUCTION
The role of health care in the spread of HIV / AIDS in Africa: evidence
from Kenya.
Author: Deuchert E; Brody S
Abstract: It is commonly asserted that the sub-Saharan African HIV/AIDS epidemic is

predominantly due to heterosexual transmission. However, recent reexamination
of the available evidence strongly suggests that unsafe health care is the more
likely vector. The present report adds to the evidence for health-care
transmission by showing that Kenyan women who received prophylactic tetanus
toxoid injections during pregnancy are 1.89 times (95% confidence interval [CI]:
1.03--3.47) more likely to be HIV-1 seropositive than women who did not receive
this vaccination. In contrast, recent sexual behaviour (condom use, number of
partners) was not related to HIV status. The findings are unconfounded by
reverse causality (all injections were purely prophylactic rather than for
treatment of any HIV-related illnesses, and none of the women reported
knowing that she was HIV seropositive). Focus on a specific injection may have
improved participant recall. The results are consistent with health care being a
very important vector for HIV in sub-Saharan Africa. It is recommended that
there be a reallocation of resources to address healthcare transmission of
HIV/AIDS. (author's)
Language: English

DEMOGRAPHIC AND HEALTH SURVEYS | PERSONS LIVING WITH
HIV/AIDS | PREGNANT WOMEN | HEALTH PERSONNEL | HIV
TRANSMISSION | NEEDLE PIERCING | VACCINATION | QUALITY OF
HEALTH CARE | SAFETY | AFRICA | DEVELOPING COUNTRIES |
AFRICA, EASTERN | DEMOGRAPHIC SURVEYS | POPULATION
DYNAMICS | DEMOGRAPHIC FACTORS | POPULATION | HIV
CHARACTERISTICS | DELIVERY OF HEALTH CARE | HEALTH | RISK
BEHAVIOR | BEHAVIOR | IMMUNIZATION | PRIMARY HEALTH CARE
| HEALTH SERVICES | HEALTH SERVICES EVALUATION | PROGRAM
39
ADMINISTRATION | PUBLIC HEALTH
Male circumcision for HIV prevention: Research implications for policy

and programming WHO / UNAIDS technical consultation 6 -- 8 March
2007 conclusions and recommendations (excerpts).
Source: Reproductive Health Matters. 2007 May;15(29):11-14.
Abstract: A number of observational studies indicate that circumcised men have lower
levels of HIV infection than uncircumcised men. On 13 December 2006, the US
National Institutes of Health announced that two trials assessing the impact of
male circumcision on HIV risk would be stopped on the recommendation of the
Data Safety and Monitoring Board. The trials being carried out in Kisumu,
Kenya, and Rakai District, Uganda revealed at least a 53% and 51% reduction in
risk of acquiring HIV infection, respectively. These results support findings
published in 2005 from the South Africa Orange Farm Intervention Trial,
sponsored by the French National Agency for Research on AIDS, which
demonstrated at least a 60% reduction in HIV infection among men who were
circumcised. WHO and UNAIDS convened an international consultation to
review the results of the three randomised controlled trials and other evidence
on male circumcision and HIV prevention, to discuss the policy and programme
implications, and to make recommendations regarding public health issues. This
document summarizes the principal conclusions and recommendations of the
meeting. The international consultation was attended by experts representing a
wide range of stakeholders, including government representatives, researchers,
civil society representatives, gender experts, human rights and women's health
advocates, young people, funding agencies and implementing partners. (excerpt)
Language: English
Keywords: KENYA | UGANDA | RESEARCH REPORT | TECHNICAL ASSISTANCE |

MEN | MALE CIRCUMCISION | HIV PREVENTION |
RECOMMENDATIONS | PROGRAM EVALUATION | AFRICA, EASTERN
| AFRICA, SUB SAHARAN | AFRICA | DEVELOPING COUNTRIES |
PROGRAMS | ORGANIZATION AND ADMINISTRATION |
DEMOGRAPHIC FACTORS | POPULATION | MEDICAL PROCEDURES |
HEALTH | HIV INFECTIONS | VIRAL DISEASES | DISEASES
40
Male circumcision for HIV prevention: The research evidence and some
critical responses.
Abstract: Three randomised clinical trials, in South Africa, Uganda and Kenya, have
shown a substantial reduction in female-to-male transmission of HIV to men
who had been circumcised as compared to men who had not, during a follow-up
period of up to 24 months. The question of what to do with this evidence is
currently being debated around the world. WHO and UNAIDS took the lead by
developing technical, policy and programmatic guidance following a series of
consultations with a range of stakeholders in the field, using the research
evidence as the basis. Consensus on many aspects of this matter is far from being
achieved, however. Many questions and different points of view are emerging -
clinical, public health, sociological, anthropological and cultural; in relation to
priority setting in HIV prevention and delivery of health services; and in relation
to sexuality, ethics, gender and rights. On 28 March 2007, WHO and UNAIDS
published a set of conclusions and recommendations regarding the research
implications for HIV policy and programming. The introduction and excerpts
from these follow below. They are, in turn, followed by a roundtable of nine
papers which contain a range of critical thinking and analysis of these issues.
Male circumcision is generating debate across the globe. This can only be a good
thing, as it is a complex matter and far more than a straightforward public health
intervention. We hope these papers will help to inform that debate. (author's)
Language: English
Keywords: KENYA | SOUTH AFRICA | UGANDA | RESEARCH REPORT | CLINICAL

TRIALS | MEN | MALE CIRCUMCISION | GENDER ISSUES |
SEXUALITY | SAFER SEX | HIV TRANSMISSION | HEALTH POLICY |
HIV PREVENTION | PROGRAM EVALUATION | AFRICA, EASTERN |
COUNTRIES | AFRICA, SOUTHERN | CLINICAL RESEARCH |
RESEARCH METHODOLOGY | DEMOGRAPHIC FACTORS |
POPULATION | MEDICAL PROCEDURES | MEDICINE | HEALTH
SERVICES | DELIVERY OF HEALTH CARE | HEALTH |
SOCIOCULTURAL FACTORS | PERSONALITY | PSYCHOLOGICAL
FACTORS | BEHAVIOR | SEX BEHAVIOR | HIV INFECTIONS | VIRAL
DISEASES | DISEASES | POLICY | POLITICAL FACTORS | PROGRAMS
| ORGANIZATION AND ADMINISTRATION
41
Putting on a brave face: the experiences of women living with HIV and
AIDS in informal settlements of Nairobi, Kenya.
Author: Amuyunzu-Nyamongo M; Okeng'o L; Wagura A; Mwenzwa E
Source: AIDS Care. 2007 Feb;19 Suppl 1:S25-S34.
Abstract: This paper examines two key dimensions of HIV and AIDS in sub-Saharan
Africa, namely poverty and gender, within the particular context of informal
settlements. The study, conducted in five informal settlements of Nairobi, Kenya
explored the challenges facing women living with HIV and AIDS (WLWA) in
informal settlements in Nairobi in terms of the specific risk environments of
informal settlements, the support they receive and their perceptions of their
future. The data were gathered through an interviewer-based questionnaire
administered to 390 WLWA and 20 key informant interviews with Kenya
Network of Women with AIDS (KENWA) project personnel. The results show
that for WLWA in informal settlements, poverty and poor living conditions
combine to increase the risk environment for HIV infection and other
opportunistic infections and that the WLWA then face HIV- and AIDS-related
problems that are exacerbated by poverty and by the poor living environments.
In response, the WLWA had devised coping strategies that were largely centred
on survival, including commercial sex work and the sale of illicit liquor, thus
increasing their susceptibility to re-infections. Insecurity in informal settlements
curtailed their participation in income generating activities (IGAs) and increased
their risk of rape and HIV reinfection. Recognising the disadvantaged position of
communities in informal settlements, the non-governmental organizations
(NGOs), community-based organizations (CBOs) and faith-based organizations
(FBOs) provide a range of services including HIV and AIDS information and
therapy. Paradoxically, living in urban informal settlements was found to
increase WLWA's access to HIV and AIDS prevention and treatment services
through NGOs and social networks that are not found in more established
residential areas. The sustainability of these services is, however, questioned,
given the lack of local resources, weak state support and high donor
dependency. We suggest that the economic and tenure insecurity found among
WLWA demands in response consistent support through comprehensive,
sustainable HIV and AIDS services complemented by social networks and
community sensitisation against stigma and discrimination. Fundamentally, the
upgrading of informal settlements would address the wider risk environments
that exacerbate the poor health of the WLWA who line in them. (author's)
Language: English

WITH HIV/AIDS | WOMEN IN DEVELOPMENT | SLUMS |
ORGANIZATIONS | HIV INFECTIONS | PSYCHOLOGICAL FACTORS |
PSYCHOSOCIAL FACTORS | POVERTY | GENDER ISSUES | QUALITY
OF LIFE | RISK BEHAVIOR | DEVELOPING COUNTRIES | AFRICA,
42
EASTERN | AFRICA, SUB SAHARAN | AFRICA | SURVEYS | SAMPLING

STUDIES | STUDIES | RESEARCH METHODOLOGY | VIRAL DISEASES
| DISEASES | ECONOMIC DEVELOPMENT | ECONOMIC FACTORS |
URBANIZATION | URBAN POPULATION DISTRIBUTION |
POPULATION DISTRIBUTION | GEOGRAPHIC FACTORS |
POPULATION | POLITICAL FACTORS | SOCIOCULTURAL FACTORS |
BEHAVIOR | SOCIOECONOMIC FACTORS | SOCIAL WELFARE
Clinical screening for HIV in a health centre setting in urban Kenya: An

entry point for voluntary counselling, HIV testing and early diagnosis of
Author: Arendt V; Mossong J; Zachariah R; Inwani C; Farah B
Source: Tropical Doctor. 2007 Jan;37(1):45-47.
Abstract: A study was conducted among patients attending a public health centre in
Nairobi, Kenya in order to (a) verify the prevalence of HIV, (b) identify clinical
risk factors associated with HIV and (c) determine clinical markers for clinical
screening of HIV infection at the health centre level. Of 304 individuals involved
in the study, 107 (35%) were HIV positive. A clinical screening algorithm based
on four clinical markers, namely oral thrush, past or present TB, past or present
herpes zoster and prurigo would pick out 61 (57%) of the 107 HIV-positive
individuals. In a resource-poor setting, introducing a clinical screening algorithm
for HIV at the health centre level could provide an opportunity for targeting
voluntary counselling and HIV testing, and early access to a range of prevention
and care interventions. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | PREVALENCE | URBAN AREAS |

CLIENTS | VOLUNTARY COUNSELING AND TESTING | HIV TESTING |
HIV INFECTIONS | EXAMINATIONS AND DIAGNOSES | SCREENING |
AFRICA, EASTERN | AFRICA SOUTH OF THE SAHARA | AFRICA |
DEVELOPING COUNTRIES | MEASUREMENT | RESEARCH
METHODOLOGY | GEOGRAPHIC FACTORS | POPULATION |
PROGRAM ACTIVITIES | PROGRAMS | ORGANIZATION AND
ADMINISTRATION | LABORATORY EXAMINATIONS AND
SERVICES | DELIVERY OF HEALTH CARE | HEALTH | VIRAL DISEASES
| DISEASES
43
Relationship between markers of HIV-1 disease progression and serum

beta-carotene concentrations in Kenyan women.
Author: Baeten JM; McClelland RS; Wener MH; Bankson DD; Lavreys L
Source: International Journal of STD and AIDS. 2007 Mar;18(3):202-206.
Abstract: Observational studies have suggested that low serum ß-carotene concentrations
may influence HIV-1 disease progression. However, randomized trials have not
demonstrated beneficial effects of ß-carotene supplementation. To understand
this discrepancy, we conducted a cross-sectional study among 400 HIV-1-
seropositive women in Mombasa, Kenya, to correlate serum ß-carotene
concentrations with several measures of HIV-1 disease severity. ß-Carotene
concentrations were significantly associated with biologic markers of HIV-1
disease progression (CD4 count, HIV-1 plasma viral load, serum C-reactive
protein [CRP] concentration, and serum albumin level). In multivariate analysis,
ß-carotene concentrations below the median were associated with elevated CRP
(>10 mg/l, adjusted odds ratio [aOR] 3.32, 95% confidence interval [CI] 1.99-5.53,
P < 0.001) and higher HIV-1 plasma viral load (for each log10 copies/mL
increase, aOR 1.38, 95% CI 1.01-1.88, P = 0.04). In the context of negative findings
from randomized trials of ß-carotene supplementation in HIV-1-seropositive
individuals, these results suggest that low ß-carotene concentrations primarily
reflect more active HIV-1 infection rather than a deficiency amenable to
intervention. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | CLINICAL TRIALS | CROSS SECTIONAL

ANALYSIS | HIV POSITIVE PERSONS | WOMEN | SOCIOECONOMIC
STATUS | VITAMIN A | DEFICIENCY DISEASES | NUTRITION INDEXES
| FOOD SUPPLEMENTATION | IMMUNITY, CELLULAR | AFRICA,
EASTERN | AFRICA SOUTH OF THE SAHARA | AFRICA | DEVELOPING
COUNTRIES | CLINICAL RESEARCH | RESEARCH METHODOLOGY |
PERSONS LIVING WITH HIV/AIDS | HIV INFECTIONS | VIRAL
DISEASES | DISEASES | DEMOGRAPHIC FACTORS | POPULATION |
SOCIOECONOMIC FACTORS | ECONOMIC FACTORS | VITAMINS AND
MINERALS | PHYSIOLOGY | BIOLOGY | NUTRITION DISORDERS |
NUTRITION | HEALTH | NUTRITION PROGRAMS | PRIMARY HEALTH
CARE | HEALTH SERVICES | DELIVERY OF HEALTH CARE |
IMMUNITY | IMMUNE SYSTEM
44
High uptake of postpartum hormonal contraception among HIV-1-

seropositive women in Kenya.
Author: Balkus J; Bosire R; John-Stewart G; Mbori-Ngacha D
Source: Sexually Transmitted Diseases. 2007 Jan;34(1):25-29.
Abstract: The objectives of this study were to determine patterns of contraceptive

utilization among sexually active HIV-1-seropositive women postpartum and to
identify correlates of hormonal contraception uptake. The goal of this study was
to improve delivery of family planning services to HIV-1-infected women in
resource-limited settings. HIV-1-infected pregnant women were followed
prospectively in a perinatal HIV-1 transmission study. Participants were referred
to local clinics for contraceptive counseling and management. Among 319 HIV-1-
infected women, median time to sexual activity postpartum was 2 months and
231 (72%) women used hormonal contraception for at least 2 months during
follow-up, initiating use at approximately 3 months postpartum (range, 1-11
months). Overall, 101 (44%) used DMPA, 71 (31%) oral contraception, and 59
(25%) switched methods during follow-up. Partner notification, infant mortality,
and condom use were similar between those using and not using contraception.
Using existing the healthcare infrastructure, it is possible to achieve high levels of
postpartum hormonal contraceptive utilization among HIV-1-seropositive
women. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | PROSPECTIVE STUDIES | KAP

SURVEYS | CONTRACEPTIVE PREVALENCE SURVEYS | POSTPARTUM
WOMEN | WOMEN IN DEVELOPMENT | HIV POSITIVE PERSONS |
POSTPARTUM | CONTRACEPTIVE USAGE | TIME FACTORS | DEPO-
PROVERA | ORAL CONTRACEPTIVES | CONTRACEPTIVE METHOD
SWITCHING | PARTNER COMMUNICATION | AFRICA, EASTERN |
COUNTRIES | STUDIES | RESEARCH METHODOLOGY | SURVEYS |
SAMPLING STUDIES | FAMILY PLANNING SURVEYS | FAMILY
PLANNING | PUERPERIUM | REPRODUCTION | ECONOMIC
DEVELOPMENT | ECONOMIC FACTORS | PERSONS LIVING WITH
HIV/AIDS | HIV INFECTIONS | VIRAL DISEASES | DISEASES |
CONTRACEPTION | POPULATION DYNAMICS | DEMOGRAPHIC
FACTORS | POPULATION | MEDROXYPROGESTERONE ACETATE |
CONTRACEPTIVE AGENTS, PROGESTIN | CONTRACEPTIVE AGENTS,
FEMALE | CONTRACEPTIVE AGENTS | CONTRACEPTIVE METHODS |
INTERPERSONAL RELATIONS | BEHAVIOR
45
Polymorphisms in IRF-1 associated with resistance to HIV-1 infection in

highly exposed uninfected Kenyan sex workers.
Author: Ball TB; Ji H; Kimani J; McLaren P; Marlin C
Source: AIDS. 2007 May 31;21(9):1091-1101.
Abstract: The objective was to determine the correlation between polymorphisms in the IL-
4 gene cluster and resistance to HIV-1 infection. A cross-sectional genetic
analysis of polymorphisms within the IL-4 gene cluster was conducted in a well-
described female sex worker cohort from Nairobi, Kenya, known to exhibit
differential susceptibility to HIV-1 infection. Microsatellite genotyping was used
to screen six microsatellite markers in the IL-4 gene cluster for associations with
HIV-1 resistance. Further analysis of the interferon regulatory factor 1 (IRF-1)
gene was conducted by genomic sequencing. Associations between IRF-1 gene
polymorphisms and the HIV-1 resistance phenotype were determined using the
chi-square test and Kaplan-Meier survival analysis. The functional consequence
of IRF-1 polymorphism was conducted by quantitative Western blot. Three
polymorphisms in IRF-1, located at 619, the microsatellite region and 6516 of the
gene, showed associations with resistance to HIV-1 infection. The 619A, 179at
IRF-1 microsatellite and 6516G alleles were associated with the HIV-1-resistant
phenotype and a reduced likelihood of seroconversion. Peripheral blood
mononuclear cells from patients with protective IRF-1 genotypes exhibited
significantly lower basal IRF-1 expression and reduced responsiveness to
exogenous IFN-t stimulation. Polymorphisms in the IRF-1 gene are associated
with resistance to infection by HIV-1 and a lowered level of IRF-1 protein
expression. This study adds IRF-1, a transcriptional immunoregulatory gene, to
the list of genetic correlates of altered susceptibility to HIV-1. This is the first
report suggesting that a viral transcriptional regulator might contribute to
resistance to HIV-1. Further functional analysis on the role of IRF-1
polymorphisms and HIV-1 resistance is underway. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | CROSS SECTIONAL ANALYSIS | SEX

WORKERS | WOMEN | HIV INFECTIONS | GENETICS | LABORATORY
PROCEDURES | IMMUNITY | HIV PREVENTION | AFRICA, EASTERN |
COUNTRIES | RESEARCH METHODOLOGY | SEX BEHAVIOR |
BEHAVIOR | DEMOGRAPHIC FACTORS | POPULATION | VIRAL
DISEASES | DISEASES | BIOLOGY | LABORATORY EXAMINATIONS
AND DIAGNOSES | EXAMINATIONS AND DIAGNOSES | MEDICAL
HEALTH CARE | HEALTH | IMMUNE SYSTEM | PHYSIOLOGY
46
Male circumcision for HIV prevention in young men in Kisumu, Kenya:

a randomised controlled trial.
Author: Balley RC; Moses S; Parker CB; Agot K; Maclean I
Source: Lancet. 2007 Feb 24;369(9562):643-656.
Abstract: Male circumcision could provide substantial protection against acquisition of

HIV-1 infection. Our aim was to determine whether male circumcision had a
protective effect against HIV infection, and to assess safety and changes in sexual
behaviour related to this intervention. We did a randomised controlled trial of
2784 men aged 18-24 years in Kisumu, Kenya. Men were randomly assigned to
an intervention group (circumcision; n = 1391) or a control group (delayed
circumcision, 1393), and assessed by HIV testing, medical examinations, and
behavioural interviews during follow-ups at 1, 3, 6, 12, 18, and 24 months. HIV
seroincidence was estimated in an intention-to-treat analysis. This trial is
registered with ClinicalTrials.gov, with the number NCT00059371. The trial was
stopped early on December 12, 2006, after a third interim analysis reviewed by
the data and safety monitoring board. The median length of follow-up was 24
months. Follow-up for HIV status was incomplete for 240 (8.6%) participants. 22
men in the intervention group and 47 in the control group had tested positive for
HIV when the study was stopped. The 2-year HIV incidence was 2.1% (95% CI
1.2-3.0) in the circumcision group and 4.2% (3.0-5.4) in the control group (p =
0.0065); the relative risk of HIV infection in circumcised men was 0.47 (0.28-0.78),
which corresponds to a reduction in the risk of acquiring an HIV infection of 53%
(22-72). Adjusting for non-adherence to treatment and excluding four men found
to be seropositive at enrolment, the protective effect of circumcision was 60% (32-
77). Adverse events related to the intervention (21 events in 1.5% of those
circumcised) resolved quickly. No behavioural risk compensation after
circumcision was observed. Male circumcision significantly reduces the risk of
HIV acquisition in young men in Africa. Where appropriate, voluntary, safe, and
affordable circumcision services should be integrated with other HIV preventive
interventions and provided as expeditiously as possible. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | CLINICAL TRIALS | CONTROL GROUPS

| INCIDENCE | MEN | HIV TESTING | MALE CIRCUMCISION |
EXAMINATIONS AND DIAGNOSES | HIV PREVENTION | PROGRAM
EFFECTIVENESS | DEVELOPING COUNTRIES | AFRICA, EASTERN |
AFRICA SOUTH OF THE SAHARA | AFRICA | CLINICAL RESEARCH |
RESEARCH METHODOLOGY | MEASUREMENT | DEMOGRAPHIC
FACTORS | POPULATION | LABORATORY EXAMINATIONS AND
SERVICES | DELIVERY OF HEALTH CARE | HEALTH | HIV INFECTIONS
47
| VIRAL DISEASES | DISEASES | PROGRAM EVALUATION |

PROGRAMS | ORGANIZATION AND ADMINISTRATION
Self-reported adherence to single dose nevirapine in the prevention of

mother to child transmission of HIV at Kitale District Hospital.
Author: Bii SC; Otieno-Nyunya B; Siika A; Rotich JK
Source: East African Medical Journal. 2007 Dec;84(12):571-576.
Abstract: Objectives:
To evaluate the uptake and adherence to single dose nevirapine among HIV
positive mothers.
Design:
Descriptive cross-sectional study. Setting: The maternal and child health and
family planning (MCH-FP) clinics in Kitale district hospital, Western Kenya.
Subjects: HIV positive postnatal women attending MCH-FP clinic who had gone
through the PMTCT programme.
Results:
A total of 146 respondents were recruited for this study. Most (90%) of them
reported swallowing their nevirapine tablets, however only 55 swallowed their
tablets within 4-12 hours before delivery. The most important factor affecting
nevirapine adherence was place or delivery (p<0.05). Most (71%) of mothers who
did not swallow their nevirapine delivered at home. Women attending ANC for
two times or less young women under 20 years of age and single women were
also less likely to swallow their nevirapine (p < 0.05). Most (91%) of the babies
received their nevirapine syrup with 98% of them getting it within 72 hours of
delivery. Eighty eight percent of babies who did not take their nevirapine were
delivered at home. Babies whose mothers did not take their nevirapine were also
more likely to miss it.
Conclusions:
Self reported adherence to take home nevirapine is high. However mothers who
deliver in a health facility were more likely to access nevirapine both for
themselves and their babies than those delivering at home. (author's)
Language: English

WITH HIV/AIDS | WOMEN IN DEVELOPMENT | PREGNANT WOMEN |
INFANT | ANTIRETROVIRAL DRUGS | USER COMPLIANCE |
PREVENTION OF MOTHER-TO-CHILD TRANSMISSION | HIV
48
PREVENTION | ANTENATAL CARE | AGE FACTORS | CHILDBIRTH |

TIME FACTORS | DEVELOPING COUNTRIES | AFRICA, EASTERN |
AFRICA, SUB SAHARAN | AFRICA | SURVEYS | SAMPLING STUDIES |
STUDIES | RESEARCH METHODOLOGY | HIV INFECTIONS | VIRAL
DISEASES | DISEASES | ECONOMIC DEVELOPMENT | ECONOMIC
FACTORS | POPULATION | YOUTH | TREATMENT | MEDICAL
HEALTH CARE | HEALTH | BEHAVIOR | DISEASE TRANSMISSION
CONTROL | PREVENTION AND CONTROL | MATERNAL HEALTH
SERVICES | MATERNAL-CHILD HEALTH SERVICES | PRIMARY
HEALTH CARE | PREGNANCY OUTCOMES | PREGNANCY |
REPRODUCTION | POPULATION DYNAMICS
Correlation of CD4 counts and CD4 / CD8 ratio with HIV-infection

associated oral manifestations.
Author: Butt FM; Vaghela VP; Chindia ML
Abstract: Background:
The relationship between oral lesions arising from HIV infection and CD4/CD8
cell ratios is of relevance in clinical assessment of immune suppression.
Objective:
To correlate the prevalence of oral manifestations arising from HIV infection and
the levels of CD4/CD8 cell ratios.
Design:
A cross-sectional study. Setting: Kenyatta National Hospital, Nairobi, Kenya.
Subjects:
Two hundred and seven HIV-infected patients in medical wards were recruited
in the study.
Results:
Seventy eight (37.7%) were male and 129 (62.3%) female, with an age range of 18-
73 years (mean = 34.81 years). Oral manifestations encountered with highest
prevalence in the oral cavity included: hyperplastic candidosis (labial mucosa)
15%, erythematous candidosis (gingival) 5%, angular cheilitis 32.4%, herpes
simplex(corner of the mouth) 0.5%, persistent oral ulceration (labial mucosa)
0.5%, Parotid enlargement 2% and Kaposi's sarcoma (hard/soft palate) 2.9%.
49
Conclusion:
The prevalence of oral manifestations was higher with low CD4 count <200
cell/mm3 and mean CD4/CD8<0.39(95%CI 0.32-0.48). (author's)
Language: English

CLIENTS | HIV POSITIVE PERSONS | ORAL EFFECTS | BACTERIAL
AND FUNGAL DISEASES | HIV INFECTIONS | DEVELOPING
RESEARCH METHODOLOGY | PROGRAM ACTIVITIES | PROGRAMS |
| PERSONS LIVING WITH HIV/AIDS | VIRAL DISEASES | DISEASES |
Heavy episodic drinking among Kenyan female sex workers is

associated with unsafe sex, sexual violence and sexually transmitted
infections.
Author: Chersich MF; Luchters SM; Malonza IM; Mwarogo P; King’ola N
Abstract: This study examined patterns of alcohol use and its association with unsafe sex
and related sequelae among female sex workers in Mombasa, Kenya. A
community-based cross-sectional study was conducted using snowball sampling.
Binge drinkers (>/= 5 alcoholic drinks on >/= 1 occasion in the previous month)
were compared with non-binge drinkers. Of 719 participants, 22.4% were
lifetime-alcohol abstainers, 44.7% non-binge and 33.0% binge drinkers.
Compared with non-binge drinkers, binge drinkers were more likely to report
unprotected sex (adjusted odds ratio (AOR) = 1.59, 95% confidence interval [CI]
= 1.00-2.53; P = 0.047) and sexual violence (AOR = 1.85, 95% CI = 1.27-2.71; P =
0.001) and to have either syphilis, Neisseria gonorrhoeae or Trichomonas
vaginalis infection (AOR = 1.56, 95% CI = 1.00-2.41; P = 0.048). HIV prevalence
was higher among women having ever drunk (39.9%) than lifetime abstainers
(23.2%; P < 0.001), but was not associated with drinking patterns. Interventions
are needed to assist female sex workers adopt safer drinking patterns.
Investigation is needed for the effectiveness of such interventions in reducing
unprotected sex, sexual violence and sexually transmitted infections. (author's)
Language: English

WORKERS | WOMEN | ALCOHOL USE AND ABUSE |
50
SOCIOECONOMIC FACTORS | SEX BEHAVIOR | RISK BEHAVIOR |

VIOLENCE | HIV INFECTIONS | SEXUALLY TRANSMITTED DISEASES |
SAHARAN | AFRICA | RESEARCH METHODOLOGY | BEHAVIOR |
DEMOGRAPHIC FACTORS | POPULATION | ECONOMIC FACTORS |
VIRAL DISEASES | DISEASES | REPRODUCTIVE TRACT INFECTIONS |
INFECTIONS
Mycoplasma genitalium infection and persistence in a cohort of female

sex workers in Nairobi, Kenya.
Author: Cohen CR; Nosek M; Meier A; Astete SG; Iverson-Cabral S
Source: Sexually Transmitted Diseases. 2007 May;34(5):274-279.
Abstract: The objective of this study was to assess the risk factors for and persistence of
Mycoplasma genitalium (MG) in a highly exposed female population in Kenya.
Two hundred fifty-eight sex workers in Nairobi, Kenya, 18 to 35 years of age,
were enrolled. Every 2 months, cervical samples were collected for MG,
Chlamydia trachomatis (CT), and Neisseria gonorrhoeae (GC) testing by
polymerase chain reaction. At enrollment, 16% were infected with MG. Seventy-
seven subjects acquired 107 MG infections, giving an incidence of 22.7 per 100
women-years. Incident CT (adjusted hazard ratio [HR] = 2.4; 95% confidence
interval [CI] = 1.5- 4.0), GC (HR = 2.0; 95% CI =1.2-3.5), and HIV infection
(adjusted HR = 2.2; 95% CI = 1.3-3.7) were associated with an increased risk of
MG. Seventeen percent, 9%, and 21% of MG infections persisted 3, 5, and greater
than or equal to 7 months, respectively. The high incidence of MG, greater than
that for both CT (14.0%) and GC (8%), association with common sexually
transmitted infection risk factors, and persistence in the female genital tract
supports its role as a common sexually transmitted infection in Kenyan women.
(author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | CLINICAL RESEARCH | COHORT

ANALYSIS | SEX WORKERS | WOMEN | SEXUALLY TRANSMITTED
DISEASES | UROGENITAL EFFECTS | PREVALENCE | AFRICA,
COUNTRIES | RESEARCH METHODOLOGY | SEX BEHAVIOR |
BEHAVIOR | DEMOGRAPHIC FACTORS | POPULATION |
REPRODUCTIVE TRACT INFECTIONS | INFECTIONS | DISEASES |
UROGENITAL SYSTEM | PHYSIOLOGY | BIOLOGY | MEASUREMENT
51
Infectious correlates of HIV-1 shedding in the female upper and lower

genital tracts.
Author: Coleman JS; Hitti J; Bukusi EA; Mwachari C; Muliro A
Source: AIDS. 2007 Mar 30;21(6):755-759.
Abstract: The objectives were to determine the effects of vaginal, cervical, and endometrial
infections on shedding of HIV-1 RNA in the female genital tract. Design: Cross-
sectional. Antiretroviral-naive women from Nairobi, Kenya with CD4 cell counts
>/= 350 cells/microliter had plasma and endocervical wick samples collected for
HIV quantification by real-time RNA reverse transcriptase-polymerase chain
reaction. Vaginal and cervical Gram stains and endometrial biopsies were
obtained. Vaginal Gram stain was used to diagnose bacterial vaginosis and to
quantify Lactobacillus levels. Twenty-six of 50 (52%) women had detectable
endocervical HIV-1 RNA with a median endocervical viral load of 1760
copies/ml (range: undetectable to 1 030 000 copies/ml). Women with decreased
Lactobacillus had 15.8-fold [95% confidenceinterval (CI), 2.0-123] greater
endocervical HIV-1 RNA than women with normal Lactobacillus levels. Women
with plasma cell (PC) endometritis [>/= 1 PC/ high-power field (hpf)] had a
15.8-fold (95% CI, 2.0-120) higher endocervical HIV RNA level than women
without PC endometritis. Both these associations remained after controlling for
plasma viral load. Cervicitis (>/= 30 polymorphonuclear leukocytes/hpf),
however, was not associated with endocervical HIV-1 RNA shedding (P=0.81). In
HIV-1-infected, antiretroviral-naive women without symptoms of pelvic
inflammatory disease infection, abnormal vaginal flora and inflammatory cells in
the endometrium affected HIV-1 shedding from the lower genital tract. These
data suggest that both the upper and lower genital tracts contribute to female
HIV-1 genital shedding. (author's)
Language: English

WOMEN | HIV POSITIVE PERSONS | IMMUNITY, CELLULAR |
LABORATORY PROCEDURES | GENITAL EFFECTS, FEMALE |
ENDOMETRITIS | VAGINOSIS | PELVIC INFLAMMATORY DISEASE |
SEXUALLY TRANSMITTED DISEASES | AFRICA, EASTERN | AFRICA
SOUTH OF THE SAHARA | AFRICA | DEVELOPING COUNTRIES |
POPULATION | PERSONS LIVING WITH HIV/AIDS | HIV INFECTIONS |
VIRAL DISEASES | DISEASES | IMMUNITY | IMMUNE SYSTEM |
PHYSIOLOGY | BIOLOGY | LABORATORY EXAMINATIONS AND
52
HEALTH CARE | HEALTH | GENITALIA, FEMALE | GENITALIA |

UROGENITAL SYSTEM | REPRODUCTIVE TRACT INFECTIONS |
INFECTIONS | VAGINAL ABNORMALITIES
Market incentives, human lives, and AIDS vaccines.
Author: Craddock S
Source: Social Science and Medicine. 2007 Mar;64(5):1042-1056.
Abstract: For many, an AIDS vaccine holds the promise of intervening in a widespread
epidemic because it is not predicated on changing economic structures and social
contexts underlying vulnerability to HIV for millions of individuals. Yet 20 years
into the AIDS epidemic, there is still no vaccine. Based on interviews of AIDS
vaccine researchers, watchdog organizations, and ethics groups from the United
States, South Africa, and Kenya conducted between August and December of
2003, this paper explores possible answers to the question of why there is no
vaccine, looking in particular at contradictions between a biomedical research
industry increasingly driven by market incentives and a disease that primarily
affects individuals living in low-income countries with little vaccine purchasing
power. Producing a vaccine that could be effective in low-income regions
requires new kinds of initiatives that can coordinate research nationally and
globally, and circumvent current regulatory mechanisms that dictate against the
development and dissemination of low-profit medical technologies. Until such
initiatives are supported, however, vaccine research will continue at a
devastatingly slow pace at the cost of millions of lives annually. (author's)
Language: English
Keywords: UNITED STATES | SOUTH AFRICA | KENYA | RESEARCH REPORT |

RESEARCH AND DEVELOPMENT | VACCINES | PHARMACY
DISTRIBUTION | AIDS | MEDICINE | ECONOMIC FACTORS | NORTH
AMERICA | AMERICAS | DEVELOPED COUNTRIES | AFRICA,
SOUTHERN | AFRICA SOUTH OF THE SAHARA | AFRICA |
DEVELOPING COUNTRIES | AFRICA, EASTERN | TECHNOLOGY |
MEDICAL PROCEDURES | HEALTH SERVICES | DELIVERY OF HEALTH
CARE | HEALTH | NONCLINICAL DISTRIBUTION | DISTRIBUTIONAL
ACTIVITIES | PROGRAM ACTIVITIES | PROGRAMS | ORGANIZATION
AND ADMINISTRATION | HIV INFECTIONS | VIRAL DISEASES |
DISEASES
53
Urban-rural differences in the socioeconomic deprivation -- Sexual

behavior link in Kenya.
Author: Dodoo FN; Zulu EM; Ezeh AC
Abstract: We compare the impact of socioeconomic deprivation on risky sexual outcomes

in rural and urban Kenya. Quantitative data are drawn from the Demographic &
Health Surveys (DHS) and qualitative data from the Sexual Networking and
Associated Reproductive and Social Health Concerns study. Using two separate
indicators of deprivation we show that, although poverty is significantly
associated with the examined sexual outcomes in all settings, the urban poor are
significantly more likely than their rural counterparts to have an early sexual
debut and a greater incidence of multiple sexual partnerships. The disadvantage
of the urban poor is accentuated for married women; those in Nairobi's slums are
at least three times as likely to have multiple sexual partners as their rural
counterparts. The implications of these findings are discussed. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | COMPARATIVE STUDIES | RURAL

AREAS | URBAN AREAS | MULTIPLE PARTNERS | SEXUAL PARTNERS
| SEX BEHAVIOR | CONDOM USE | POVERTY | SOCIOECONOMIC
FACTORS | AFRICA, EASTERN | AFRICA SOUTH OF THE SAHARA |
AFRICA | DEVELOPING COUNTRIES | STUDIES | RESEARCH
METHODOLOGY | GEOGRAPHIC FACTORS | POPULATION |
BEHAVIOR | RISK REDUCTION BEHAVIOR | ECONOMIC FACTORS

Sero-discordant couples in five African countries: Implications for
prevention strategies.
Author: De Walque D
Source: Population and Development Review. 2007 Sep;33(3):501-523.
Abstract: THE HIV/AIDS EPIDEMIC is one of the greatest challenges facing Africa.
According to UNAIDS (2006), as of December 2006, between 21.8 and 27.7
million people in sub-Saharan Africa were infected by HIV/AIDS. This
represents around 62.5 percent of the estimated worldwide total and implies that
between 5.2 and 6.7 percent of adults living in that region are HIV positive.
Between 1.8 and 2.4 million sub-Saharan Africans died from the virus in 2006
and between 2.4 and 3.2 million became newly infected. Only recently have
54
individual-level data, including HIV test results, become available for nationally
representative samples in Africa and other developing regions. Previously,
studies of the HIV epidemic relied either on aggregate data or on HIV status data
from nonrepresentative samples or on data from self-reported sexual behavior.
The new wave of Demographic and Health Surveys (DHS), which include HIV
status, now permits analysis of the socioeconomic determinants of HIV infection
for nationally representative samples. The present study of sero-discordant
couples uses an additional feature of the data available in the Demographic and
Health Surveys. The data make it possible to assess the HIV status of cohabiting
couples (formally married or not) and to compare sexual behavior reported by
the man and the woman. (excerpt)
Language: English
Keywords: CAMEROON | KENYA | TANZANIA | BURKINA FASO | GHANA |

RESEARCH REPORT | DEMOGRAPHIC AND HEALTH SURVEYS |
PERSONS LIVING WITH HIV/AIDS | COUPLES | HIV PREVENTION |
HIV TRANSMISSION | EXTRAMARITAL SEX BEHAVIOR |
DEVELOPING COUNTRIES | AFRICA, WESTERN | AFRICA, SUB
SAHARAN | AFRICA | AFRICA, EASTERN | DEMOGRAPHIC SURVEYS |
POPULATION DYNAMICS | DEMOGRAPHIC FACTORS | POPULATION
| HIV INFECTIONS | VIRAL DISEASES | DISEASES | FAMILY
FACTORS | SEX BEHAVIOR | BEHAVIOR
55
Orphans and schooling in Africa: A longitudinal analysis.
Author: Evans DK; Miguel E
Source: Demography. 2007 Feb;44(1):35-57.
Abstract: AIDS deaths could have a major impact on economic development by affecting
the human capital accumulation of the next generation. We estimate the impact
of parent death on primary school participation using an unusual five-year panel
data set of over 20,000 Kenyan children. There is a substantial decrease in school
participation following a parent death and a smaller drop before the death
(presumably due to pre-death morbidity). Estimated impacts are smaller in
specifications without individual fixed effects, suggesting that estimates based
on cross-sectional data are biased toward zero. Effects are largest for children
whose mothers died and, in a novel finding, for those with low baseline
academic performance. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | LONGITUDINAL STUDIES | SURVEYS |

ORPHANS AND VULNERABLE CHILDREN | PARENTS | MORTALITY |
AIDS | RURAL AREAS | PRIMARY SCHOOLS | SOCIOECONOMIC
STATUS | EDUCATIONAL STATUS | DEVELOPING COUNTRIES |
AFRICA, EASTERN | AFRICA, SUB SAHARAN | AFRICA | STUDIES |
RESEARCH METHODOLOGY | SAMPLING STUDIES | YOUTH | AGE
FACTORS | POPULATION | FAMILY RELATIONSHIPS | FAMILY
FACTORS | POPULATION DYNAMICS | HIV INFECTIONS | VIRAL
DISEASES | DISEASES | GEOGRAPHIC FACTORS | SCHOOLS |
EDUCATION | SOCIOECONOMIC FACTORS | ECONOMIC FACTORS
Validity of self-reported "safe sex" among female sex workers in

Mombasa, Kenya -- PSA analysis.
Author: Gall MF; Behets FM; Steiner MJ; Thomsen SC; Ombidi W
Abstract: We assessed the validity of self-reported sex and condom use by comparing self-
reports with prostate-specific antigen (PSA) detection in a prospective study of
210 female sex workers in Mombasa, Kenya. Participants were interviewed on
recent sexual behaviours at baseline and 12-month follow-up visits. At both
56
visits, a trained nurse instructed participants to self-swab to collect vaginal fluid

specimens, which were tested for PSA using enzyme-linked immunosorbent
assay (ELISA). Eleven percent of samples (n¼329) from women reporting no
unprotected sex for the prior 48 hours tested positive for PSA. The proportions of
women with this type of discordant self-reported and biological data did not
differ between the enrolment and 12-month visit (odds ratio [OR] 1.1; 95%
confidence interval [CI] 0.99, 1.2). The study found evidence that participants
failed to report recent unprotected sex. Furthermore, because PSA begins to clear
immediately after exposure, our measures of misreported semen exposure likely
are underestimations. (author's)
Language: English

WORKERS | WOMEN | LABORATORY EXAMINATIONS AND
DIAGNOSES | ANTIGENS | IMMUNOLOGIC FACTORS | SELF-
PERCEPTION | POSTCOITAL DOUCHING | SAFER SEX | CONDOM USE
| AFRICA, EASTERN | AFRICA SOUTH OF THE SAHARA | AFRICA |
DEVELOPING COUNTRIES | STUDIES | RESEARCH METHODOLOGY |
SEX BEHAVIOR | BEHAVIOR | DEMOGRAPHIC FACTORS |
POPULATION | EXAMINATIONS AND DIAGNOSES | MEDICAL
HEALTH CARE | HEALTH | IMMUNITY | IMMUNE SYSTEM |
PHYSIOLOGY | BIOLOGY | PERCEPTION | PSYCHOLOGICAL FACTORS
| FERTILITY CONTROL, POSTCOITAL | FAMILY PLANNING | RISK
REDUCTION BEHAVIOR
'Are you on the market?': A capture -- recapture enumeration of men who

sell sex to men in and around Mombasa, Kenya.
Author: Geibel S; van der Elst EM; King'ola N; Luchters S; Davies A
Source: AIDS. 2007 Jun;21(10):1349-1354.
Abstract: Men who have sex with men (MSM) are highly vulnerable to HIV infection, but
this population can be particularly difficult to reach in sub-Saharan Africa. We
aimed to estimate the number of MSM who sell sex in and around Mombasa,
Kenya, in order to plan HIV prevention research. We identified 77 potential
MSM contact locations, including public streets and parks, brothels, bars and
nightclubs, in and around Mombasa and trained 37 MSM peer leader
enumerators to extend a recruitment leaflet to MSM who were identified as 'on
the market', that is, a man who admitted to selling sex to men. We captured men
on two consecutive Saturdays, 1 week apart. A record was kept of when, where
57
and by whom the invitation was extended and received, and of refusals. The
total estimate of MSM who sell sex was derived from capture-recapture
calculation. Capture 1 included 284 men (following removal of 15 duplicates); 89
men refused to participate. Capture 2 included 484 men (following removal of 35
duplicates); 75 men refused to participate. Of the 484 men in capture 2, 186 were
recaptures from capture 1, resulting in a total estimate of 739 (95% confidence
interval, 690-798) MSM who sell sex in the study area. We estimated that 739
MSM sell sex in and around Mombasa. Of these, 484 were contacted through
trained peer enumerators in a single day. MSM who sell sex in and around
Mombasa represent a sizeable population who urgently need to be targeted by
HIV prevention strategies. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | EPIDEMIOLOGIC METHODS |

INDIRECT ESTIMATION TECHNICS | MEN HAVING SEX WITH MEN |
SEX WORKERS | INFLUENTIALS | HIV PREVENTION | SEX BEHAVIOR
| AFRICA, EASTERN | AFRICA, SUB SAHARAN | AFRICA |
DEVELOPING COUNTRIES | RESEARCH METHODOLOGY |
ESTIMATION TECHNICS | BEHAVIOR | KNOWLEDGE SOURCES |
COMMUNICATION | HIV INFECTIONS | VIRAL DISEASES | DISEASES
Total lymphocyte count as a surrogate marker for CD4+ T cell count in

initiating antiretroviral therapy at Kenyatta National Hospital, Nairobi.
Author: Gitura B; Joshi MD; Lule GN; Anzala O
Source: East African Medical Journal. 2007 Oct;84(10):466-473.
Abstract: Objective:
To evaluate the utility of Total Lymphocyte Count (TLC) as a surrogate marker
for CD4 + T cell count in antiretroviral (ARV) treatment initiation in a Kenyan
population of HIV seropositive patients at Kenyatta National Hospital.
Design:
Cross-sectional descriptive study. Setting: Kenyatta National Hospital, HIV
treatment and follow-up outpatient facility; Comprehensive Care Centre,
Nairobi, Kenya. Subjects: Two hundred and twenty five HIV Elisa positive, ARV
naive patients visiting the Comprehensive Care Centre between January 2006 to
March 2006.
58
Results:
A significant linear correlation was found between TLC and CD4 cell count for
the whole group with a Spearman rank correlation of 0.761 (p < 0.01); and was
also independently observed in the four WHO clinical stages. The classification
utility of TLC 1200 cells/mm3 cut-off was suboptimal; sensitivity 37% specificity
of 99% and the NPV of 56%. The receiver operator characteristics (ROC) curve
generated an optimal TLC cut-off of 1900 cells/mm3 cut-off to be of greatest
utility with a sensitivity of 81.1%, specificity of 90.3%, PPV of 90.8% and NPV of
80.2%. This implies that a TLC cut-off of 1900 cells/mm3 correctly classify eight
out of ten HIV positive patients as having a CD4 < 200 cells/mm3 and only
misclassify two such patients. Serial CD4 testing can then be performed on the
minority of patients who despite a TLC >or= 1900 cells/mm3 are, on basis of
clinical data, suspect of more advanced disease warranting ARV therapy. This
would reduce the number of patients tested for and focus the application of CD4
testing and thus reduce attendant cost in care provision in CD4 resource poor
settings.
Conclusion:
Our data showed a good positive correlation between TLC and CD4 cell count,
however the WHO recommended TLC cut-off of 1200/mm3 was found to be of
low sensitivity in classifying patients as having a CD4 counts < 200 cells/mm3.
This would result in underestimation of advanced stage of disease and to
withholding ARVs treatment to persons who need treatment. We recommend a
TLC cut-off of 1900 cells/mm3 for our population to classify patients as either
above or below the CD4 count cut-off of 200 cells/mm3 as an indicator of when
to start antiretroviral therapy. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | CROSS SECTIONAL ANALYSIS | HIV

POSITIVE PERSONS | CLIENTS | ANTIRETROVIRAL THERAPY |
ANTIRETROVIRAL DRUGS | AUTOIMMUNE RESPONSE | TREATMENT
| LABORATORY PROCEDURES | TESTING | TIME FACTORS |
RECOMMENDATIONS | DEVELOPING COUNTRIES | AFRICA,
EASTERN | AFRICA, SUB SAHARAN | AFRICA | RESEARCH
METHODOLOGY | PERSONS LIVING WITH HIV/AIDS | HIV
INFECTIONS | VIRAL DISEASES | DISEASES | PROGRAM ACTIVITIES
| PROGRAMS | ORGANIZATION AND ADMINISTRATION | HIV |
MEDICAL PROCEDURES | MEDICINE | HEALTH SERVICES | DELIVERY
OF HEALTH CARE | HEALTH | ANTIBODIES | IMMUNOLOGIC
FACTORS | IMMUNITY | IMMUNE SYSTEM | PHYSIOLOGY | BIOLOGY
| LABORATORY EXAMINATIONS AND DIAGNOSES | EXAMINATIONS
AND DIAGNOSES | MEASUREMENT | POPULATION DYNAMICS |
DEMOGRAPHIC FACTORS | POPULATION
59
Associations between intravaginal practices and bacterial vaginosis in

Kenyan female sex workers without symptoms of vaginal infections.
Author: Hassan WM; Lavreys L; Chohan V; Richardson BA; Mandaliya K
Abstract: Bacterial vaginosis (BV) is highly prevalent among African women and has been
associated with adverse pregnancy outcomes, sexually transmitted diseases, and
HIV-1. The goal of this study was to analyze the relationship among intravaginal
practices, bathing, and BV. The authors conducted a cross-sectional study of
HIV-1-seronegative Kenyan female sex workers without symptoms of vaginal
infections. Of 237 women enrolled, 206 (87%) reported vaginal washing using
either a finger or cloth. Increasing frequency of vaginal washing was associated
with a higher likelihood of BV (x/2 test for trend, P = 0.05). In multivariate
analysis, vaginal lubrication with petroleum jelly (odds ratio [OR] = 2.8, 95%
confidence interval [CI] = 1.4 -5.6), lubrication with saliva (OR = 2.3, 95% CI =
1.1-4.8), and bathing less than the median for the cohort (14 times/week; OR =
4.6, 95% CI = 1.2-17.5) were associated with a significantly higher likelihood of
BV. Modification of intravaginal and general hygiene practices should be
evaluated as potential strategies for reducing the risk of BV. (author's)
Language: English

WORKERS | WOMEN | VAGINOSIS | BACTERIAL AND FUNGAL
DISEASES | SIGNS AND SYMPTOMS | SEX BEHAVIOR | HYGIENE |
RISK FACTORS | AFRICA, EASTERN | AFRICA SOUTH OF THE SAHARA
| AFRICA | DEVELOPING COUNTRIES | RESEARCH METHODOLOGY |
BEHAVIOR | DEMOGRAPHIC FACTORS | POPULATION | VAGINAL
ABNORMALITIES | DISEASES | INFECTIONS | PUBLIC HEALTH |
HEALTH | BIOLOGY
Cohabitation, marriage, and "sexual monogamy" in Nairobi's slums.
Author: Hattori MK; Dodoo FN
Abstract: The current study investigates the extent to which sexual exclusivity--the
restriction of one's sexual engagements to a single partner--prevails across
various marital status, union type, and co-residence categories among Nairobi's
poorest residents, slum dwellers. This question is central to the spread of HIV in
60
the increasingly urban and poor, high prevalence countries of sub-Saharan

Africa, where transmission is primarily via heterosexual sex. In many circles,
sexual exclusivity is considered a prominent feature of the marriage institution.
Yet, marriage and cohabitation are often not easily distinguishable in sub-
Saharan Africa, meaning that the frequent use, as a proxy, of the ''in union''
category, which includes married as well as cohabiting persons can, at best, be
considered tenuous. Using the 2000 Nairobi Cross-Sectional Slum Survey
(NCSS), this paper confirms that marriage is associated with higher reports of
sexual exclusivity even in settings where poverty provokes risky behavior. The
finding, here, is of lower risk of HIV infection for married respondents, with a
smaller effect observed among non-married cohabiters. Converse to the implied
benefits of marriage, though, women with co-wives are more likely to report
multiple partners. The implications of these findings are discussed. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | CROSS SECTIONAL ANALYSIS | SLUMS

| URBAN AREAS | LOW INCOME POPULATION | POVERTY |
MARRIAGE | MONOGAMY | HIV INFECTIONS | AIDS | AFRICA,
COUNTRIES | RESEARCH METHODOLOGY | URBANIZATION |
URBAN POPULATION DISTRIBUTION | POPULATION DISTRIBUTION |
GEOGRAPHIC FACTORS | POPULATION | SOCIAL CLASS |
SOCIOECONOMIC STATUS | SOCIOECONOMIC FACTORS |
ECONOMIC FACTORS | NUPTIALITY | DEMOGRAPHIC FACTORS |
MARRIAGE PATTERNS | VIRAL DISEASES | DISEASES
Clinical and laboratory characteristics of hospitalised patients with

neurological manifestations of HIV / AIDS at the Nairobi Hospital.
Author: Jowi JO; Mativo PM; Musoke SS
Source: East African Medical Journal. 2007 Feb;84(2):67-76.
Abstract: The objective was to determine the profile of clinical and laboratory
characteristics of hospitalised HIV positive patients with neurological
complications at a private hospital in Nairobi, Kenya from January 2000 to June
2005. The design used was a retrospective observational study. The Nairobi
Hospital, Nairobi, Kenya was the setting. One hundred and fifty hospitalised
patients were the subjects used in the study. Records of 708 HIV positive
hospitalised patients were reviewed, 150 patients had neurological
complications; giving a six-year point prevalence of 21.2%. Males were 86 (57.3%)
and females 64 (42.7%) M: F ratio = 1.3:1. Mean age was 38.84 years. The five
61
commonest neurological complications were; cryptococcal meningitis 33 (22%),

encephalitis 28 (18.7%), cerebral toxoplasmosis 19 (12.7%), stroke 19 (12.7%) and
tuberculous meningitis 16 (10.7%). Overall, 72 patients (63%) had CD4+ counts
done. Cryptococcal meningitis patients' CD4+ count, (mean 60, median 17, range
1-273/cmm). Encephalitis patients' CD4+count, (mean 82, median 54, range 3-
495/cmm). Cerebral toxoplasmosis patients' CD4+count, (mean 59, median 58,
range 11-120 /cmm). Stroke patients' CD4+ count, (mean 120, median 30, range
15-394/cmm) and Tuberculous meningitis patients' CD4+ count, (mean 67,
median 62 and range 12-1 54/cmm). The other rare neurological manifestations
included peripheral neuropathy, HIV associated dementia (HAD), myelopathy
and myopathy amongst others. One hundred and eight (72%) patients were on
anti-retroviral therapy. The commonest drugs used in various regimen
combinations included efavirenz and combivir. Fourteen (9.3%) patients died
while in hospital; eight of them were among those with the top five neurological
complications. The findings show that patients come to hospital when severely
immune compromised and hence have overwhelming opportunistic infections.
The profile of opportunistic infection is comparable to that observed in studies
elsewhere. Some of the facts observed here may not reflect the situation in public
health institutions where resources are scarce. Recommendation: To do a multi-
centre prospective study of neurological manifestations of HIV/ AIDS. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | RETROSPECTIVE STUDIES | CLIENTS |

HIV POSITIVE PERSONS | HOSPITALS | NEUROLOGIC EFFECTS |
LABORATORY PROCEDURES | DEVELOPING COUNTRIES | AFRICA,
METHODOLOGY | PROGRAM ACTIVITIES | PROGRAMS |
ORGANIZATION AND ADMINISTRATION | PERSONS LIVING WITH
HIV/AIDS | HIV INFECTIONS | VIRAL DISEASES | DISEASES | HEALTH
FACILITIES | DELIVERY OF HEALTH CARE | HEALTH | PHYSIOLOGY |
MEDICINE | HEALTH SERVICES
Risk factors for treatment denial and loss to follow-up in an

antiretroviral treatment cohort in Kenya.
Author: Karcher H; Omondi A; Odera J; Kunz A; Harms G
Source: Tropical Medicine and International Health. 2007 May;12(5):687-694.
62
Abstract: The objectives were to evaluate risk factors for treatment denial and loss to
follow-up in an antiretroviral treatment (ART) cohort in a rural African setting in
western Kenya. Sociodemographic and clinical data of patients enrolled in an
ART cohort were collected within 18 months of an observational longitudinal
study and analysed by logistic and Cox regression models. Of 159 patients with
treatment indication 35 (22%) never started ART. Pregnancy [adjusted odds ratio
(AOR) 3.60, 95% confidence interval (CI) 1.10-11.8; P = 0.035] and lower level of
education (AOR 3.80, 95% CI 1.14-12.7; P = 0.03) were independently associated
with treatment denial. The incidence of total loss of patients under therapy was
43.2 per 100 person years (pys) (mortality rate 19.2 per 100 pys plus drop out rate
24 per 100 pys). Older age [adjusted hazard ratio (AHR) 1.06, 95% CI 1.01-1.12; P
= 0.04], AIDS before starting treatment (AHR 5.83, 95% CI 1.15-29.5; P = 0.03) and
incomplete adherence to treatment (AHR 1.05, 95% CI 1.03-1.07; P < 0.001) were
independent risk factors for death. Incomplete adherence also independently
predicted drop out because of other reasons (AHR 1.06, 95% CI 1.04-1.09; P <
0.001). Pregnancy and lower level of education, higher age, advanced AIDS stage
and impaired compliance to ART were identified as risk factors for treatment
denial and death, respectively. Adequate counselling strategies for patients with
these characteristics could help to improve adherence and outcome of treatment
programmes in resource-limited settings. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | COHORT ANALYSIS | LONGITUDINAL

STUDIES | HIV POSITIVE PERSONS | ANTIRETROVIRAL THERAPY |
TREATMENT | DROPOUTS | PREGNANCY | EDUCATION | AGE
FACTORS | MORTALITY | AFRICA, EASTERN | AFRICA, SUB SAHARAN
| AFRICA | DEVELOPING COUNTRIES | RESEARCH METHODOLOGY |
STUDIES | PERSONS LIVING WITH HIV/AIDS | HIV INFECTIONS |
VIRAL DISEASES | DISEASES | HIV | MEDICAL PROCEDURES |
HEALTH | PROGRAMS | ORGANIZATION AND ADMINISTRATION |
REPRODUCTION | POPULATION CHARACTERISTICS |
DEMOGRAPHIC FACTORS | POPULATION | POPULATION DYNAMICS
Determinants of tuberculosis diagnosis and the role of counselling.
Author: Kivihya-Ndugga L; van Cleeff M; Nyamwaya J; Miheso B; Ndalo E
Source: East African Medical Journal. 2007 Feb;84(2):77-82.
Abstract: The objective was to study patient determinants that may affect completion of
the diagnostic process in tuberculosis control, highlighting the role of
counselling. Cross-sectional study was the design used. All of the subjects used
63
in the study were TB patients. The setting for the study was the Rhodes Chest
Clinic, Nairobi, City Council. Ninety five percent of the suspects delivered three
sputum samples but only 27% consented to a HIV test; several determinants for
none consenting were mentioned. On average US$2.27 was spent for one clinic
visit and US$8.62 for following the entire diagnostic process. Cost factors
included transport, loss of income and food. Individual pre-test counselling
seems important for obtaining three sputum specimens. It takes time and for
settings with a large number of suspects, alternative methods may be required.
To obtain consensus for a HIV test in a TB clinic is complicated. Costs spent on
transport and loss in income are important determinants and may contribute to
poor patient adherence to the diagnostic process. (author's)
Language: English

CLIENTS | TUBERCULOSIS | EXAMINATIONS AND DIAGNOSES |
COUNSELING | HIV TESTING | FEES | OBSTACLES | DEVELOPING
RESEARCH METHODOLOGY | PROGRAM ACTIVITIES | PROGRAMS |
ORGANIZATION AND ADMINISTRATION | INFECTIONS | DISEASES |
OF HEALTH CARE | HEALTH | CLINIC ACTIVITIES | LABORATORY
EXAMINATIONS AND DIAGNOSES | FINANCIAL ACTIVITIES |
ECONOMIC FACTORS
Social networks and HIV / AIDS risk perceptions.
Author: Kohler H; Behrman JR; Watkins SC
Source: Demography. 2007 Feb;44(1):1-33.
Abstract: Understanding the determinants of individuals' perceptions of their risk of

becoming infected with HIV and their perceptions of acceptable strategies of
prevention is an essential step toward curtailing the spread of this disease. We
focus in this article on learning and decision-making about AIDS in the context of
high uncertainty about the disease and appropriate behavioral responses. We
argue that social interactions are important for both. Using longitudinal survey
data from rural Kenya and Malawi, we test this hypothesis. We investigate
whether social interactions--and especially the extent to which social network
partners perceive themselves to be at risk--exert causal influences on
respondents' risk perceptions and on one approach to prevention, spousal
communication about the threat of AIDS to the couple and their children. The
study explicitly allows for the possibility that important characteristics, such as
unobserved preferences or community characteristics, determine not only the
64
outcomes of interest but also the size and composition of networks. The most
important empirical result is that social networks have significant and substantial
effects on risk perceptions and the adoption of new behaviors even after we
control for unobserved factors. (author's)
Language: English
Keywords: KENYA | MALAWI | RESEARCH REPORT | SURVEYS | LONGITUDINAL

STUDIES | SEXUAL PARTNERS | SEX BEHAVIOR | SOCIAL NETWORKS
| PERCEPTION | RISK FACTORS | HIV TRANSMISSION | AIDS |
SAHARAN | AFRICA | AFRICA, SOUTHERN | SAMPLING STUDIES |
STUDIES | RESEARCH METHODOLOGY | BEHAVIOR | FRIENDS AND
RELATIVES | FAMILY AND HOUSEHOLD | SOCIOCULTURAL FACTORS
| PSYCHOLOGICAL FACTORS | BIOLOGY | HIV INFECTIONS | VIRAL
DISEASES | DISEASES
A nested case -- control study of sexual practices and risk factors for
prevalent HIV-1 infection among young men in Kisumu, Kenya.
Author: Mattson CL; Bailey RC; Agot K; Ndinya-Achola JO; Moses S
Source: Sexually Transmitted Diseases. 2007 Oct;34(10):731-736.
Abstract: The objectives were to investigate sexual practices and risk factors for prevalent
HIV infection among young men in Kisumu, Kenya. Goal: The goal of this study
was to identify behaviors associated with HIV in Kisumu to maximize the
effectiveness of future prevention programs. Lifetime sexual histories were
collected from a nested sample of 1337 uncircumcised participants within the
context of a randomized controlled trial of male circumcision to reduce HIV
incidence. Sixty-five men (5%) tested positive for HIV. Multiple logistic
regression revealed the following independent predictors of HIV: older age, less
education, being married, being Catholic, >4 lifetime sex partners, prior
treatment for an STI, sex during partner's menstruation, ever practicing
bloodletting, and receipt of a medical injection in the last 6 months. Prior HIV
testing and postcoital cleansing were protective. This analysis confirms the
importance of established risk factors for HIV and identifies practices that
warrant further investigation. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | CASE CONTROL STUDIES | MEN |

YOUTH | SEX BEHAVIOR | RISK BEHAVIOR | RISK FACTORS | HIV
65
TRANSMISSION | MALE CIRCUMCISION | DEVELOPING COUNTRIES

| AFRICA, EASTERN | AFRICA, SUB SAHARAN | AFRICA | STUDIES |
POPULATION | AGE FACTORS | POPULATION CHARACTERISTICS |
BEHAVIOR | BIOLOGY | HIV INFECTIONS | VIRAL DISEASES |
DISEASES | MEDICAL PROCEDURES | MEDICINE | HEALTH SERVICES
| DELIVERY OF HEALTH CARE | HEALTH
HIV-1 infection in high risk men who have sex with men in Mombasa,
Kenya.
Author: Sanders EJ; Graham SM; Okuku HS; van der Elst EM; Muhaari A
Source: AIDS. 2007 Nov 30;21(18):2513-2520.
Abstract: The role of homosexuality and anal sex practices in the African HIV -1 epidemic
is not well described. We aimed to assess the risk factors for prevalent HIV-1
infection among men who have sex with men (MSM) to guide HIV-1 prevention
efforts. Socio-behavioural characteristics, signs and symptoms of sexually
transmitted diseases (STD), and serological evidence of HIV-1 were determined
for 285MSM at enrolment into a vaccine preparedness cohort study. We used
multivariate logistic regression to assess risk factors for prevalent HIV-1
infection. HIV-1 prevalence was 43.0% [49/114, 95% confidence interval (CI), 34-
52%] for men who reported sex with men exclusively (MSME), and 12.3%
(21/171, 95% CI, 7-17%) for men who reported sex with both men and women
(MSMW). Eighty-six (75%) MSME and 69 (40%) MSMW reported recent
receptive anal sex. Among 174 MSM sexually active in the last week, 44%
reported no use of condoms with casual partners. In the previous 3 months, 210
MSM (74%) reported payment for sex, andmost clients (93%) were local
residents. Prevalent HIV-1 infection was associated with recent receptive anal sex
[odds ratio (OR), 6.1; 95% CI, 2.4-16], exclusive sex with men (OR, 6.3; 95% CI,
2.3-17), and increasing age (OR, 1.1 per year; 95% CI, 1.04-1.12). Only four MSM
reported injecting drug use. The high prevalence of HIV-1 in Kenyan MSM is
probably attributable to unprotected receptive anal sex. There is an urgent need
for HIV-1 prevention programmes to deliver targeted risk-reduction
interventions and STD services to MSM in Kenya. (author's)
Language: English

MULTIVARIATE ANALYSIS | HIV POSITIVE PERSONS | MEN HAVING
SEX WITH MEN | MULTIPLE PARTNERS | IV DRUG USERS | HIV
INFECTIONS | ANAL SEX | RISK FACTORS | SEX BEHAVIOR |
66
CONDOM USE | PREVALENCE | AGE FACTORS | DEVELOPING

RESEARCH METHODOLOGY | DATA ANALYSIS | PERSONS LIVING
WITH HIV/AIDS | VIRAL DISEASES | DISEASES | BEHAVIOR | SEXUAL
PARTNERS | DRUG USE AND ABUSE | BIOLOGY | RISK REDUCTION
BEHAVIOR | MEASUREMENT | POPULATION CHARACTERISTICS |
DEMOGRAPHIC FACTORS | POPULATION
Identification of novel risks for nonulcerative sexually transmitted

infections among young men in Kisumu, Kenya.
Author: Mehta SD; Moses S; Ndinya-Achola JO; Agot K; Maclean I
Source: Sexually Transmitted Diseases. 2007 Nov;34(11):892-899.
Abstract: STI prevention interventions often aim to reduce HIV incidence. Understanding
STI risks may lead to more effective HIV prevention. The goal was to identify STI
risks among men aged 18-24 in Kisumu, Kenya. We analyzed baseline data from
a randomized trial of male circumcision. Participants were interviewed for
sociodemographic and behavioral risks. Neisseria gonorrhoeae (NG) and
Chlamydia trachomatis (CT) were diagnosed by polymerase chain reaction assay
and Trichomonas vaginalis (TV) by culture. The outcome for logistic regression
analysis was infection with NG, CT, or TV. Among 2743 men, 214 (7.8%; 95% CI:
6.8%-8.8%) were infected with any STI. In multivariable analysis, statistically
significant risks for infection were: living one's whole life in Kisumu (OR = 1.50;
95% CI: 1.12-2.01), preferring "dry" sex (OR = 1.47; 95% CI: 1.05-2.07), HSV-2
seropositivity (OR = 1.37; 95% CI: 1.01-1.86), and inability to ejaculate during sex
(OR = 2.04; 95% CI: 1.15-3.62). Risk decreased with increasing age and education,
and cleaning one's penis less than 1 hour after sex (OR = 0.51; 95% CI: 0.33-0.80).
Understanding how postcoital cleaning, "dry" sex, and sexual dysfunction relate
to STI acquisition may improve STI and HIV prevention. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | INTERVIEWS | MULTIVARIATE

ANALYSIS | MEN | SEXUALLY TRANSMITTED DISEASES | RISK
BEHAVIOR | SEX BEHAVIOR | RISK ASSESSMENT | SEX EDUCATION |
RISK REDUCTION BEHAVIOR | LABORATORY PROCEDURES |
SAHARAN | AFRICA | DATA COLLECTION | RESEARCH
METHODOLOGY | DATA ANALYSIS | DEMOGRAPHIC FACTORS |
POPULATION | REPRODUCTIVE TRACT INFECTIONS | INFECTIONS |
DISEASES | BEHAVIOR | EVALUATION | EDUCATION | LABORATORY
67

SERVICES | DELIVERY OF HEALTH CARE | HEALTH
Human papillomavirus detection by penile site in young men from

Kenya.
Author: Smith JS; Moses S; Hudgens MG; Agot K; Franceschi S
Source: Sexually Transmitted Diseases. 2007 Nov;34(11):928-934.
Abstract: Limited data are available on whether sampling from the penile shaft or urethra
increases detection of penile HPV infection in men beyond that found in the
glans and coronal sulcus. Within a randomized clinical trial, a validation study of
penile sampling was conducted in Kisumu, Kenya. Young men (18-24 years)
were invited to provide penile exfoliated cells using prewetted Dacron swabs to
determine the best site for HPV detection. beta-Globin gene PCR and HPV DNA
type GP5+/6+ PCR status were ascertained from 3 anatomical sites. A total of 98
young HIV-seronegative, uncircumcised men participated. Penile HPV
prevalence varied by anatomical site: 50% in penile exfoliated cells from the
glans, coronal sulcus, and inner foreskin tissue; 43% in the shaft and external
foreskin tissue; and 18% in the urethra (P less than 0.0001). For each anatomical
site, over 87% of samples were beta-globin positive. Beyond that found in the
glans/coronal sulcus, urethral sampling resulted in no increase in HPV positivity
andshaft sampling resulted in an additional 7.3% of overall HPV positivity. The
prevalence of high-risk HPV positivity varied by anatomical site: 39% in
glans/coronal sulcus, 31% in shaft, and 13% in the urethra (P less than 0.0001).
HPV 16 was the most common type identified. Penile HPV prevalence was
approximately 50% among young men in Kisumu, Kenya. Urethral sampling for
HPV detection in men added no sensitivity for HPV detection over that found
from sampling the glans/coronal sulcus and penile shaft. These data will help
inform studies on HPV transmission dynamics, and on the efficacy of HPV
prophylactic vaccines on penile HPV carriage in men. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | CLINICAL TRIALS | MEN | HPV |

PREVALENCE | TRANSMISSION | GENITALIA, MALE | RISK FACTORS
SAHARAN | AFRICA | CLINICAL RESEARCH | RESEARCH
METHODOLOGY | DEMOGRAPHIC FACTORS | POPULATION | VIRAL
DISEASES | DISEASES | MEASUREMENT | INFECTIONS | GENITALIA |
UROGENITAL SYSTEM | PHYSIOLOGY | BIOLOGY
68
Female sex workers and unsafe sex in urban and rural Nyanza, Kenya:
regular partners may contribute more to HIV transmission than clients.
Author: Voeten HA; Egesah OB; Varkevisser CM; Habbema JD
Source: Tropical Medicine and International Health. 2007 Feb;12(2):174-182.
Abstract: The objectives were to compare the sexual behaviour of female sex workers in
urban and rural areas in Nyanza province in Kenya, and to compare their unsafe
sex with clients and with regular partners. In a cross-sectional study among 64
sex workers (32/32 in urban/rural areas), sex workers kept a sexual diary for 14
days after being interviewed face-to-face. Most sex workers were
separated/divorced and had one or two regular partners, who were mostly
married to someone else. Sex workers in Kisumu town were younger, had
started sex work at an earlier age, and had more clients in the past 14 days than
rural women (6.6 vs. 2.4). Both groups had an equal number of sex contacts with
regular partners (4.7). With clients, condom use was fairly frequent (75%) but
with regular partners, it was rather infrequent (< 40%). For both urban and rural
areas, the mean number of sex acts in which no condom was used was greater for
regular partners (3.2 and 2.8 respectively) than for clients (1.9 and 1.0
respectively). Sex workers in urban and rural areas of Nyanza province practise
more unsafe sex with regular partners than with clients. Interventions for sex
workers should also focus on condom use in regular partnerships. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | KAP SURVEYS | COMPARATIVE

STUDIES | SEX WORKERS | SEXUAL PARTNERS | RURAL POPULATION
| URBAN POPULATION | WOMEN IN DEVELOPMENT | SEX BEHAVIOR
| RISK ASSESSMENT | AGE FACTORS | MARITAL STATUS | RISK
FACTORS | CONDOM USE | AFRICA, EASTERN | AFRICA SOUTH OF
THE SAHARA | AFRICA | DEVELOPING COUNTRIES | SURVEYS |
SAMPLING STUDIES | STUDIES | RESEARCH METHODOLOGY |
BEHAVIOR | POPULATION CHARACTERISTICS | DEMOGRAPHIC
FACTORS | POPULATION | ECONOMIC DEVELOPMENT | ECONOMIC
FACTORS | EVALUATION | NUPTIALITY | BIOLOGY | RISK
REDUCTION BEHAVIOR
69
Kenya's mixed HIV / AIDS response.
Author: Wakabi W
Source: Lancet. 2007 Jan 6;369(9555):17-18.
Abstract: Government delays providing audited accounts to the Global Fund to Fight
AIDS, Tuberculosis, and Malaria, could harm Kenya's anti-AIDS efforts, say
some faith-based groups. But the government insists its strict procedures ensure
money is well spent. Wairagala Wakabi reports. Kenya says though it has
managed a small reduction in HIV/AIDS prevalence rate over the past year,
delays by donors like the Global Fund for HIV/ AIDS, Tuberculosis, and Malaria
to release funds could harm the country's anti-AIDS campaign. In November,
Kenya received an additional US$70 million from the Global Fund to support its
fight against tuberculosis and HIV/AIDS. The release of the funds came after
months of wrangles between government and faith-based agencies, which have
accused authorities of failing to account for Global Fund monies and
jeopardising Kenya's chances of receiving more funds. Until a few years ago, the
country had kept its AIDS problem under wraps for fear of scaring away
tourists, given that tourism is the country's highest foreign exchange earner.
(excerpt)
Language: English
Keywords: KENYA | PROGRESS REPORT | EVALUATION | FAITH-BASED

ORGANIZATION | GOVERNMENT | TUBERCULOSIS | MALARIA |
FINANCING, GOVERNMENT | FUNDS | HIV PREVENTION | FOREIGN
AID | EXPENDITURES | PREVALENCE | STIGMA | ANTIRETROVIRAL
THERAPY | AFRICA, EASTERN | AFRICA, SUB SAHARAN | AFRICA |
DEVELOPING COUNTRIES | ORGANIZATIONS | POLITICAL FACTORS
| SOCIOCULTURAL FACTORS | INFECTIONS | DISEASES | PARASITIC
DISEASES | FINANCIAL ACTIVITIES | ECONOMIC FACTORS | HIV
INFECTIONS | VIRAL DISEASES | MEASUREMENT | RESEARCH
METHODOLOGY | SOCIAL PROBLEMS | HIV
Female genital cutting and HIV / AIDS among Kenyan women.
Author: Yount KM; Abraham BK
Source: Studies in Family Planning. 2007 Jun;38(2):73-88.
Abstract: Female genital cutting (FGC) and HIV/AIDS are both highly prevalent in sub-
Saharan Africa, and researchers have speculated that the association may be
more than coincidental. Data from 3,167 women aged 15-49 who participated in
70
the 2003 Kenya Demographic and Health Survey (KDHS) are used to test the
direct and indirect associations of FGC with HIV. Our adjusted models suggest
that FGC is not associated directly with HIV, but is associated indirectly through
several pathways. Cut women are 1.72 times more likely than uncut women to
have older partners, and women with older partners are 2.65 times more likely
than women with younger partners to test positive for HIV. Cut women have
1.94 times higher odds than uncut women of initiating sexual intercourse before
they are 20, and women who experience their sexual debut before age 20 have
1.73 times higher odds than those whose sexual debut comes later of testing
positive for HIV. Cut women have 27 percent lower odds of having at least one
extra-union partner, and women with an extra-union partner have 2.63 times
higher odds of testing positive for HIV. Therefore, in Kenya, FGC may be an
early life-course event that indirectly alters women's odds of becoming infected
with HIV through protective and harmful practices in adulthood. (author's)
Language: English

DEMOGRAPHIC AND HEALTH SURVEYS | WOMEN IN DEVELOPMENT
| HIV POSITIVE PERSONS | SEXUAL PARTNERS | MULTIPLE
PARTNERS | FEMALE GENITAL CUTTING | PREVALENCE | RISK
BEHAVIOR | AGE FACTORS | HIV TRANSMISSION | EXTRAMARITAL
SEX BEHAVIOR | SEX BEHAVIOR | AFRICA, EASTERN | AFRICA
SOUTH OF THE SAHARA | AFRICA | DEVELOPING COUNTRIES |
RESEARCH METHODOLOGY | DEMOGRAPHIC SURVEYS |
POPULATION DYNAMICS | DEMOGRAPHIC FACTORS | POPULATION
| ECONOMIC DEVELOPMENT | ECONOMIC FACTORS | PERSONS
LIVING WITH HIV/AIDS | HIV INFECTIONS | VIRAL DISEASES |
DISEASES | BEHAVIOR | HARMFUL TRADITIONAL PRACTICES |
TRADITIONAL HEALTH PRACTICES | CULTURE | SOCIOCULTURAL
FACTORS | MEASUREMENT | POPULATION CHARACTERISTICS
Male circumcision for HIV prevention: The research evidence and some
critical responses.
Abstract: Three randomised clinical trials, in South Africa, Uganda and Kenya, have
shown a substantial reduction in female-to-male transmission of HIV to men
who had been circumcised as compared to men who had not, during a follow-up
period of up to 24 months. The question of what to do with this evidence is
currently being debated around the world. WHO and UNAIDS took the lead by
developing technical, policy and programmatic guidance following a series of
71
consultations with a range of stakeholders in the field, using the research

evidence as the basis. Consensus on many aspects of this matter is far from being
achieved, however. Many questions and different points of view are emerging -
clinical, public health, sociological, anthropological and cultural; in relation to
priority setting in HIV prevention and delivery of health services; and in relation
to sexuality, ethics, gender and rights. On 28 March 2007, WHO and UNAIDS
published a set of conclusions and recommendations regarding the research
implications for HIV policy and programming. The introduction and excerpts
from these follow below. They are, in turn, followed by a roundtable of nine
papers which contain a range of critical thinking and analysis of these issues.
Male circumcision is generating debate across the globe. This can only be a good
thing, as it is a complex matter and far more than a straightforward public health
intervention. We hope these papers will help to inform that debate. (author's)
Language: English
Keywords: KENYA | SOUTH AFRICA | UGANDA | RESEARCH REPORT | CLINICAL

TRIALS | MEN | MALE CIRCUMCISION | GENDER ISSUES |
SEXUALITY | SAFER SEX | HIV TRANSMISSION | HEALTH POLICY |
HIV PREVENTION | PROGRAM EVALUATION | AFRICA, EASTERN |
COUNTRIES | AFRICA, SOUTHERN | CLINICAL RESEARCH |
SERVICES | DELIVERY OF HEALTH CARE | HEALTH |
SOCIOCULTURAL FACTORS | PERSONALITY | PSYCHOLOGICAL
FACTORS | BEHAVIOR | SEX BEHAVIOR | HIV INFECTIONS | VIRAL
DISEASES | DISEASES | POLICY | POLITICAL FACTORS | PROGRAMS
| ORGANIZATION AND ADMINISTRATION
Sex with an Ugly Man: Cleansing Widows in the Era of HIV/AIDS in

Siaya District, Kenya.
Author: Ambasa-Shisanya C.,
Institution: Kenyatta University, School of Humanities & Social Sciences, Philosophy &
Religious Studies Department, Nairobi, Kenya
Abstract: This paper presents findings of a study that investigated the implications of
widowhood rites on the socio-economic development of Siaya District, Kenya.
The objective of the paper is to provide insights into reasons for continuity of
widowhood rites and consequences of the cleansing ritual on the socio-economic
development of Siaya District. The paper addresses the following questions: Why
do some widows engage in an apparent life threatening cleansing ritual? What
72
are the qualities and socio-economic status of widows and professional cleansers
who engage in this ritual? Do widows have alternative coping mechanisms?
What are the effects of the widow cleansing ritual on the socio-economic
development of Siaya District?
Data were collected from 2003 to 2004 in three divisions of Siaya District: Boro,
Ukwala and Yala. The data were mainly qualitative and were generated using
focus group discussions (FGDs) and in-depth interviews. Eight FGDs were
conducted with youth, adults and elderly respondents of varied sex in each
division, giving a total of twenty four sessions. Additionally, twenty in-depth
interviews were conducted with key respondents and widows. Data were
analyzed using content analysis.
Results revealed that Luo widows are believed to acquire contagious cultural
impurity "chira" after the death of spouses. Widows are perceived as a source of
danger to offspring and the community. To neutralize this impure state, Luo
widows are expected to observe cleansing rites involving a sexual component. In
the indigenous setting, the ritual was observed by a brother-in-law or cousin to
the deceased through a guardianship institution. However, with the emergence
of HIV/AIDS, professional cleansers are hired to perform the sex ritual.
Professional cleansers usually look ugly, drunken, poor and dirty. If the deceased
spouses were HIV/AIDS seropositive, the cleansing ritual places professional
cleansers at risk of infection. Thereafter, they could act as a bridge for HIV/
AIDS transmission to other widows and to the general population thereby
increasing morbidity, mortality and slowing down socio-economic development.
However, some widows use Christianity, education and economic

empowerment as coping mechanisms to shield themselves from cultural violence
against widows through mandatory cleansing ritual. Others propose condom
use, though most cleansers reject them because of myths about condoms and
excessive alcohol use. Some cleansed widows engage in sexual relationships for
survival. These findings call for efforts to increase awareness about the widows'
rights, window period, condom myths, alcohol abuse, re-evaluation of
widowhood rites and reduction of poverty as risk factors for HIV/AIDS
transmission.
Keywords: COPING MECHANISMS| CULTURAL| VIOLENCE AGAINST WIDOWS|

HIV/AID5| PROFESSIONAL SEX CLEANSERS| WIDOWS' RIGHTS.
Male circumcision for HIV prevention: A prospective study of

complications in clinical and traditional settings in Bungoma, Kenya.
Author: Bailey RC; Egesah O; Rosenberg S. DP: 2008
Abstract: Male circumcision reduces the risk of HIV acquisition by approximately 60%.
Male circumcision services are now being introduced in selected populations in
sub-Saharan Africa and further interventions are being planned. A serious
73
concern is whether male circumcision can be provided safely to large numbers of

adult males in developing countries. This prospective study was conducted in
the Bungoma district, Kenya, where male circumcision is universally practised.
Young males intending to undergo traditional or clinical circumcision were
identified by a two-stage cluster sampling method. During the July-August 2004
circumcision season, 1007 males were interviewed 30-89 days post- circumcision.
Twenty-four men were directly observed during and 3, 8, 30 and 90 days post-
circumcision, and 298 men underwent clinical exams 45-89 days post-procedure.
Twenty-one traditional and 20 clinical practitioners were interviewed to assess
their experience and training. Inventories of health facilities were taken to assess
the condition of instruments and supplies necessary for performing safe
circumcisions. Of 443 males circumcised traditionally, 156 (35.2%) experienced
an adverse event compared with 99 of 559 (17.7%) circumcised clinically (odds
ratio: 2.53; 95% confidence interval: 1.89-3.38). Bleeding and infection were the
most common adverse effects, with excessive pain, lacerations, torsion and
erectile dysfunction also observed. Participants were aged 5 to 21 years and half
were sexually active before circumcision. Practitioners lacked knowledge and
training. Proper instruments and supplies were lacking at most health facilities.
Extensive training and resources will be necessary in sub-Saharan Africa before
male circumcision can be aggressively promoted for HIV prevention. Two-thirds
of African men are circumcised, most by traditional or unqualified practitioners
in informal settings. Safety of circumcision in communities where it is already
widely practised must not be ignored. (author's)
: Male circumcision reduces the risk of HIV acquisition by approximately 60%.
Male circumcision services are now being introduced in selected populations in
sub-Saharan Africa and further interventions are being planned. A serious
concern is whether male circumcision can be provided safely to large numbers of
adult males in developing countries. This prospective study was conducted in
the Bungoma district, Kenya, where male circumcision is universally practised.
Young males intending to undergo traditional or clinical circumcision were
identified by a two-stage cluster sampling method. During the July-August 2004
circumcision season, 1007 males were interviewed 30-89 days post- circumcision.
Twenty-four men were directly observed during and 3, 8, 30 and 90 days post-
circumcision, and 298 men underwent clinical exams 45-89 days post-procedure.
Twenty-one traditional and 20 clinical practitioners were interviewed to assess
their experience and training. Inventories of health facilities were taken to assess
the condition of instruments and supplies necessary for performing safe
circumcisions. Of 443 males circumcised traditionally, 156 (35.2%) experienced
an adverse event compared with 99 of 559 (17.7%) circumcised clinically (odds
ratio: 2.53; 95% confidence interval: 1.89-3.38). Bleeding and infection were the
most common adverse effects, with excessive pain, lacerations, torsion and
erectile dysfunction also observed. Participants were aged 5 to 21 years and half
were sexually active before circumcision. Practitioners lacked knowledge and
training. Proper instruments and supplies were lacking at most health facilities.
Extensive training and resources will be necessary in sub-Saharan Africa before
male circumcision can be aggressively promoted for HIV prevention. Two-thirds
of African men are circumcised, most by traditional or unqualified practitioners
74
in informal settings. Safety of circumcision in communities where it is already

widely practised must not be ignored. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | PROSPECTIVE STUDIES | CLINICAL

RESEARCH | MEN | MALE CIRCUMCISION | TRADITIONAL HEALTH
PRACTICES | COMPLICATIONS | HIV PREVENTION | HEALTH
SERVICES EVALUATION | AFRICA, EASTERN | AFRICA, SUB SAHARAN
| AFRICA | DEVELOPING COUNTRIES | STUDIES | RESEARCH
METHODOLOGY | DEMOGRAPHIC FACTORS | POPULATION |
OF HEALTH CARE | HEALTH | CULTURE | SOCIOCULTURAL FACTORS
| DISEASES | HIV INFECTIONS | VIRAL DISEASES | PROGRAM
ADMINISTRATION
HIV treatment.
Source: International Journal of STD and AIDS. 2008 Jan
Langauage: English

75

Dihydrofolate reductase I164L mutations in Plasmodium falciparum

isolates: Clinical outcome of 14 Kenyan adults infected with parasites
harbouring the I164L mutation.
Author: Hamel MJ; Poe A; Bloland P; McCollum A; Zhou Z
Source: Transactions of the Royal Society of Tropical Medicine and Hygiene. 2008 Apr
Abstract: Recently, Plasmodium falciparum bearing dihydrofolate reductase (DHFR) I164L

was isolated from Africa. Quadruple mutations containing I164L confer high-
level resistance to antifolate antimalarials. We prospectively measured the effect
of co-trimoxazole (CTX) prophylaxis on P. falciparum antifolate resistance
development among HIV-infected persons. HIV-positive patients with CD4 cell
count less than 350 cells/microl (n = 692) received CTX; HIV-positive patients
with CD4 cell count greater than or equal to 350 cells/microl (n = 336) and HIV-
negative patients (n = 132) received multivitamins. Malaria microscopy-positive
samples (n = 413) and selected microscopy-negative/PCR-positive samples (n =
76) were analysed for DHFR mutations at baseline and during six months follow
up. We identified I164L in 14 patients. Seven were malaria microscopy-positive:
two failed sulfadoxine-pyrimethamine (SP). Among seven microscopynegative/
PCR-positive patients, none developed patent infections with I164L. I164L
wasnot associated with high-level SP resistance or poor outcome among adults
living where malaria is highly endemic. Surveillance to monitor spread of I164L
is critical, especially among children and pregnant women, who are potentially a
source for I164L amplification. (author's)
Langauage: English
76
Keywords: KENYA | RESEARCH REPORT | CLINICAL RESEARCH | ADULTS | HIV

POSITIVE PERSONS | PARASITES | MALARIA | ANTIMALARIAL
DRUGS | DRUG RESISTANCE | VITAMINS AND MINERALS |
SAHARAN | AFRICA | RESEARCH METHODOLOGY | AGE FACTORS |
POPULATION CHARACTERISTICS | DEMOGRAPHIC FACTORS |
POPULATION | PERSONS LIVING WITH HIV/AIDS | HIV INFECTIONS |
VIRAL DISEASES | DISEASES | BIOLOGY | PARASITIC DISEASES |
TREATMENT | MEDICAL PROCEDURES | MEDICINE | HEALTH
SERVICES | DELIVERY OF HEALTH CARE | HEALTH | PHYSIOLOGY

workers.
Author: Hirbod T; Kaul R; Reichard C; Kimani J; Ngugi. DP: 2008 Mar 30
Abstract: HIV-neutralizing immunoglobulin A (IgA) and HIV-specific cellular immunity

a prospective, nested case-control study to examine the association of genital IgA
and systemic cellular immune responses with subsequent HIV acquisition in
high-risk Kenyan female sex workers (FSWs). A randomized trial of monthly
antibiotic prophylaxis to prevent sexually transmitted disease/HIV infection was
performed from 1998 to 2002 in HIV-uninfected Kenyan of genital IgA to
neutralize primary HIV isolates as well as systemic HIV-specific cellular IFNy-
modified enzyme-linked immunospot and proliferativeresponses. The study
cohort comprised 113 FSWs: 24 cases who acquired HIV and 89 matched
controls. Genital HIV-neutralizing IgA was associated with reduced HIV
acquisition (P = 0.003), as was HIV-specific proliferation (P = 0.002), and these
associations were additive. HIV-specific IFNg production did not differ between
case and control groups. In multivariable analysis, HIV-neutralizing IgA and
HIV-specific proliferation each remained independently associated with lack of
HIV acquisition. Genital herpes (HSV2) FSWs. After the completion of trial,
FSWs who had acquired HIV (cases) were matched 1 : 4 with persistently
uninfected controls based on study arm, duration of HIV-seronegative follow-up,
and time of cohort enrolment. Blinded investigators assayed the ability at
enrolment was associated with increased HIV risk and with reduced detection of
HIV-neutralizing IgA. Genital HIV-neutralizing IgA and systemic HIV-specific
proliferative responses, assayed by blinded investigators, were prospectively
associated with HIV nonacquisition. The induction of these immune responses
may be an important goal for HIV vaccines. (author's)
Langauage: English
77

WORKERS | HIV | BLOOD | LABORATORY PROCEDURES | EXPOSURE
| AUTOIMMUNE RESPONSE | DEVELOPING COUNTRIES | AFRICA,
METHODOLOGY | SEX BEHAVIOR | BEHAVIOR | HIV INFECTIONS |
VIRAL DISEASES | DISEASES | HEMIC SYSTEM | PHYSIOLOGY |
HEALTH | RISK FACTORS | ANTIBODIES | IMMUNOLOGIC FACTORS
| IMMUNITY | IMMUNE SYSTEM
The impact of maternal HIV status on infant feeding patterns in Nakuru,

Kenya.
Author: Kamau-Mbuthia E; Elmadfa I; Mwonya R
Source: Journal of Human Lactation
Abstract: The aim of the study was to assess the impact of maternal HIV status on infant
feeding patterns. Two hundred eighty mothers (205 HIV uninfected, 75 infected)
and their infants were recruited from the Provincial General Hospital, Nakuru,
Kenya, from delivery and were followed for 14 weeks. From the feeding patterns,
HIV-infected mothers were more likely to exclusively breastfeed in week 1 than
HIV-uninfected mothers (71.7% vs 56.3%, P = .001), but there were no differences
by week 14 (9.8% vs 4.8% P = .212). Mixed feeding increased for both groups
from weeks 1 to 14. In multivariate logistic regression analysis, maternal age
(younger mothers, P less than .05) was associated with exclusive breastfeeding in
the 6th week and infant birth weight (greater than mean birth weight, P less
than .05) in the 10th week. The results indicate a need to reassess adherence to
infant feeding recommendations irrespective of maternal HIV status and also the
infant feeding counseling process in the hospital. (author's)
The aim of the study was to assess the impact of maternal HIV status on infant
78
The aim of the study was to assess the impact of maternal HIV status on infant
Langauage: English
Keywords: KENYA | RESEARCH REPORT | INTERVIEWS | QUESTIONNAIRES |

MOTHERS | INFANT | HIV | INFANT NUTRITION | BREASTFEEDING,
EXCLUSIVE | SUPPLEMENTARY FEEDING | SOCIOECONOMIC STATUS
SAHARAN | AFRICA | DATA COLLECTION | RESEARCH
METHODOLOGY | PARENTS | FAMILY RELATIONSHIPS | FAMILY
FACTORS | YOUTH | AGE FACTORS | POPULATION
CHARACTERISTICS | DEMOGRAPHIC FACTORS | POPULATION | HIV
INFECTIONS | VIRAL DISEASES | DISEASES | NUTRITION | HEALTH |
BREASTFEEDING | SOCIOECONOMIC FACTORS | ECONOMIC
FACTORS
Human immunodeficiency virus (HIV) type 1 proviral hypermutation

correlates with CD4 count in HIV-infected women from Kenya.
Author: Land AM; Ball TB; Luo M; Pilon R; Sandstrom P; Embree JE; Wachihi C; Kimani
J; Plummer FA
Source: Journal of Virology. 2008 Aug
Abstract: APOBEC3G is an important innate immune molecule that causes human

immunodeficiency virus type 1 (HIV-1) hypermutation, which can result in
detrimental viral genome mutations. The Vif protein of wild-type HIV-1
counteracts APOBEC3G activity by targeting it for degradation and inhibiting its
incorporation into viral particles. Additional APOBEC cytidine deaminases have
been identified, such as APOBEC3F, which has a similar mode of action but
79
different sequence specificity. A relationship between APOBEC3F/G and HIV

disease progression has been proposed. During HIV-1 sequence analysis of the
vpu/env region of 240 HIV-infected subjects from Nairobi, Kenya, 13 drastically
hypermutated proviral sequences were identified. Sequences derived from
plasma virus, however, lacked hypermutation, as did proviral vif. When
correlates of disease progression were examined, subjects with hypermutated
provirus were found to have significantly higher CD4 counts than the other
subjects. Furthermore, hypermutation as estimated by elevated adenine content
positively correlated with CD4 count for all 240 study subjects. The sequence
context of the observed hypermutation was statistically associated with
APOBEC3F/G activity. In contrast to previous studies, this study demonstrates
that higher CD4 counts correlate with increased hypermutation in the absence of
obvious mutations in the APOBEC inhibiting Vif protein. This strongly suggests
that host factors, such as APOBEC3F/G, are playing a protective role in these
patients, modulating viral hypermutation and host disease progression. These
findings support the potential of targeting APOBEC3F/G for therapeutic
purposes. (author's)
Langauage: English
Keywords: KENYA | RESEARCH REPORT | CLINICAL RESEARCH | WOMEN |

PERSONS LIVING WITH HIV/AIDS | HIV INFECTIONS | IMMUNE
SYSTEM | IMMUNOLOGIC FACTORS | GENETICS | CYTOLOGY |
COUNTRIES | RESEARCH METHODOLOGY | DEMOGRAPHIC
FACTORS | POPULATION | VIRAL DISEASES | DISEASES |
PHYSIOLOGY | BIOLOGY | IMMUNITY
Safer sexual behaviors after 12 months of antiretroviral treatment in

Mombasa, Kenya: a prospective cohort.
Author: Luchters S; Sarna A; Geibel S; Chersich MF; Munyao P
Source: AIDS Patient Care and STDs. 2008 Jul
Abstract: Roll-out of antiretroviral treatment (ART) raises concerns about the potential for
unprotected sex if sexual activity increases with well-being, resulting in
continued HIV spread. Beliefs about reduced risk for HIV transmission with
ART may also influence behavior. From September 2003 to November 2004, 234
adults enrolled in a trial assessing the efficacy of modified directly observed
therapy in improving adherence to ART. Unsafe sexual behavior (unprotected
sex with an HIV-negative or unknown status partner) before starting ART and 12
months thereafter was compared. Participants were a mean 37.2 years (standard
deviation [SD] = 7.9 years) and 64% (149/234) were female. Nearly half (107/225)
80
were sexually active in the 12 months prior to ART, the majority (96/107)
reporting one sexual partner. Unsafe sex was reported by half of those sexually
active in the 12 months before ART (54/107), while after 12 months ART, this
reduced to 28% (30/107). Unsafe sex was associated with nondisclosure of HIV
status to partner; recent HIV diagnosis; not being married or cohabiting; stigma;
depression and body mass index <18.5 kg/m(2). ART beliefs, adherence, and
viral suppression were not associated with unsafe sex. After adjusting for gender
and stigma, unsafe sex was 0.59 times less likely after 12 months ART than before
initiation (95% confidence interval [CI] = 0.37-0.94; p = 0.026). In conclusion,
although risky sexual behaviors had decreased, a considerable portion do not
practice safe sex. Beliefs about ART's effect on transmission, viral load, and
adherence appear not to influence sexual behavior but require long-term
surveillance. Positive prevention interventions for those receiving ART must
reinforce safer sex practices and partner disclosure. (author's)
Langauage: English
Keywords: KENYA | RESEARCH REPORT | PROSPECTIVE STUDIES | COHORT

ANALYSIS | ADULTS | ANTIRETROVIRAL THERAPY | SAFER SEX | SEX
BEHAVIOR | KNOWLEDGE | ATTITUDE | RISK FACTORS | TIME
FACTORS | USER COMPLIANCE | INTERVENTIONS | PROGRAM
EFFECTIVENESS | AFRICA, EASTERN | AFRICA, SUB SAHARAN |
AFRICA | DEVELOPING COUNTRIES | STUDIES | RESEARCH
METHODOLOGY | AGE FACTORS | POPULATION CHARACTERISTICS
| DEMOGRAPHIC FACTORS | POPULATION | HIV | HIV INFECTIONS |
VIRAL DISEASES | DISEASES | BEHAVIOR | SOCIOCULTURAL
FACTORS | PSYCHOLOGICAL FACTORS | BIOLOGY | POPULATION
DYNAMICS | PROGRAMS | ORGANIZATION AND ADMINISTRATION
| PROGRAM EVALUATION
Maternal HLA homozygosity and mother-child HLA concordance

increase the risk of vertical transmission of HIV-1.
Author: Mackelprang RD; John-Stewart G; Carrington M; Richardson B; Rowland-Jones S
Source: Journal of Infectious Diseases. 2008
Abstract: Mother-child human leukocyte antigen (HLA) concordance and maternal HLA
homozygosity may increase the risk of vertical transmission of human
immunodeficiency virus type 1 (HIV-1) risk by reducing infant immune
responses. We analyzed mother-child HLA concordance and maternal HLA
homozygosity in a Kenyan perinatal cohort receiving antenatal zidovudine. HLA
concordance was scored as the number of shared class I alleles, and relative risk
estimates were adjusted for maternal HIV-1 load. Among 277 mother-infant
81
pairs, HIV-1 transmission occurred in 58 infants (21%), with in utero

transmission in 21 (36%), peripartum transmission in 26 (45%), and transmission
via breast-feeding in 11 (19%). With increased concordance, we observed a
significant increase in the risk of transmission overall (adjusted hazard ratio
[aHR], 1.3 [95% confidence interval {CI}, 1.0 -1.7]; P = .04), in utero (adjusted
odds ratio, 1.72 [95% CI, 1.0 -1.7]; P = .04), and via breast-feeding (aHR, 1.6 [95%
CI, 1.0 -2.5]; P = .04). Women with homozygosity had higher plasma HIV-1 RNA
levels at 32 weeks of gestation (5.1 vs. 4.8 log10 copies/mL; P = .03) and an
increased risk of transmission overall (aHR, 1.7 [95% CI, 1.1-2.7]; P = .03) and via
breast-feeding (aHR, 5.8 [95% CI, 1.9 -17.7]; P = .002). The risks of overall, in
utero, and breast milk HIV-1 transmission increased with HLA concordance and
homozygosity. The increased risk may be due to reduced alloimmunity or less
diverse protective immune responses. (author'sMother-child human leukocyte
antigen (HLA) concordance and maternal HLA homozygosity may increase the
risk of vertical transmission of human immunodeficiency virus type 1 (HIV-1)
risk by reducing infant immune responses. We analyzed mother-child HLA
concordance and maternal HLA homozygosity in a Kenyan perinatal cohort
receiving antenatal zidovudine. HLA concordance was scored as the number of
shared class I alleles, and relative risk estimates were adjusted for maternal HIV-
1 load. Among 277 mother-infant pairs, HIV-1 transmission occurred in 58
infants (21%), with in utero transmission in 21 (36%), peripartum transmission in
26 (45%), and transmission via breast-feeding in 11 (19%). With increased
concordance, we observed a significant increase in the risk of transmission
overall (adjusted hazard ratio [aHR], 1.3 [95% confidence interval {CI}, 1.0 -1.7]; P
= .04), in utero (adjusted odds ratio, 1.72 [95% CI, 1.0 -1.7]; P = .04), and via
breast-feeding (aHR, 1.6 [95% CI, 1.0 -2.5]; P = .04). Women with homozygosity
had higher plasma HIV-1 RNA levels at 32 weeks of gestation (5.1 vs. 4.8 log10
copies/mL; P = .03) and an increased risk of transmission overall (aHR, 1.7 [95%
CI, 1.1-2.7]; P = .03) and via breast-feeding (aHR, 5.8 [95% CI, 1.9 -17.7]; P = .002).
The risks of overall, in utero, and breast milk HIV-1 transmission increased with
HLA concordance and homozygosity. The increased risk may be due to reduced
alloimmunity or less diverse protective immune responses. (author's
Langauage: English
Keywords: KENYA | RESEARCH REPORT | COHORT ANALYSIS | MOTHER-TO-

CHILD TRANSMISSION | HIV INFECTIONS | RISK FACTORS |
AUTOIMMUNE RESPONSE | PREVENTION OF MOTHER-TO-CHILD
TRANSMISSION | EXPOSURE | HUMAN MILK | DEVELOPING
RESEARCH METHODOLOGY | TRANSMISSION | INFECTIONS |
DISEASES | VIRAL DISEASES | BIOLOGY | ANTIBODIES |
IMMUNOLOGIC FACTORS | IMMUNITY | IMMUNE SYSTEM |
PHYSIOLOGY | DISEASE TRANSMISSION CONTROL | PREVENTION
AND CONTROL | LACTATION | MATERNAL PHYSIOLOGY
82
Risk compensation is not associated with male circumcision in Kisumu,

Kenya: A multi-faceted assessment of men enrolled in a randomized
controlled trial.
Author: Mattson CL; Campbell RT; Bailey RC; Agot K; Ndinya-Achola JO
Source: PLoS One. 2008 Jun
Abstract: Three randomized controlled trials (RCTs) have confirmed that male
circumcision (MC) significantly reduces acquisition of HIV-1 infection among
men. The objective of this study was to perform a comprehensive, prospective
evaluation of risk compensation, comparing circumcised versus uncircumcised
controls in a sample of RCT participants. Between March 2004 and September
2005, we systematically recruited men enrolled in a RCT of MC in Kenya.
Detailed sexual histories were taken using a modified Timeline Follow-back
approach trichomoniasis between circumcised and uncircumcised men. These
results are based on the most comprehensive analysis of risk compensation yet
done. In the context of a RCT, circumcision did not result in increased HIV risk
behavior. Continued monitoring and evaluation of risk compensation associated
with circumcision is needed as evidence supporting its' efficacy is disseminated
and MC is widely promoted for HIV prevention. (author's)
Langauage: English
Keywords: KENYA | RESEARCH REPORT | CLINICAL TRIALS | MALE

CIRCUMCISION | HIV PREVENTION | RISK BEHAVIOR | SEXUALLY
TRANSMITTED DISEASES | INCIDENCE | DEVELOPING COUNTRIES |
AFRICA, EASTERN | AFRICA, SUB SAHARAN | AFRICA | CLINICAL
RESEARCH | RESEARCH METHODOLOGY | MEDICAL PROCEDURES |
HEALTH | HIV INFECTIONS | VIRAL DISEASES | DISEASES |
BEHAVIOR | REPRODUCTIVE TRACT INFECTIONS | INFECTIONS |
MEASUREMENT
The influence and benefits of controlling for inflammation on plasma

ferritin and hemoglobin responses following a multi-micronutrient
supplement in apparently healthy, HIV+ Kenyan adults.
Author: Mburu AS; Thurnham DI; Mwaniki DL; Muniu EM; Alumasa F
Source: Journal of Nutrition
83
Abstract: Hemoglobin and ferritin are important biomarkers of iron status but are both
altered by inflammation. We used the inflammation biomarkers C-reactive
protein (CRP) and alpha1-acid glycoprotein (AGP) to adjust hemoglobin and
ferritin concentrations to clarify interpretation of iron status. Apparently healthy
adults who tested positive twice for HIV but who had not reached stage IV or
clinical AIDS were randomly allocated to receive a food supplement (n = 17 and
21) or the food plus a micronutrient capsule (MN; 10 men and 34 women,
respectively) containing 30 mg iron/d. Hemoglobin, ferritin, CRP, and AGP
concentrations were measured at baseline and 3 mo and subjects were divided
into 4 groups (reference, no inflammation; incubating, raised CRP; early
convalescence, raised AGP and CRP; and late convalescence, raised AGP).
Correction factors (the ratios of the median for the reference group over each
inflammatory group) improved the consistency of the ferritin but not the
hemoglobin results. After correction, ferritin (but not hemoglobin) increased in
both men (48 microg/L; P = 0.02) and women (12 microg/L; P = 0.04) who
received MN but not in the food-only group. However, hemoglobin did improve
in subjects who showed no inflammation both at baseline and mo 3 (P = 0.019),
but ferritin did not increase in this group. In conclusion, ferritin concentrations
were more closely linked to current inflammation than hemoglobin; hence,
correction by inflammation biomarkers improved data consistency. However,
low hemoglobin concentrations were the consequence of long-term chronic
inflammation and improvements in response to MN supplements were only
detected in subjects with no inflammation. (author's)
Langauage: English
Keywords: KENYA | RESEARCH REPORT | CLINICAL RESEARCH | COMPARATIVE
STUDIES | ADULTS | HIV POSITIVE PERSONS | HIV INFECTIONS |
HEMOGLOBIN LEVEL | SERUM IRON LEVEL | FOOD
SUPPLEMENTATION | VITAMINS AND MINERALS |
ADMINISTRATION AND DOSAGE | HISTOCHEMICAL EFFECTS |
SAHARAN | AFRICA | RESEARCH METHODOLOGY | STUDIES | AGE
FACTORS | POPULATION | PERSONS LIVING WITH HIV/AIDS | VIRAL
DISEASES | DISEASES | HEMIC SYSTEM | PHYSIOLOGY | BIOLOGY |
NUTRITION PROGRAMS | PRIMARY HEALTH CARE | HEALTH
SERVICES | DELIVERY OF HEALTH CARE | HEALTH | DRUGS |
TREATMENT | MEDICAL PROCEDURES | MEDICINE | CYTOLOGIC
EFFECTS
Improvement of vaginal health for Kenyan women at risk for acquisition

of human immunodeficiency virus type 1: Results of a randomized trial.
Author: McClelland RS; Richardson BA; Hassan WM; Chohan V; Lavreys L
84
Source: Journal of Infectious Diseases
Abstract: Vaginal infections are common and have been associated with increased risk for
acquisition of human immunodeficiency virus type 1 (HIV-1). We conducted a
randomized trial of directly observed oral treatment administered monthly to
reduce vaginal infections among Kenyan women at risk for HIV-1 acquisition. A
trial intervention of 2 g of metronidazole plus 150 mg of fluconazole was
compared with metronidazole placebo plus fluconazole placebo. The primary
end points were bacterial vaginosis (BV), vaginal candidiasis, trichomoniasis
vaginalis (hereafter, "trichomoniasis"), and colonization with Lactobacillus
organisms. Of 310 HIV-1-seronegative female sex workers enrolled (155 per arm),
303 were included in the primary end points analysis. A median of 12 follow-up
visits per subject were recorded in both study arms (P = .8). Compared with
control subjects, women receiving the intervention had fewer episodes of BV
(hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.49-0.63) and more
frequent vaginal colonization with any Lactobacillus species (HR, 1.47; 95% CI,
1.19 -1.80) and H2O2-producing Lactobacillus species (HR, 1.63; 95% CI, 1.16
-2.27). The incidences of vaginal candidiasis (HR, 0.84; 95% CI, 0.67-1.04) and
trichomoniasis (HR, 0.55; 95% CI, 0.27-1.12) among treated women were less than
those among control subjects, but the differences were not statistically
significant. Periodic presumptive treatment reduced the incidence of BV and
promoted colonization with normal vaginal flora. Vaginal health interventions
have the potential to provide simple, female-controlled approaches for reducing
the risk of HIV-1 acquisition. (author's)
Langauage: English
Keywords: KENYA | RESEARCH REPORT | CLINICAL TRIALS | WOMEN | SEX

WORKERS | VAGINAL ABNORMALITIES | INFECTIONS | RISK
FACTORS | HIV INFECTIONS | DRUGS | ADMINISTRATION AND
DOSAGE | DEVELOPING COUNTRIES | AFRICA, EASTERN | AFRICA,
SUB SAHARAN | AFRICA | CLINICAL RESEARCH | RESEARCH
METHODOLOGY | DEMOGRAPHIC FACTORS | POPULATION | SEX
BEHAVIOR | BEHAVIOR | DISEASES | BIOLOGY | VIRAL DISEASES |
TREATMENT | MEDICAL PROCEDURES | MEDICINE | HEALTH
SERVICES | DELIVERY OF HEALTH CARE | HEALTH
Herpes simplex virus type 2 infection among young uncircumcised men

in Kisumu, Kenya.
Author: Mehta SD; Moses S; Agot K; Agingu W; Parker C
Source: Sexually Transmitted Infections.
85
Abstract: The objectives were to identify factors associated with herpes simplex virus type
2 (HSV-2) infection among men aged 18-24 in Kisumu, Kenya. Baseline data from
a randomised trial of male circumcision were analysed. Participants were
interviewed for tors were considered singly and in combination through logistic
regression models. Asociodemographic and behavioural risks. The outcome was
HSV-2 by antibody status. Risk facmong 2771 uncircumcised men, 766 (27.6%;
95% confidence interval (CI) 26.0% to 29.3%) tested antibody positive for HSV-2.
The median age at first sex was 16 years, and the median number of lifetime
sexual partners was four. HSV-2 seroprevalence increased from 19% among 18-
year-olds to 43% among 24-year-olds (p less than 0.001). In multivariable
analysis, statistically significant risks for infection were increasing age (adjusted
odds ratio (AOR)=1.22-2.58), being married or having a live-in female partner
(AOR=1.80; 95% CI 1.28 to 2.53), preferring "dry" sex (AOR=1.39; 95% CI 1.14 to
1.69), reported penile cuts or abrasions during sex (AOR=1.58; 95% CI 1.32 to
1.91), increasing lifetime sex partners (multiple response categories; AORs
ranging from 1.65 to 1.97), and non-student occupation (multiple response
categories; AORs ranging from 1.44 to 1.93). Risk decreased with reported
condom used at last sex (AOR=0.82; 95% CI 0.68 to 0.99). Primary prevention
efforts should be initiated at an early age. The same behavioural interventions
used currently for HIV prevention-abstinence, reducing the number of sex
partners and increasing condom use-should be effective for HSV-2 prevention.
(author's)
Langauage: English
Keywords: KENYA | RESEARCH REPORT | INTERVIEWS | CLINICAL RESEARCH |

CROSS SECTIONAL ANALYSIS | YOUTH | MEN | MALE
CIRCUMCISION | HERPES GENITALIS | RISK FACTORS | DEVELOPING
DATA COLLECTION | RESEARCH METHODOLOGY | AGE FACTORS |
POPULATION CHARACTERISTICS | DEMOGRAPHIC FACTORS |
SERVICES | DELIVERY OF HEALTH CARE | HEALTH | SEXUALLY
TRANSMITTED DISEASES | REPRODUCTIVE TRACT INFEC IVE TIONS
| INFECTIONS | DISEASES | BIOLOGY
Sexual and demographic determinants for herpes simplex virus type 2

among fishermen along Lake Victoria, Kenya.
Author: Ng'ayo MO; Bukusi E; Morrow RA; Rowhani-Rahbar A; Obare BA
Source: Sexually Transmitted Infections
86
Abstract: The objectives were to determine the prevalence and correlates of herpes simplex
virus type 2 (HSV-2) seropositivity among fishermen along the shores of Lake
Victoria in Kisumu district, Kenya. Sera from a random sample of 250 fishermen
from 18 beaches were collected after a detailed sociodemographic interview.
HSV-2 infection was tested by Kalon HSV-2 ELISA. The HSV-2 seroprevalence
was 63.9%. In multivariate analysis, fishermen were more likely to be infected
with HSV-2 if they were HIV positive (prevalence ratio (PR) 1.27; 95% CI 1.06 to
1.52) compared with those testing HIV negative, were aged 18-20 (PR 0.49; 95%
CI 0.24 to 0.99) and older than 40 (PR 1.66; 95% CI 1.30 to 2.14) years compared
with those aged 21-25 years, perceived their last two sexual partners to have a
sexually transmitted infection (STI; PR 1.27; 95% CI 1.06 to 1.52) compared with
those who did not and were more likely to be circumcised (PR 1.49; 95% CI 1.19
to 1.86). HSV-2 seroprevalence is high among this population and is associated
with HIV serostatus, age, perception about partner's STI status and circumcision.
(author's)
Langauage: English
Keywords: KENYA | RESEARCH REPORT | SAMPLING STUDIES | MEN | ADULTS

| HERPES GENITALIS | PREVALENCE | RISK FACTORS |
DEMOGRAPHIC FACTORS | FISHING | DEVELOPING COUNTRIES |
AFRICA, EASTERN | AFRICA, SUB SAHARAN | AFRICA | STUDIES |
RESEARCH METHODOLOGY | POPULATION | AGE FACTORS |
POPULATION CHARACTERISTICS | SEXUALLY TRANSMITTED
DISEASES | REPRODUCTIVE TRACT INFECTIONS | INFECTIONS |
DISEASES | MEASUREMENT | BIOLOGY | OCCUPATIONS | HUMAN
RESOURCES | ECONOMIC FACTORS
Role of governmental and non-governmental organizations in mitigation

of stigma and discrimination among HIV / AIDS persons in Kibera,
Kenya.
Author: Odindo MA; Mwanthi MA
Source: East African Journal of Public Health
Abstract: This study assessed the role of governmental and non-governmental

organizations in mitigation of stigma and discrimination among people infected
and affected by HIV/AIDS in informal settlements of Kibera. This was a
descriptive cross-sectional study and used a multi stage stratified sampling
method. The study was conducted in Kibera, an informal settlement with a
population of over one million people which makes it the largest slum not only
in Kenya but in sub-Saharan Africa. The study targeted infected individuals,
non-infected community members, managers of the organizations implementing
HIV/AIDS programmes and service providers. In the process 1331 households
87
were interviewed using qualitative and quantitative data collection instruments.

Statistical Package for Social Sciences (SPSS) and Nudist 4 packages were used to
analyze the quantitative and qualitative data respectively. More than 61% of the
respondents had patients in their households. Fifty five percent (55%) of the
households receivedassistance from governmental and non-governmental
organizations in taking care of the sick. Services provided included awareness,
outreach, counseling, testing, treatment, advocacy, home based care, assistance
to the orphans and legal issues. About 90% of the respondents perceived health
education, counseling services and formation of post counseling support groups
to combat stigma and discrimination to be helpful. Stigma and discrimination
affects the rights of People Living with HIV/AIDS (PLWHAs). Such
stigmatization and discrimination goes beyond and affects those who care for the
PLWHAs, and remains the biggest impediment in the fight against HIV/AIDS in
Kibera. Governmental and non-governmental organizations continue to provide
key services in the mitigation of stigma and discrimination in Kibera. However,
personal testimonies by PLWHAs showed that HIV positive persons still suffer
from stigma and discrimination. Approximately 43% of the study population
experienced stigma and discrimination. (author's)
Langauage: English

SAMPLING STUDIES | INTERVIEWS | PERSONS LIVING WITH
HIV/AIDS | GOVERNMENT | NONGOVERNMENTAL ORGANIZATIONS
| STIGMA | SOCIAL DISCRIMINATION | DEVELOPING COUNTRIES |
METHODOLOGY | STUDIES | DATA COLLECTION | HIV INFECTIONS
| VIRAL DISEASES | DISEASES | POLITICAL FACTORS |
SOCIOCULTURAL FACTORS | ORGANIZATIONS | SOCIAL PROBLEMS
Acute HIV infection among Kenyan infants.

Author: Richardson BA; Nduati R; Mbori-Ngacha D; Overbaugh J; John-Stewart GC
Source: Clinical Infectious Diseases
Abstract: Clinical signs and symptoms of acute human immunodeficiency virus (HIV)
infection in infants are not well characterized. Serial clinical assessments and
HIV PCR assays were conducted in a cohort of children born to HIV-seropositive
mothers from birth to 2 years of age. Acute HIV infection visits were defined as
those up to 3 months prior to and including the visit at which HIV DNA was first
detected. Noninfection visits included all visits at which the child had test results
negative for HIV, including the last visit at which a test result negative for HIV
DNA was obtained in children who later acquired HIV infection. Differences in
88
the prevalence of symptoms at acute infection versus noninfection visits were

determined overall and were stratified by age at infection (< 2 months vs. >/= 2
months). HIV RNA was measured serially in infected infants and was compared
between infants with and infants without symptoms of acute HIV infection.
There were 125 acute infection visits (among 56 infants) and 3491 noninfection
visits (among 306 infants). Acute HIV infection was associated with rash (odds
ratio [OR], 1.8; 95% confidence interval [CI], 1.1-2.8), failure to thrive (OR, 1.9;
95% CI, 1.0-3.5), and lymphadenopathy (OR, 2.5; 95% CI, 1.4-4.8). Acute HIV
infection was associated with lymphadenopathy (OR, 2.6; 95% CI, 1.3-5.0) in
infants < 2 months of age and with pneumonia (OR, 3.2; 95% CI, 1.1-9.3) and
dehydration (OR, 6.0; 95% CI, 1.9-18.5) in infants >/= 2 months of age. Infant
peak viral load and mortality were not associated with symptoms of acute HIV
infection. However, infants with symptoms had higher viral levels later in the
course of infection than did those without symptoms (P = .05). Infants may
manifest symptoms early during the course of HIV infection, and symptoms of
acute HIV infection may correlate with poor viral control. Rash, failure to thrive,
lymphadenopathy, pneumonia, and dehydration may signify acute HIV
infection in infants. (author's)
Clinical signs and symptoms of acute human immunodeficiency virus (HIV)
infection in infants are not well characterized. Serial clinical assessments and
HIV PCR assays were conducted in a cohort of children born to HIV-seropositive
mothers from birth to 2 years of age. Acute HIV infection visits were defined as
those up to 3 months prior to and including the visit at which HIV DNA was first
detected. Noninfection visits included all visits at which the child had test results
negative for HIV, including the last visit at which a test result negative for HIV
DNA was obtained in children who later acquired HIV infection. Differences in
the prevalence of symptoms at acute infection versus noninfection visits were
determined overall and were stratified by age at infection (< 2 months vs. >/= 2
months). HIV RNA was measured serially in infected infants and was compared
between infants with and infants without symptoms of acute HIV infection.
There were 125 acute infection visits (among 56 infants) and 3491 noninfection
visits (among 306 infants). Acute HIV infection was associated with rash (odds
ratio [OR], 1.8; 95% confidence interval [CI], 1.1-2.8), failure to thrive (OR, 1.9;
95% CI, 1.0-3.5), and lymphadenopathy (OR, 2.5; 95% CI, 1.4-4.8). Acute HIV
infection was associated with lymphadenopathy (OR, 2.6; 95% CI, 1.3-5.0) in
infants < 2 months of age and with pneumonia (OR, 3.2; 95% CI, 1.1-9.3) and
dehydration (OR, 6.0; 95% CI, 1.9-18.5) in infants >/= 2 months of age. Infant
peak viral load and mortality were not associated with symptoms of acute HIV
infection. However, infants with symptoms had higher viral levels later in the
course of infection than did those without symptoms (P = .05). Infants may
manifest symptoms early during the course of HIV infection, and symptoms of
acute HIV infection may correlate with poor viral control. Rash, failure to thrive,
lymphadenopathy, pneumonia, and dehydration may signify acute HIV
infection in infants. (author's)
Language: English
89
Keywords: KENYA | RESEARCH REPORT | COHORT ANALYSIS | PREGNANT

WOMEN | INFANT | HIV INFECTIONS | PREVALENCE | LABORATORY
PROCEDURES | MOTHER-TO-CHILD TRANSMISSION | AGE FACTORS
| SIGNS AND SYMPTOMS | MORTALITY | DEVELOPING COUNTRIES |
METHODOLOGY | POPULATION CHARACTERISTICS |
DEMOGRAPHIC FACTORS | POPULATION | YOUTH | VIRAL DISEASES
| DISEASES | MEASUREMENT | LABORATORY EXAMINATIONS AND
HEALTH CARE | HEALTH | TRANSMISSION | INFECTIONS |
POPULATION DYNAMICS
Langauage: English
Characteristics of psychosocial support seeking during HIV-related

treatment in western Kenya.
Author: Shacham E; Reece M; Ong'or WO; Omollo O; Monahan PO; Ojwang C
Source: AIDS Patient Care and STDs
Abstract: While the characteristics of those who seek psychosocial support following an
HIV diagnosis have been well documented in western countries where linkages
between HIV-related treatment and psychosocial support programs are well
established, little is known about those who become engaged with such services
in countries of the world where comprehensive HIV-related care and prevention
systems are continuing to develop. Data were collected from 397 individuals
who had enrolled in HIV-related psychosocial support groups in western Kenya
in November 2005. Demographic and HIV-related characteristics, as well as
assessments of psychological distress, were collected from each participant and
analyzed by gender in order to document the characteristics of those seeking
psychosocial care in conjunction with their participation in an HIV-related
treatment and prevention program. Those seeking psychosocial support were
primarily female (72%), living with HIV for an average of 2.5 years, and
unemployed (70%). Women were younger and more likely to be either widowed
or never married; while men were more likely to have advanced HIV disease,
including lower CD4 counts and an AIDS diagnosis. Across all participants, HIV
serostatus disclosure was rarely reported to sex partners, family members, and
friends. Symptoms of psychological distress were more prevalent among women
on multiple measures, including depression, anxiety, paranoid ideation,
interpersonal sensitivity, and somatization. An increased understanding of the
characteristics of those likely to seek psychosocial support groups will help HIV
program managers to develop protocols necessary for facilitating linkages to
psychosocial support for those enrolled in HIV-related treatment programs.
90
Patient engagement in psychosocial support may facilitate improvements in

psychological function and support an individual's maintenance of HIV
treatment and prevention behaviors. (author's)
Langauage: English

QUESTIONNAIRES | PERSONS LIVING WITH HIV/AIDS | HIV
INFECTIONS | PSYCHOSOCIAL FACTORS | STRESS | SIGNS AND
SYMPTOMS | TREATMENT | CARE AND SUPPORT | AFRICA, EASTERN
| AFRICA, SUB SAHARAN | AFRICA | DEVELOPING COUNTRIES |
RESEARCH METHODOLOGY | VIRAL DISEASES | DISEASES |
BEHAVIOR | PSYCHOLOGICAL FACTORS | MEDICAL PROCEDURES |
HEALTH

Author: McClelland RS; Richardson BA; Graham SM; Masese LN; Gitau R
Abstract: Bacterial vaginosis (BV) is common and has been associated with increased HIV-
African women at high risk for acquiring HIV-1. We conducted a prospective
study among 151 HIV-1-seronegative Kenyan female sex workers. Nonpregnant
women were eligible if they did not have symptoms of abnormal vaginal itching
or discharge at the time of enrollment. At monthly follow-up, a vaginal
examination and laboratory testing for genital tract infections were performed.
Multivariate Andersen-Gill proportional hazards analysis was used to identify
correlates of BV. Participants completed a median of 378 (interquartile range 350-
412) days of follow-up. Compared with women reporting no vaginal washing,
those who reported vaginal washing 1 to 14 [adjusted hazard ratio (aHR) 1.29,
95% confidence interval (CI) 0.88-1.89], 15 to 28 (aHR 1.60, 95% CI 0.98 -2.61), and
greater than 28 times/wk (aHR 2.39, 95% CI 1.35-4.23) were at increased risk of
BV. Higher BV incidence was also associated with the use of cloth for
intravaginal cleansing (aHR 1.48, 95% CI 1.06 -2.08) and with recent unprotected
intercourse (aHR 1.75, 95% CI 1.47-2.08). Women using depot
medroxyprogesterone acetate contraception were at lower risk for BV (aHR 0.59,
95% CI 0.48-0.73). Vaginal washing and unprotected intercourse were associated
with increased risk of BV. These findings could help to inform the development
of novel vaginal health approaches for HIV-1 risk reduction in women. (author's)
91
Language: English

WORKERS | VAGINOSIS | RISK FACTORS | LABORATORY
EXAMINATIONS AND DIAGNOSES | SEX BEHAVIOR | HYGIENE |
DEPO-PROVERA | DEVELOPING COUNTRIES | AFRICA, EASTERN |
METHODOLOGY | BEHAVIOR | VAGINAL ABNORMALITIES |
DISEASES | BIOLOGY | EXAMINATIONS AND DIAGNOSES | MEDICAL
HEALTH CARE | HEALTH | PUBLIC HEALTH |
MEDROXYPROGESTERONE ACETATE | CONTRACEPTIVE AGENTS,
PROGESTIN | CONTRACEPTIVE AGENTS, FEMALE | CONTRACEPTIVE
AGENTS | CONTRACEPTION | FAMILY PLANNING
HIV / AIDS and cultural practices in western Kenya: The impact of

sexual cleansing rituals on sexual behaviours.
Author: Ayikukwei R; Ngare D; Sidle J; Ayuku D; Baliddawa J
Source: Culture, Health and Sexuality. 2008 Aug;10(6):587-599.
Abstract: This paper reports on an exploratory study examining the role of sexual
cleansing rituals in the transmission of HIV among the Luo community in
western Kenya. Data were collected using both i-ndepth interviews and focus
group discussions. The study population consisted of 38 widows, 12 community
elders and 44 cleansers. Data were collected on non-behavioural causes,
behavioural causes and behavioural indicators associated with sexual rituals.
Content analysis revealed five central themes: the effect of the ritual on sexual
behaviours; factors contributing to the continued practice of the ritual, including
a sub-theme on the commercialization of the ritual; the inseparable relationship
between the sanctity of sex, prosperity and fertility of the land; and the effects of
modernization on the ritual, including a sub-theme on the effects of mass media
on HIV-prevention awareness campaigns. Causal factors of unchanging sexual
behaviours are deeply rooted in traditional beliefs, which the community uphold
strongly. These beliefs encourage men and women to have multiple sexual
partners in a context where the use of condoms is rejected and little HIV testing
is carried out. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | PILOT PROJECTS | INTERVIEWS |

FOCUS GROUPS | HIV TRANSMISSION | SEX BEHAVIOR | CULTURE |
92
BELIEFS | ETHNIC GROUPS | TRADITIONAL HEALTH PRACTICES |

COUNTRIES | STUDIES | RESEARCH METHODOLOGY | DATA
COLLECTION | HIV INFECTIONS | VIRAL DISEASES | DISEASES |
BEHAVIOR | SOCIOCULTURAL FACTORS | CULTURAL BACKGROUND
POPULATION
93
Kaposi’s sarcoma in patients with and without human

immunodeficiency virus infection, in a tertiary referral centre in Kenya.
Author: Mwanda OW; Fu P; Collea R; Whalen C; Remick SC
Source: Annals of Tropical Medicine and Parasitology
Abstract: The clinical features of Kaposi’s sarcoma (KS), in patients with and without HIV
infection, were investigated in a tertiary referral centre in Kenya between 1997
and 1999. Although 186 cases were identified prospectively, the data analysis
was restricted to the 91 (49%) cases who had pathological confirmation of
Kaposi’s sarcoma and documented HIV serostatus. Among these 91 subjects
(58% of whom were male), the age-group holding the largest number of KS cases
was that of individuals aged 31–40 years; most of the paediatric cases were aged
6–10 years. The ratio of HIV-seropositives to HIV-seronegatives was 8.5:1 for the
adult cases and 0.9:1 for the paediatric. Of the signs and symptoms of Kaposi’s
sarcoma seen at presentation, only peripheral lympadenopathy was found to be
significantly associated with underlying HIV infection (P=0.05). The median
survival was 104 days. It is apparent that, as the HIV epidemic advances in
regions of the world with endemic KS, the clinical presentation and natural
history of the endemic KS are blending with those of the epidemic or AIDS-
associated disease, leading to a reduction in the mean age of the cases and a
nearly identical incidence in men and women. In regions of the world where
patients have ready access to such chemotherapy, the impact of treatment with
highly active antiretroviral drugs on the incidence and natural history of KS has
been dramatic. It will be important to monitor the clinico–pathological features
of KS in the developing world, as more active antiretroviral regimens become
available in clinical practice there. (author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | CLINICAL RESEARCH | PROSPECTIVE

STUDIES | HIV POSITIVE PERSONS | TARGET POPULATION | CANCER
| REFERRAL AND CONSULTATION PROGRAM DESIGN | PROGRAMS |
ORGANIZATION AND ADMINISTRATION | NEOPLASMS | PROGRAM
ACTIVITIES | POPULATION CHARACTERISTICS | DEMOGRAPHIC
FACTORS | POPULATION | MEASUREMENT | HIV
94
Men's condom use in higher-risk sex: Trends and determinants in five

Sub-Saharan countries.
Author: Adair T
Source: Calverton, Maryland, Macro International, MEASURE DHS, 2008 Apr.
Abstract: This paper examines men's condom use at last higher-risk sex (i.e., nonmarital,
noncohabiting partner) in five sub-Saharan countries: Burkina Faso, Cameroon,
Kenya, Tanzania, and Zambia. The two most recent Demographic and Health
Surveys (DHS) in each country are analyzed to show trends in various indicators.
Condom use is an important way to prevent the transmission of HIV, the virus
that causes AIDS. Encouragingly, use of condoms has increased substantially in
Burkina Faso, Cameroon, and Tanzania, with smaller increases in Kenya and
Zambia. At the same time, levels of higher-risk sex have declined in four of the
five countries, although use of a condom at last higher-risk sex remains below 50
percent in Kenya and Zambia. Multivariate analysis shows that higher education
is a consistently strong, positive predictor of condom use at last higher-risk sex,
whereas higher wealth status is not significant in most surveys. Knowledge that
use of condoms can reduce the risk of HIV transmission is a consistently strong,
positive predictor of condom use, but urban-rural residence and region are
significant only in some surveys. Comparing the two most recent DHS surveys in
each of the five countries, there are no clear patterns of change in the predictive
strength of explanatory variables. However, there is evidence of widening gaps
in condom use by level of education in Cameroon and by urban-rural residence
in Kenya. One important policy finding that emerged from this study is that low
wealth status is not a barrier to condom use in most countries, but lack of
education is. (author's)
Language: English
Keywords: BURKINA FASO | CAMEROON | KENYA | TANZANIA | ZAMBIA |

RESEARCH REPORT | DEMOGRAPHIC AND HEALTH SURVEYS |
MULTIVARIATE ANALYSIS | MEN | CONDOM USE | RISK BEHAVIOR |
EDUCATIONAL STATUS | DEVELOPING COUNTRIES | AFRICA,
WESTERN | AFRICA, SUB SAHARAN | AFRICA | AFRICA, EASTERN |
DYNAMICS | DEMOGRAPHIC FACTORS | POPULATION | DATA
ANALYSIS | RESEARCH METHODOLOGY | RISK REDUCTION
BEHAVIOR | BEHAVIOR | SOCIOECONOMIC STATUS |
SOCIOECONOMIC FACTORS | ECONOMIC FACTORS
95
Does cotrioxazole prophylaxis for the prevention of HIV-associated

opportunistic infections select for resistant pathogens in Kenyan adults?
Author: Hamel MJ, Greene C, Chiller T, Ouma P, Polyak C, Otieno K, Williamson J,
Shi YP, Feikin DR, Marston B, Brooks JT, Poe A, Zhou Z
Source: Am J Trop Med Hyg. 2008 Sep;79(3):320-30.
Abstract: We assessed the effect of daily cotrimoxazole, essential for HIV care, on
development of antifolate-resistant Plasmodium falciparum, naso-pharyngeal
Streptococcus pneumoniae (pneumococcus), and commensal Escherichia coli.
HIV-positive subjects with CD4 cell count < 350 cells/muL (lower-CD4; N = 692)
received cotrimoxazole; HIV-positive with CD4 cell count > or = 350 cells/muL
(higher-CD4; N = 336) and HIV-negative subjects (N = 132) received
multivitamins.
Specimens were collected at baseline, 2 weeks, monthly, and at sick visits during
6 months of follow-up to compare changes in resistance, with higher-CD4 as
referent. P. falciparum parasitemia incidence density was 16 and 156/100
person-years in lower-CD4 and higher-CD4, respectively (adjusted rate ratio
[ARR] = 0.11; 95% confidence interval [CI] = 0.06-0.15; P < 0.001) and 97/100
person-years in HIV-negative subjects (ARR = 0.62; 95% CI = 0.44-0.86; P = 005).
Incidence density of triple and quintuple dihydrofol reductase/dihydropteroate-
synthetase mutations was 90% reduced in lower-CD4 compared with referent.
Overall, cotrimoxazole non-susceptibility was high among isolated
pneumococcus (92%) and E. coli (76%) and increased significantly in lower-CD4
subjects by Week 2 (P < 0.005). Daily cotrimoxazole prevented malaria and
reduced incidence of antifolate-resistant P. falciparum but
contributed to increased pneumococcus and commensal Escherichia coli
resistance.
Language: English
Keywords: |AIDS-RELATED OPPORTUNISTIC INFECTIONS|PREVENTION &

CONTROL|ADOLESCENT|ADULT|AGED|ANIMALS|ANTI-
BACTERIAL AGENTS/PHARMACOLOGY|ANTI-INFECTIVE
GENTS/ADMINISTRATION & DOSAGE THERAPEUTICUSE |
ANTIMALARIALS/PHARMACOLOGY|COHORT STUDIES |DRUG
RESISTANCE|ESCHERICHIA COLI/DRUG EFFECTS|FEMALE|HIV
INFECTIONS|DRUG THERAPY|HUMANS|KENYA|MALARIA,
ALCIPARUM/PARASITOLOGY/PREVENTION & CONTROL |MALE|
MIDDLE AGED|PLASMODIUM FALCIPARUM/DRUG EFFECTS|
PROSPECTIVE STUDIES|STREPTOCOCCUS PNEUMONIAE|DRUG
EFFECTS|TRIMETHOPRIM-SULFAMETHOXAZOLE
COMBINATION/ADMINISTRATION & DOSAGE| THERAPEUTIC
HIV infection does not disproportionately affect the poorer in sub-

Saharan Africa.
96
Author: Mishra V
Source: AIDS. 2007 Nov;21 Suppl 7:S17-28.
Language: English
Wealthier populations do better than poorer ones on most measures of
health status, including nutrition, morbidity and mortality, and healthcare
utilization.
Objectives:
This study examines the association between household
wealth status and HIV serostatus to identify what characteristics and behaviours
are associated with HIV infection, and the role of confounding factors such as
place of residence and other risk factors.
Methods:
Data are from eight national surveys in sub-Saharan Africa (Kenya, Ghana,
Burkina Faso, Cameroon, Tanzania, Lesotho, Malawi, and Uganda) conducted
during 2003-2005. Dried blood spot samples were collected and tested for HIV,
following internationally accepted ethical standards and laboratory procedures.
The association between household wealth (measured by an index based on
household ownership of durable assets and other amenities) and HIV serostatus
is examined using both descriptive and multivariate statistical methods.
Results:
In all eight countries, adults in the wealthiest quintiles have a higher prevalence
of HIV than those in the poorer quintiles. Prevalence increases monotonically
with wealth in most cases. Similarly for cohabiting couples, the likelihood that
one or both partners is HIV infected increases with wealth. The positive
association between wealth and HIV prevalence is only partly explained by an
association of wealth with other underlying factors, such as place of residence
and education, and by differences in sexual behaviour, such as multiple sex
partners, condom use, and male circumcision.
Conclusion:
In sub-Saharan Africa, HIV prevalence does not exhibit the same
pattern of association with poverty as most other diseases. HIV programmes
should also focus on the wealthier segments of the population.
Language: English
97
The impact of onset controllability on stigmatization and supportive

communication goals toward persons with HIV versus lung cancer: a
comparison between Kenyan and U.S. participants.
Author: Miller AN, Fellows KL, Kizito MN
Source: Health Commun. 2007;22(3):207-19.
Abstact: This study examined the impact of controllability of onset (i.e., means of
transmission), disease type (HIV and lung cancer), and culture (Kenya and U.S.)
on stigmatizing attitudes and goals for supportive communication. Four
hundred sixty-four Kenyan students and 526 American students, and 441
Kenyan nonstudents and 591 American nonstudents were randomly assigned to
1 of 12 hypothetical scenario conditions and asked to respond to questions
regarding 3 different types of stigmatizing attitudes and 6 types of supportive
communication goals with respect to the character in the scenario. Means of
transmission had a strong effect on the blame component of stigma, but none on
cognitive attitudes and social interaction components. Similarly, although an
effect for means of transmission emerged on intention to provide "recognize own
responsibility" and "see others' blame" types of support, no effect was evident for
most other supportive interaction goals. Although effects for culture were small,
Kenyan participants, student and nonstudent alike, were not as quick as
American participants to adopt goals of communicating blame in any direction.
Implications for measurement of stigma in future research are discussed.
Language: English
Keywords: |ADOLESCENT |ADULT |AGED |AGED, 80 AND OVER|ATTITUDE TO

HEALTH| CROSS-CULTURAL COMPARISON| EDUCATIONAL STATUS
|FEMALE |HIINFECTIONS|EPIDEMIOLOGY|ETIOLOGY|PSYCHOLOGY
|HEALTH BEHAVIOR|HUMANS |INTERNAL-EXTERNAL CONTROL|
KENYA|EPIDEMIOLOGY| LUNG
NEOPLASMS/EPIDEMIOLOGY/ETIOLOGY|PSYCHOLOGY
| MALE| MIDDLE AGED| PRECIPITATING FACTORS|PREJUDICE |
QUESTIONNAIRES|SOCIAL SUPPORT |STEREOTYPING |STUDENTS|
PSYCHOLOGY |UNITED STATES/EPIDEMIOLOGY| UNIVERSITIES
Education and nutritional status of orphans and children of HIV-infected

parents in Kenya.
Author: Mishra V, Arnold F, Otieno F, Cross A, Hong R
Source: AIDS Educ Prev. 2007 Oct;19(5):383-95.
Abstract: We examined whether orphaned and fostered children and children of HIV-
infected parents are disadvantaged in schooling, nutrition, and health care. We
98
analyzed data on 2,756 children aged 0-4 years and 4,172 children aged 6-14
years included in the 2003 Kenya Demographic and Health Survey, with linked
anonymous HIV testing, using multivariate logistic regression. Results indicate
that orphans, fostered children, and children of HIV-infected parents are
significantly less likely to attend school than non-orphaned/non-fostered
children of HIV-negative parents. Children of HIV-infected parents are more
likely to be underweight and wasted, and less likely to receive medical care for
ARI and diarrhea. Children of HIV-negative single mothers are also
disadvantaged on most indicators. The findings highlight the need to expand
child welfare programs to include not only orphans but also fostered children,
children of single mothers, and children of HIV-infected parents, who tend to be
equally, if not more, disadvantaged.
Language: English
Keywords: |ADOLESCENT|ADULT|CHILDCHILD WELFARE/*STATISTICS &

NUMERICAL DATA|CHILD OF IMPAIRED
ARENTS/EDUCATION/*STATISTICS & NUMERICAL DATA
|CHILD, ORPHANED/EDUCATION/*STATISTICS & NUMERICAL DATA|
CHILD, PRESCHOOL|EDUCATIONAL STATUS|FAMILY
CHARACTERISTICS|FEMALE|FOSTER HOME CARE
|HIV INFECTIONS|HEALTH STATUS DISPARITIES|HUMANS|
INFANT|INFANT, NEWBORN
|KENYA/EPIDEMIOLOGY|LOGISTIC MODELS|MALE|MIDDLE AGED|
MULTIVARIATE ANALYSIS|NUTRITIONAL STATUS|VULNERABLE
POPULATIONS
Religious and cultural traits in HIV/AIDS epidemics in sub-Saharan

Africa.
Author: Bakayev V,Velayati AA, Bahadori M, Tabatabaei SJ, Alaei A, Farahbood A,
Masjedi MR
Source: Arch Iran Med. 2007 Oct;10(4):486-97.
The pandemic of HIV/AIDS in sub-Saharan Africa and the rise of epidemics in
Asia to the previously unforeseen level are likely to have global social, economic,
and political impacts. In this emergency, it is vital to reappraise the weight of
powerful religious and cultural factors in spreading the disease. The role of Islam
in shaping values, norms, and public policies in North African states is to be
appreciated for the lowest HIV prevalence in their populations. Yet, the place of
religion in prevention of the disease diffusion is not fully understood nor
worldwide acknowledged by the primary decision makers.
Another topic, which has received little attention to date, despite the abundance
of literature concerning the unfortunate Africa's anti-AIDS campaign, is an issue
of colonial past.
99
Methods:
To better comprehend the share of both traits in
diverse spread of HIV in sub-Saharan Africa, we studied the correlation between
Muslim and Christian proportions in the state's population and HIV rate.
Results:
By this method, Muslim percentage came out as a potential predictor of HIV
prevalence in a given state. In another approach, most subcontinental countries
were clustered by colocalization and similarity in their leading religion,
colonial past, and HIV seroprevalence starting from barely noticeable (0.6 - 1.2%,
for Mauritania, Senegal, Somalia, and Niger) and low levels (1.9 - 4.8%, for Mali,
Eritrea, Djibouti, Guinea, Guinea-Bissau, Burkina-Faso, and Chad) for Muslim
populated past possessions of France and Italy, in the northern part of the
subcontinent. Former territories of France, Belgium, Portugal, and the UK
formed two other groups of the countries nearing the equator with Catholic
prevailing (Democratic Republic of Congo, Republic of Congo, Rwanda, Gabon,
and Burundi) or mixed populations comprising Christian, Muslim, and
indigenous believers (Benin, Ghana, Uganda, Togo, Angola, Nigeria, Liberia,
Kenya, Cameroon, Cote d'Ivoire, and Sierra-Leone), which covered the HIV
prevalence range from 1.9% to 7%. Albeit being traced by origin to the central
part of the continent, HIV has reached the highest rates in the South, particularly
Malawi (14.2%), Zambia (16.5%), South Africa (21.5%), Zimbabwe (24.6%),
Lesotho (28.9%), Botswana (37.3%), and Swaziland (38.8%)-all former British
colonies with dominating Christian population.
Conclusion:
In the group ranking list, a distinct North to
South oriented incline in HIV rates related to prevailing religion and previous
colonial history of the country was found, endorsing the preventive role of the
Islam against rising HIV and the increased vulnerability to menace in states with
particular colonial record.
Language: English
Keywords: |ACQUIRED IMMUNODEFICIENCY SYNDROME| EPIDEMIOLOGY|

ETHNOLOGY| VIROLOGY|ADOLESCENT|ADULT|AFRICA SOUTH OF
THE SAHARA/EPIDEMIOLOGY|CULTURE|FEMALE |GEOGRAPHY |
HIV/GENETICS|HUMANS|MALE|PREVALENCE|RELIGION
|RISK FACTORS|SEXUAL BEHAVIOR|VIRAL LOAD
100
High prevalence of HIV infection among rural tea plantation residents in

Kericho, Kenya.
Author: Foglia G, Sateren WB, Renzullo PO, Bautista CT, Langat L
Source: Epidemiol Infect. 2008 May;136(5):694-702. Epub 2007 Jun 29.
Abstract: Human immunodeficiency virus type 1 (HIV-1) epidemiology among residents

of a rural agricultural plantation in Kericho, Kenya was studied. HIV-1
prevalence was 14.3%, and was higher among women (19.1%) than men (11.3%).
Risk factors associated with HIV-1 for men were age (>or=25 years), marital
history (one or more marriages), age difference from current spouse (>or=5
years), Luo ethnicity, sexually transmitted infection (STI) symptoms in the past 6
months, circumcision (protective), and sexual activity (>or=7 years). Among
women, risk factors associated with HIV-1 were age (25-29 years, >or=35 years),
marital history (one or more marriages), age difference from current spouse
(>or=10 years), Luo ethnicity, STI symptoms in the past 6 months, and a STI
history in the past 5years. Most participants (96%) expressed a willingness to
participate in a future HIV vaccine study. These findings will facilitate targeted
intervention and prevention measures for HIV-1 infection in Kericho.
Language: English
Keywords: |ADOLESCENT|ADULT|AGE FACTORS|ETHNIC GROUPS |FEMALE|

HIV INFECTIONS |EPIDEMIOLOGY |VIROLOGY|HIV-1 |ISOLATION &
PURIFICATION|HUMANS |KENYA |EPIDEMIOLOGY|MALE|MIDDLE
AGED|PREVALENCE
|RISK FACTORS|RURAL POPULATION|SEX FACTORS
The protective effect of circumcision on HIV incidence in rural low-risk

men circumcised predominantly by traditional circumcisers in Kenya:
two-year follow-up of the Kericho HIV Cohort Study.
Author: Shaffer DN, Bautista CT, Sateren WB, Sawe FK, Kiplangat SC, Miruka AO,
Renzullo PO, Scott PT, Robb ML, Michael NL, Birx DL
Source: J Acquir Immune Defic Syndr. 2007 Aug 1;45(4):371-9.
Three randomized controlled trials (RCTs) have demonstrated that male
circumcision prevents female-to-male HIV transmission in sub-Saharan Africa.
Data from prospective cohort studies are helpful in considering generalizability of
RCT results to populations with unique epidemiologic/cultural characteristics.
101
Methods:
Prospective observational cohort sub-analysis. A total of 1378 men were
evaluated after 2 years of follow-up. Baseline sociodemographic and
behavioral/HIV risk characteristics were compared between 270 uncircumcised
and 1108 circumcised men. HIV incidence rates (per 100 person-years) were
calculated, and Cox proportional hazards regression analyses estimated hazard
rate ratios (HRs).
Results:
Of the men included in this study, 80.4% were circumcised; 73.9% were
circumcised by traditional circumcisers. Circumcision was associated with tribal
affiliation, high school education, fewer marriages, and smaller age difference
between spouses (P < 0.05). After 2 years of follow-up, there were 30 HIV
incident cases (17 in circumcised and 13 in uncircumcised men). Two-year HIV
incidence rates were 0.79 (95% confidence interval [CI]: 0.46 to 1.25) for
circumcised men and 2.48 (95% CI: 1.33 to 4.21) for uncircumcised men
corresponding to a HR = 0.31 (95% CI: 0.15 to 0.64). In one model controlling for
sociodemographic factors, the HR increased and became non-significant (HR =
0.55; 95% CI: 0.20 to 1.49). CONCLUSIONS: Circumcision by traditional
circumcisers offers protection from HIV infection in adult men in rural Kenya.
Data from well-designed prospective cohort studies in populations with unique
cultural characteristics can supplement RCT data in recommending public health
policy.
Language: English
Keywords: |ADOLESCENT| ADULT| CHILD|CIRCUMCISION, MALE/STATISTICS

& NUMERICAL DATA| COHORT STUDIES| HIV INFECTIONS |
EPIDEMIOLOGY/*PREVENTION & CONTROL/VIROLOGY|HIV-1|
HUMANS|INCIDENCE|KENYA/EPIDEMIOLOGY| MALE |MEDICINE,
AFRICAN TRADITIONAL|RISK FACTORS|RURAL POPULATION
|SEXUAL BEHAVIOR
Antiretroviral durability and tolerability in HIV-infected adults living in

urban Kenya.
Author: Hawkins C, Achenbach C, Fryda W, Ngare D, Murphy R
Source: J Acquir Immune Defic Syndr. 2007 Jul 1;45(3):304-10.
Insufficient data exist on the durability and tolerability of
first-line antiretroviral therapy (ART) regimens provided by HIV treatment
programs implemented in developing countries.
102
Methods:
Longitudinal observation of clinical, immunologic, and treatment parameters of
all HIV-infected adult patients initiated on ART was performed at Saint Mary's
Mission Hospital in Nairobi, Kenya from September 2004 until August 2006.
Results:
A total of 1286 patients were analyzed (59.1% female). Initial ART regimens were
primarily stavudine, lamivudine, and nevirapine (62.1%). Median ART duration
was 350 days (11.6 months). Significant improvements in clinical and
immunologic status were noted after 12 months of therapy. ART switches
occurred in 701 (54.5%) patients. The cumulative incidence of ART switch at 12
months was 78.4%. Concurrent ART-related toxicities (40.6%) and tuberculosis
treatment interactions (28.1%) were the most frequent reasons for ART switch.
Baseline AIDS symptoms (hazard rate [HR]=1.59, 95% confidence interval [CI]:
1.28 to 1.98; P<0.01) and a CD4 count<or=100 cells/mm3 (HR=1.20, CI: 1.01 to
1.43; P=0.04) were independent predictors of ART switch. ART-related clinical
toxicity occurred in 341 (26.5%) patients. Peripheral neuropathy was reported
most frequently (20.7%). A CD4 count<or=100 cells/mm3 was an independent
predictor of clinical toxicity.
Conclusions:
Excellent clinical and immunologic responses to ART were observed in
this urban Kenyan population; however, frequent switches in ART among
medication classes because of toxicity or drug interactions may limit the
durability of these responses.
Language: English
Keywords: |ADOLESCENT |ADULT |AGED|ANTI-RETROVIRAL AGENTS |

ADVERSE EFFECTS |THERAPEUTIC USE|CD4 LYMPHOCYTE COUNT|
DEVELOPING COUNTRIES|DRUG THERAPY, COMBINATION |
EXANTHEMA|CHEMICALLY INDUCED|PREVENTION & CONTROL |
FEMALE|GOVERNMENT PROGRAMS|TRENDS|HIV INFECTIONS |
DRUG THERAPY|IMMUNOLOGY|PREVENTION & CONTROL |
HUMANS |KENYA|EPIDEMIOLOGY|MALE |MIDDLE AGED|PATIENT
COMPLIANCE|PERIPHERAL NERVOUS SYSTEM DISEASES|
CHEMICALLY INDUCED|PREVENTION & CONTROL |PROBABILITY|
SENTINEL SURVEILLANCE |TREATMENT OUTCOME |URBAN
POPULATION
103
Understanding the differences between contrasting HIV epidemics in

east and west Africa: results from a simulation model of the Four Cities
Study.
Author: Orroth KK, Freeman EE, Bakker R, Buve A, Glynn JR, Boily MC, White RG,
Habbema JD, Hayes RJ
Source: Sex Transm Infect. 2007 Aug;83 Suppl 1:i5-16. Epub 2007 Apr 3.
To determine if the differences in risk behaviours, the proportions of
males circumcised and prevalences of sexually transmitted infections (STIs)
observed in two African cities with low prevalence of HIV (Cotonou, Benin, and
Yaounde, Cameroon) and two cities with high prevalence (Kisumu, Kenya, and
Ndola, Zambia) could explain the contrasting HIV epidemics in the four cities.
Methods:
An individual-based stochastic model, STDSIM, was fitted to the demographic,
behavioural and epidemiological characteristics of the four urban study
populations based on data from the Four Cities Study and other relevant sources.
Model parameters pertaining to STI and HIV natural history and transmission
were held constant across the four populations. The probabilities of HIV, syphilis
and chancroid acquisition were assumed to be doubled among uncircumcised
males. A priori plausible ranges for model inputs and outputs were defined and
sexual behaviour characteristics, including those pertaining to commercial sex
workers (CSWs) and their clients, which were allowed to vary across the sites,
were identified based on comparisons of the empirical data from the four sites.
The proportions of males circumcised in the model, 100% in Cotonou and
Yaounde, 25%in Kisumu and 10% in Ndola, were similar to those observed. A
sensitivity analysis was conducted to assess how changes in critical parameters
may affect the model fit.
Results:
Population characteristics observed from the study that
were replicated in the model included younger ages at sexual debut and
marriage in east Africa compared with west Africa and higher numbers of casual
partners in the past 12 months in Yaounde than in the other three sites. The
patterns in prevalence of STIs in females in the general population and CSWs
were well fitted. HIV prevalence by age and sex and time trends in prevalence in
the model were consistent with study data with the highest simulated
prevalences in Kisumu and Ndola, intermediate in Yaounde and lowest in
Cotonou. The sensitivity analysis suggested that the effect of circumcision on the
development of the HIV epidemics may have been mediated indirectly by its
effect on ulcerative STI.
104
Conclusions:
The contrasting HIV epidemics in east and west Africa could be
replicated in our model by assuming that male circumcision reduced
susceptibility to HIV, syphilis and chancroid. Varying rates of male circumcision
may have played an important role in explaining the strikingly different HIV
epidemics observed in different parts of sub-Saharan Africa.
Language: English
Keywords: |ADOLESCENT| ADULT|AFRICA, EASTERN |EPIDEMIOLOGY |

AFRICA, WESTERN |EPIDEMIOLOGY|CIRCUMCISION, MALE |
STATISTICS & NUMERICAL DATA|DISEASE OUTBREAKS |STATISTICS
& NUMERICAL DATA|FEMALE|HIV INFECTIONS |EPIDEMIOLOGY|
HUMANS|MALE|PREVALENCE|RISK FACTORS|RISK-TAKING|
SENSITIVITY AND SPECIFICITY|SEXUAL BEHAVIOR|STATISTICS &
NUMERICAL DATA|SEXUALLY TRANSMITTED DISEASES|
EPIDEMIOLOGY|TRANSMISSION
The ABCs of HIV prevention in men: associations with HIV risk and
protective behaviors.
Author: Steele MS, Bukusi E, Cohen CR, Shell-Duncan BA, Holmes KK
Source: J Acquir Immune Defic Syndr. 2006 Dec 15;43(5):571-6.
Abstact: Objective:
To elucidate associations between beliefs in abstinence, fidelity, and condom use
(the "ABCs" of preventing HIV and other sexually transmitted infections) and
associated self-reported risk behaviors among Kenyan men.
Methods:
We assessed associations of beliefs in the ABCs with sociodemographic
characteristics and sexual risk behaviors in a respondent-driven sample of 500
men in Nairobi.
Results:
Younger age, single marital status, and higher education
were associated with beliefs in abstinence and condom use as "best" prevention
methods; and older age and marriage were associated with belief in fidelity.
Many of these and other associations persisted in multivariate models. Men
citing abstinence or fidelity belief less often reported sex with a female sex
worker (FSW) ever or recent concurrent partnerships less often. Belief in fidelity
was negatively associated with reported use of condoms ever. Belief in condom
use to prevent HIV was most common among those having recent concurrent
partnerships.
Conclusions:
105
Beliefs in abstinence, fidelity ("being faithful"), or condom use

were associated, in plausible directions, with life stages and other demographic
factors and with corresponding risk and preventive behaviors. Context-specific
and selective educational promotion of individual ABC components rather than
comprehensive education from an early age in a wide repertoire of prevention
strategies ignores the evolution of sexual behaviors and the relative utility of
different approaches throughout the life course.
Language: English
Keywords: |ADOLESCENT |ADULT |AGING |CONDOMS|UTILIZATION |HIV

NFECTIONS|PREVENTION & CONTROL|HEALTH BEHAVIOR|HEALTH
KNOWLEDGE, ATTITUDES, PRACTICE|HUMANS|KENYA |MALE |
MARITAL STATUS |MIDDLE AGED |RISK FACTORS |SAFE SEX
Epidemiology of HIV-1 infection in agricultural plantation residents in

Kericho, Kenya: preparation for vaccine feasibility studies.
Author: Sateren WB, Foglia G, Renzullo PO, Elson L, Wasunna M, Bautista CT,
Birx DL
Source: J Acquir Immune Defic Syndr. 2006 Sep;43(1):102-6.
Abstract: A cross-sectional study was performed to determine the prevalence and risk
factors for HIV-1 infection among agricultural plantation residents in Kericho,
Kenya. Volunteers were recruited, interviewed, and phlebotomized for HIV-1
serologic testing. Sex-specific adjusted odds ratios were estimated using
logistic regression. The overall HIV-1 prevalence was 9.9% (81/820), with
prevalence in women more than twice that in men (17.4% vs 8.0%, P=0.001).
Among men, elevated HIV-1 prevalence was seen with increasing age, peaking
in those older than 30 years (10.3%), marriage (10.4%), Luo tribe affiliation
(23.5%), employment (8.9%), travel (11.0%), and being uncircumcised (29.2%).
Among women, elevated HIV-1 prevalence was seen in those with no formal
education (36.8%) and those who received goods in exchange for sex (36.0%).
More than 97% of volunteers expressed a willingness to participate in future
HIV-1 studies requiring semiannual visits. HIV prevention efforts have been
implemented, along with further research to characterize this population for
future cohort feasibility studies and HIV-1 vaccine efficacy trials.
Language: English
Keywords: | ADOLESCENT|AGRICULTURE|STATISTICS & NUMERICAL DATA |

CANCER VACCINES| CHILD, PRESCHOOL| CROSS-CULTURAL
COMPARISON| FEMALE| HIV INFECTIONS |EPIDEMIOLOGY |
IMMUNOLOGY| HUMANS| KENYA/EPIDEMIOLOGY
| MALE| PREVALENCE
106
HIV testing in national population-based surveys: experience from the

Demographic and Health Surveys.
Author: Mishra V, Vaessen M, Boerma JT, Arnold F, Way A, Barrere B, Cross A, Hong R,
Sangha J
Source: Bull World Health Organ. 2006 Jul;84(7):537-45.
To describe the methods used in the Demographic and Health Surveys
(DHS) to collect nationally representative data on the prevalence of human
immunodeficiency virus (HIV) and assess the value of such data to country HIV
surveillance systems.
Methods:
During 2001-04, national samples of adult women
and men in Burkina Faso, Cameroon, Dominican Republic, Ghana, Mali, Kenya,
United Republic of Tanzania and Zambia were tested for HIV. Dried blood spot
samples were collected for HIV testing, following internationally accepted ethical
standards. The results for each country are presented by age, sex, and urban
versus rural residence. To estimate the effects of non-response, HIV prevalence
among non-responding males and females was predicted using multivariate
statistical models for those who were tested, with a common set of predictor
variables.
Results:
Rates of HIV testing varied from 70% among Kenyan men to 92%
among women in Burkina Faso and Cameroon. Despite large differences in HIV
prevalence between the surveys (1-16%), fairly consistent patterns of HIV
infection were observed by age, sex and urban versus rural residence, with
considerably higher rates in urban areas and in women, especially at younger
ages. Analysis of non-response bias indicates that although predicted HIV
prevalence tended to be higher in non-tested males and females than in those
tested, the overall effects of non-response on the observed national estimates of
HIV prevalence are insignificant.
Conclusions:
Population-based surveys can provide reliable, direct estimates of national and
regional HIV seroprevalence among men and women irrespective of pregnancy
status. Survey data greatly enhance surveillance systems and the accuracy of
national estimates in generalized epidemics.
Language: English
107
Keywords: | ADOLESCENT |ADULT|DEMOGRAPHY |DEVELOPING COUNTRIES |

FEMALE|HIV INFECTIONS/*DIAGNOSIS|HEALTH SURVEYS |HUMANS
|MALE|MASS SCREENING |MIDDLE AGED|POPULATION
SURVEILLANCE
HIV-1 target cells in foreskins of African men with varying histories of

sexually transmitted infections.
Author: Donoval BA, Landay AL, Moses S, Agot K, Agot K, Ndinya-Achola JO, Nyagaya
EA, MacLean I, Bailey RC,
Source: Am J Clin Pathol. 2006 Mar;125(3):386-91.
Abstract: Numerous epidemiologic studies have found significant associations between

lack of circumcision and HIV-1 acquisition in men. To our knowledge, this is the
first study of human foreskin tissue that examines biologic mechanisms that
increase susceptibility of uncircumcised African men to HIV-1. Foreskin
specimens from 20 men with and 19 men with no history of sexually transmitted
infections were examined for HIV-1 target cells. Most Langerhans cells were
found in the epithelium; most CD4+ T cells and macrophages were in the
submucosa. There were no differences in HIV-1 target cells between men with
and those without history of sexually transmitted infections. However
Langerhans cells and macrophages were more abundant in the group with a
history of infection. The densities and positions of HIV-1 target cells in the
foreskin tissue of these Kenyan men indicate that the inner mucosal surface of
the human foreskin contains cells that make it highly susceptible to HIV
infection.
Language: English
Keywords: |ADOLESCENT |ADULT |ANTIGENS, CD/METABOLISM |CD4-

POSITIVE T-LYMPHOCYTES |CYTOLOGY |VIROLOGY |
CIRCUMCISION, MALE |HIV-1 |PHYSIOLOGY|HUMANS |IMMUNE
SYSTEM |IMMUNOLOGY |PATHOLOGY |VIROLOGY
|IMMUNOHISTOCHEMISTRY |KENYA |LANGERHANS CELLS |
CYTOLOGY |VIROLOGY |MACROPHAGES |CYTOLOGY |VIROLOGY |
MALE |PENIS/CYTOLOGY |SEXUALLY TRANSMITTED DISEASES |
COMPLICATIONS |SKIN |CYTOLOGY
108
Evidence for population level declines in adult HIV prevalence in

Kenya.
Author: Cheluget B, Baltazar G, Orege P, Ibrahim M, Marum LH, Stover J
Source: Sex Transm Infect. 2006 Apr;82 Suppl 1:i21-6.
Abstract: The HIV/AIDS epidemic in Kenya has been tracked through annual sentinel
surveillance in antenatal clinics since 1990. The system started with 13 sites
and now has over 35. Behaviours have been measured through national
Demographic and Health Surveys in 1993, 1998, and 2003. The surveillance data
indicate that prevalence has declined substantially starting in 1998 in five of the
original 13 sites and starting in 2000 in another four sites. No decline is evident in
the other five original sites although the 2004 estimate is the lowest recorded.
Nationally, adult prevalence has declined from 10% in the late 1990s to under 7%
today. Surveys indicate that both age at first sex and use of condoms are rising
and that the percentage of adults with multiple partners is falling. It is clear
that HIV prevalence is now declining in Kenya in a pattern similar to that seen
in Uganda but seven or eight years later. Although the coverage of preventive
interventions has expanded rapidly since 2000 this expansion was too late to
account for the beginnings of the decline in prevalence. More work is needed to
understand fully the causes of this decline, but it is encouraging to see Kenya
join the small list of countries experiencing significant declines in HIV
prevalence.
Language: English
Keywords: |ADOLESCENT |ADULT |FEMALE |HIV INFECTIONS EPIDEMIOLOGY

|PSYCHOLOGY|HUMANS |KENYA|EPIDEMIOLOGY |MALE |MIDDLE
AGED |PREVALENCE |SENTINEL SURVEILLANCE |SEXUAL
BEHAVIOR|PSYCHOLOGY|STATISTICS & NUMERICAL DATA
|SEXUALLY TRANSMITTED DISEASES|EPIDEMIOLOGY
Late marriage and the HIV epidemic in sub-Saharan Africa.

Author: Bongaarts J,
Source: Popul Stud (Camb). 2007 Mar;61(1):73-83.
Abstact: The causes of large variation in the sizes of HIV epidemics among countries in
sub-Saharan Africa are not well understood. Here we assess the potential roles of
late age at marriage and a long period of premarital sexual activity as
population risk factors, using ecological data from 33 sub-Saharan African
countries and with individual-level data from Demographic and Health Surveys
(DHS) in Kenya and Ghana in 2003. The ecological analysis finds a significant
109
positive correlation between HIV prevalence and median age at first marriage,
and between HIV prevalence and interval between first sexual intercourse and
first marriage. The individual-level analysis shows that HIV infection per year of
exposure is higher before than after first marriage. These findings support the
hypothesis of a link between a high average age at marriage and a long period of
premarital intercourse during which partner changes are relatively common and
facilitate the spread of HIV.
Language: English
Keywords: |ADOLESCENT |ADULT |AFRICA SOUTH OF THE SAHARA |

EPIDEMIOLOGY |AGE FACTORS |CIRCUMCISION, MALE |STATISTICS
& NUMERICAL DATA|DISEASE OUTBREAKS |STATISTICS &
NUMERICAL DATA |FEMALE |HIV INFECTIONS |EPIDEMIOLOGY |
HUMANS |MALE |MARRIAGE |STATISTICS & NUMERICAL DATA |
MIDDLE AGED |SEXUAL BEHAVIOR
Declines in HIV prevalence can be associated with changing sexual

behaviour in Uganda, urban Kenya, Zimbabwe, and urban Haiti.
Author: Hallett TB, Aberle-Grasse J, Bello G, Boulos LM, Cayemittes MP, Cheluget B,
Cheluget B, Cheluget B, Chipeta J ,Dorrington R, Dube S, Ekra AK, Garcia-Calleja
JM, Garnett GP, Greby S, Gregson S, Grove JT, Hader S, Hanson J, Hladik W,
Ismail S, Kassim S, Kirungi W, Kouassi L, Mahomva A, Marum L, Maurice C,
Nolan M, Rehle T, Walker N
Source: Sex Transm Infect. 2006 Apr;82 Suppl 1:i1-8.
Abstact: Objective:
To determine whether observed changes in HIV prevalence in countries with
generalised HIV epidemics are associated with changes in sexual risk
behaviour.
Methods:
A mathematical model was developed to explore the relation
between prevalence recorded at antenatal clinics (ANCs) and the pattern of
incidence of infection throughout the population. To create a null model a range
of assumptions about sexual behaviour, natural history of infection, and
sampling biases in ANC populations were explored to determine which factors
maximised declines in prevalence in the absence of behaviour change. Modelled
prevalence, where possible based on locally collected behavioural data, was
compared with the observed prevalence data in urban Haiti, urban Kenya, urban
Cote d'Ivoire, Malawi, Zimbabwe, Rwanda, Uganda, and urban Ethiopia.
110
Results:
Recent downturns in prevalence observed in urban Kenya, Zimbabwe, and
urban Haiti, like Uganda before them, could only be replicated in the model
through reductions in risk associated with changes in behaviour. In contrast,
prevalence trends in urban Cote d'Ivoire, Malawi, urban Ethiopia, and Rwanda
show no signs of changed sexual behaviour. CONCLUSIONS: Changes in
patterns of HIV prevalence in urban Kenya, Zimbabwe, and urban Haiti are
quite recent and caution is required because of doubts over the accuracy and
representativeness of these estimates. Nonetheless, the observed changes are
consistent with behaviour change and not the natural course of the HIV
epidemic.
Language: English
Keywords: |ADOLESCENT |ADULT |DISEASE OUTBREAKS/*STATISTICS &

NUMERICAL DATA |FEMALE |HIV INFECTIONS |EPIDEMIOLOGY |
PSYCHOLOGY |HAITI |EPIDEMIOLOGY |HETEROSEXUALITY
|HUMANS |KENYA |EPIDEMIOLOGY |MALE |PREVALENCE
|RISK REDUCTION BEHAVIOR|SEX DISTRIBUTION |SEXUAL
BEHAVIOR |PSYCHOLOGY |STATISTICS & NUMERICAL DATA
|UGANDA |EPIDEMIOLOGY |URBAN HEALTH |ZIMBABWE |
EPIDEMIOLOGY
Gene sequence variation among HIV-1-infected African children.

Author: Chakraborty R, Reinis M, Rostron T, Philpott S, Dong T, D'Agostino A, Musoke
R, Silva E, Stumpf M, Weiser B, Burger H, Rowland-Jones SL
Source: HIV Med. 2006 Mar;7(2):75-84.
There are few data on African children infected with nonclade B HIV-1
in endemic settings, which limits generalizations about pathogenesis and
progression. Genotypic and phenotypic variations in host immunogenetics and
HIV-1 negative factor (nef) accessory protein may influence disease progression
and have frequently been characterized in subjects infected with clade B HIV-1.
Methods:
In this descriptive study, we report nef gene sequence variation and
host genetic polymorphisms in 32 Kenyan children, including 12 slow
progressors.
Results:
Phylogenetic analysis identified HIV-1 clades A, C and D and a
recombinant A/D subtype. Grossly defective nef genes or significant changes
from relevant clade reference sequences were not identified in children with
delayed disease progression.
111
Conclusions:
nef sequence variations may not be common in perinatally infected African
children. Further studies are warranted in HIV-1-infected subjects in settings
where infection is endemic.
Language: English
Keywords: | ADOLESCENT| AMINO ACID SEQUENCE |CD4 LYMPHOCYTE COUNT

|CHILD |CHILD, PRESCHOOL |DISEASE PROGRESSION |FEMALE
|GENES, MHC CLASS I |GENES, NEF/*GENETICS |HIV
INFECTIONS/GENETICS/IMMUNOLOGY/*VIROLOGY |HIV LONG-
TERM SURVIVORS |HIV-1/CLASSIFICATION/*GENETICS
|HUMANS |INFANT |MALE |MOLECULAR SEQUENCE DATA
|PHYLOGENY |POLYMORPHISM, GENETIC |SEQUENCE ALIGNMENT
|SEQUENCE ANALYSIS, DNA/METHODS |VIRAL LOAD
Cost, affordability and cost-effectiveness of strategies to control

tuberculosis in countries with high HIV prevalence.
Author: Currie CS, Floyd K, Williams BG, Dye C
Source: BMC Public Health. 2005 Dec 12;5:130.
The HIV epidemic has caused a dramatic increase in tuberculosis (TB) in East
and southern Africa. Several strategies have the potential to reduce the burden of
TB in high HIV prevalence settings, and cost and cost-effectiveness analyses can
help to prioritize them when budget constraints exist. However, published cost
and cost-effectiveness studies are limited.
Methods:
Our objective was to compare the cost, affordability and cost-effectiveness of
seven strategies for reducing the burden of TB in countries with high HIV
prevalence. A compartmental difference equation model of TB and HIV and
recent cost data were used to assess the costs (year 2003 USD prices) and effects
(TB cases averted, deaths averted, DALYs gained) of these strategies in Kenya
during the period 2004-2023.
Results:
The three lowest cost and most cost-effective strategies were
improving TB cure rates, improving TB case detection rates, and improving both
together. The incremental cost of combined improvements to case detection and
cure was below USD 15 million per year (7.5% of year 2000 government health
expenditure); the mean cost per DALY gained of these three strategies ranged
from USD 18 to USD 34. Antiretroviral therapy (ART) had the highest
incremental costs, which by 2007 could be as large as total government health
112
expenditures in year 2000. ART could also gain more DALYs than the other
strategies, at a cost per DALY gained of around USD 260 to USD 530. Both the
costs and effects of treatment for latent tuberculosis infection (TLTI) for HIV+
individuals were low; the cost per DALY gained ranged from about USD 85 to
USD 370. Averting one HIV infection for less than USD 250 would be as cost-
effective as improving TB case detection and cure rates to WHO target levels.
Conclusion:
To reduce the burden of TB in high HIV prevalence settings, the immediate goal
should be to increase TB case detection rates and, to the extent possible, improve
TB cure rates, preferably in combination. Realising the full potential of ART will
require substantial new funding and strengthening of health system capacity so
that increased funding can be used effectively.
Language: English
Keywords: |AIDS-RELATED OPPORTUNISTIC INFECTIONS |ECONOMICS |

EPIDEMIOLOGY |PREVENTION & CONTROL|ADOLESCENT
|ADULT |ANTIRETROVIRAL THERAPY, HIGHLY ACTIVE |
UTILIZATION |ANTITUBERCULAR AGENTS |THERAPEUTIC USE
|COST OF ILLNESS |COST-BENEFIT ANALYSIS |DIRECTLY OBSERVED
THERAPY |FEMALE |HEALTH CARE COSTS | STATISTICS &
NUMERICAL DATA |HEALTH SERVICES ACCESSIBILITY
|HUMANS |KENYA |EPIDEMIOLOGY |MIDDLE AGED |MODELS,
ECONOMETRIC |PREVALENCE |QUALITY-ADJUSTED LIFE YEARS
|TUBERCULOSIS |ECONOMICS |EPIDEMIOLOGY |PREVENTION &
CONTROL
The role for government health centers in provision of same-day

voluntary HIV counseling and testing in Kenya.
Author: Arthur GR, Ngatia G, Rachier C, Mutemi R, Odhiambo J, Gilks CF
Source: J Acquir Immune Defic Syndr. 2005 Nov 1;40(3):329-35
To explore the role of primary health centers in provision of voluntary
counseling and testing (VCT) in Kenya.
Design and setting:

Prospective service evaluation at 3 (1 urban and 2 rural) government health
centers. SUBJECTS: Consecutive adult clients.
113
Main outcome measures:

Uptake of services, user characteristics, quality of service.
Results:
Counseling services received 2315 new clients over 26 months. The last quarter
averaged 101 clients per clinic. More than 80% of clients lived locally. Overall
93% opted to test, 91% receiving results, 82% on the same day. Most clients tested
HIV negative (81%). Youth and men were well represented. Few couples (10%)
attended. Seventeen percent of women were pregnant. Self-referral was common
and illness was an uncommon reason for testing (<20%). Thirty-one percent of
clients were referred from VCT to other health center services. Counseling was
perceived as high quality by users and providers. Validation of the test algorithm
showed a sensitivity of 98.0% and specificity of 98.7%.
Conclusion:
Government health centers in Kenya can be appropriate providers of VCT. This
pilot helped initiate a new strategy of health center-based VCT in Kenya and this
has facilitated rapid expansion and more equitable provision for Kenyans.
Language: English
Keywords: |AGE FACTORS |COMMUNITY HEALTH CENTERS |STATISTICS &

NUMERICAL DATA |COUNSELING |STATISTICS & NUMERICAL DATA
|FAMILY CHARACTERISTICS |FEMALE |GOVERNMENT AGENCIES |
STATISTICS & NUMERICAL DATA |HIV ANTIBODIES |BLOOD
|HIV INFECTIONS |DIAGNOSIS |EPIDEMIOLOGY |PREVENTION &
CONTROL |HIV SERONEGATIVITY |HUMANS |KENYA |
EPIDEMIOLOGY |MALE |PREGNANT WOMEN |PRIMARY HEALTH
CARE |STATISTICS & NUMERICAL DATA|QUALITY OF HEALTH CARE
|SELF CARE |SENSITIVITY AND SPECIFICITY |SEROEPIDEMIOLOGIC
STUDIES
Piloting post-exposure prophylaxis in Kenya raises specific concerns for

the management of childhood rape.
Author: Speight CG, Klufio A, Kilonzo SN, Mbugua C, Kuria E, Bunn JE, Taegtmeyer M
Source: Trans R Soc Trop Med Hyg. 2006 Jan;100(1):14-8. Epub 2005 Oct 12.
Abstract: Thika District, Kenya, is the site of an operational research study on the
provision of comprehensive post-rape care, including the free provision of HIV
post-exposure prophylaxis (PEP). It is a typical rural Kenyan district in terms
of resources and patient throughput. The high rate of children attending for
post-rape services was unexpected and had significant programming
implications. An age-disaggregated analysis of existing quantitative data from
the first 8 months of service provision was conducted. Ninety-four case records
114
were reviewed, of whom 48 (51%) were in the age range 1.5-17 years inclusive.
All three cases of male rape were in children. Children were more likely to know
their assailant than adults and were more likely to be HIV-negative at baseline.
The majority (86%) of children presented in time for PEP, with adherence and
completion rates similar to adults but lower rates of 6-week follow-up. The use
of weight bands to determine drug dosages greatly simplified the appropriate
and early administration of paediatric PEP. The high rates of childhood rape and
demand for post-rape services were an enormous challenge for service providers
and policy-makers.
Language: English
Keywords: |ADOLESCENT |ADULT |ANTI-HIV AGENTS |ADMINISTRATION &

DOSAGE |BODY WEIGHT |CHILD|CHILD ABUSE, SEXUAL |CHILD,
PRESCHOOL |FEASIBILITY STUDIES |FEMALE |HIV INFECTIONS |
PREVENTION & CONTROL |HUMANS |INFANT
|KENYA |LAMIVUDINE |ADMINISTRATION & DOSAGE
|MALE |PILOT PROJECTS |PRACTICE GUIDELINES AS TOPIC
|RAPE| RISK FACTORS| RURAL HEALTH|SEXUALLY TRANSMITTED
DISEASES/PREVENTION & CONTROL|ZIDOVUDINE |
ADMINISTRATION & DOSAGE
Adult male circumcision: results of a standardized procedure in Kisumu

District, Kenya.
Author: Krieger JN, Bailey RC, Opeya J, Ayieko B, Opiyo F, Agot K, Parker C, Ndinya-
Achola JO, Magoha GA, Moses S
Source: BJU Int. 2005 Nov;96(7):1109-13.
To develop a standard procedure for male circumcision in a resource-poor
medical setting and prospectively evaluate the outcome in a randomized,
controlled trial with the incidence of human immunodeficiency virus
(HIV) as the main outcome, as studies suggest that circumcision is associated
with a lower incidence of HIV and other sexually transmitted infections in
high-risk populations.
Subjects and methods:

Healthy, uncircumcised, HIV-seronegative men aged 18-24 years from Kisumu
District, Kenya, were offered participation in a clinical trial using a standard
circumcision procedure based on "usual" medical procedures in Western Kenya.
The follow-up included visits at 3, 8 and 30 days after circumcision, with
additional visits if necessary.
Healing, satisfaction and resumption of activities were assessed at these visits
and 3 months from randomization.
115
Results:
Overall, 17 (3.5%) of the 479 circumcisions were associated with adverse events
judged definitely, probably or possibly related to the procedure. The most
common adverse events were wound infections (1.3%), bleeding (0.8%), and
delayed wound healing or suture line disruption (0.8%). After 30 days, 99% of
participants reported being very satisfied with the procedure; approximately
23% reported having had sex and 15% reported that their partners had expressed
an opinion, all of whom were very satisfied with the outcome. About 96% of the
men resumed normal general activities within the first week after the procedure.
Conclusion:
Safe and acceptable adult male circumcision services can be delivered in
developing countries should male circumcision ultimately be advocated as a
public-health measure.
Language: English
Keywords: | ADOLESCENT |ADULT |CIRCUMCISION, MALE |METHODS

|DEVELOPING COUNTRIES |FOLLOW-UP STUDIES |HIV INFECTIONS
|PREVENTION & CONTROL |HUMANS |INCIDENCE |KENYA
|MALE |PATIENT SATISFACTION |PROSPECTIVE STUDIES
|SEXUALLY TRANSMITTED DISEASES | PREVENTION & CONTROL
|SURGICAL WOUND INFECTION |TREATMENT OUTCOME
HIV type 1 subtypes in circulation in northern Kenya.

Author: Khamadi SA, Ochieng W, Lihana RW, Kinyua J, Muriuki J, Mwangi J, Lwembe
R, Kiptoo M, Osman S, Lagat N, Pelle R, Muigai A, Carter JY, Oishi I, Ichimura
H, Mwaniki DL, Okoth FA, Mpoke S, Songok EM
Source: AIDS Res Hum Retroviruses. 2005 Sep;21(9):810-4.
Abstract: The genetic subtypes of HIV-1 circulating in northern Kenya have not been
characterized. Here we report the partial sequencing and analysis of samples
collected in the years 2003 and 2004 from 72 HIV-1-positive patients in northern
Kenya, which borders Ethiopia, Somalia, and Sudan. From the analysis of partial
env sequences, it was determined that 50% were subtype A, 39% subtype C, and
11% subtype D. This shows that in the northern border region of Kenya subtypes
A and C are the dominant HIV-1 subtypes in circulation. Ethiopia is dominated
mainly by HIV-1 subtype C, which incidentally is the dominant subtype in the
town of Moyale, which borders Ethiopia. These results show that cross-border
movements play an important role in the circulation of subtypes in Northern
Kenya.
Language: English
116
Keywords: |ADOLESCENT |ADULT |CHILD |CHILD, PRESCHOOL |GENES, ENV |

GENETICS |HIV ENVELOPE PROTEIN GP41 |GENETICS |HIV
INFECTIONS |EPIDEMIOLOGY |HIV-1 | GENETICS |HUMANS
|KENYA/EPIDEMIOLOGY |MALE |MIDDLE AGED |MOLECULAR
SEQUENCE DATA |PHYLOGENY |SPECIES SPECIFICITY
The relationship between expressed HIV/AIDS-related stigma and

beliefs and knowledge about care and support of people living with
AIDS in families caring for HIV-infected children in Kenya.
Author: Hamra M, Ross MW, Karuri K, Orrs M, D'Agostino A
Source: Trop Doct. 2005 Jul;35(3):159-60.
Abstract: At the end of 2001, AIDS-related deaths had left an estimated 900,000 living
orphans in Kenya (UNAIDS/WHO Epidemiology fact sheet, Kenya report, 2004).
Many of those orphans are also HIV+. In Eastern Kenya, the Lea Toto Kangemi
Outreach Program provides support to families caring for HIV+ children, many
of whom are orphaned or soon to be orphaned. A major challenge for these
families is the stigma attached to the family. In 2003, the Kangemi Program
conducted a household survey of client families. We examined markers of
expressed stigma and the association between expressed stigma and other
demographic and belief/knowledge domains. The focus of the present study was
the specific belief/knowledge domain surrounding care/support of HIV+
persons. Our goal was to explore this domain in the Kangemi families and to
examine its relationship to expressed stigma. We created an AIDS-related stigma
scale from selected items in the household survey and cross-tabulated stigma
scores with care/support knowledge items. We found significant associations
between less expressed stigma and greater care/support knowledge. Our results
have implications for interventions that reduce expressed stigma and/or
improve quality of care.
Language: English
Keywords: |ADOLESCENT |ADULT |CAREGIVERS/*PSYCHOLOGY |CHILD

|CHILD, PRESCHOOL|FAMILY |FEMALE |HIV INFECTIONS |
PSYCHOLOGY|HEALTH KNOWLEDGE, ATTITUDES, PRACTICE
|HUMANS|INFANT |KENYA |MALE |MIDDLE AGED|PREJUDICE
|STEREOTYPING |ABORTION, INDUCED/*LEGISLATION &
JURISPRUDENCE/STATISTICS & NUMERICAL DATA
|ADOLESCENT |ADULT |FEMALE |HUMANS |KENYA/EPIDEMIOLOGY
|MATERNAL MORTALITY|POSTOPERATIVE COMPLICATIONS
|PREGNANCY
117
Audio computer-assisted self-interviewing (ACASI) may avert socially

desirable responses about infant feeding in the context of HIV.
Author: Waruru AK, Nduati R, Tylleskar T
Source: BMC Med Inform Decis Mak. 2005 Aug 2;5:24.
Understanding infant feeding practices in the context of HIV and factors that put
mothers at risk of HIV infection is an important step towards prevention of
mother to child transmission of HIV (PMTCT). Face-to-face (FTF) interviewing
may not be a suitable way of ascertaining this information because respondents
may report what is socially desirable. Audio computer-assisted self-interviewing
(ACASI) is thought to increase privacy, reporting of sensitive issues and to
eliminate socially desirable responses. We compared ACASI with FTF
interviewing and explored its feasibility, usability, and acceptability in a
PMTCT program in Kenya.
Methods:
A graphic user interface (GUI) was developed using Macromedia Authorware
and questions and instructions recorded in local languages Kikuyu and
Kiswahili. Eighty mothers enrolled in the PMTCT program were interviewed
with each of the interviewing mode (ACASI and FTF) and responses obtained in
FTF interviews and ACASI compared using McNemar's chi2 for paired
proportions. A paired Student's t-test was used to compare means of age,
marital-time and parity when measuring interview mode effect and two-sample
Student's t-test to compare means for samples stratified by education level -
determined during the exit interview. A Chi-Square (chi2test) was used to
compare ability to use ACASI by education level. RESULTS: Mean ages for
intended time for breastfeeding as reported by ACASI were 11 months by ACASI
and 19 months by FTF interviewing (p < 0.001). Introduction of complementary
foods at <or=3 months was reported more frequently by respondents in ACASI
compared to FTF interviews for 7 of 13 complementary food items commonly
utilized in the study area (p < 0.05). More respondents reported use of
unsuitable utensils for infant feeding in ACASI than in FTF interviewing (p =
0.001). In other sensitive questions, 7% more respondents reported unstable
relationships with ACASI than when interviewed FTF (p = 0.039). Regardless of
education level, respondents used ACASI similarly and majority (65%) preferred
it to FTF interviewing mainly due to enhanced usability and privacy. Most
respondents (79%) preferred ACASI to FTF for future interviewing.
Conclusion:
ACASI seems to improve quality of information by increasing response to
sensitive questions, decreasing socially desirable responses, and by preventing
null responses and was suitable for collecting data in a setting where formal
education is low.
Language: English
118
Keywords: |ADOLESCENT |ADULT |COMPUTER SYSTEMS/*UTILIZATION

|CONFIDENTIALITY |DISEASE TRANSMISSION, VERTICAL |
PREVENTION & CONTROL |FEMALE |HIV INFECTIONS |PREVENTION
& CONTROL |TRANSMISSION |HEALTH CARE SURVEYS |METHODS |
HUMANS |INFANT |INFANT FOOD
|INFANT NUTRITION PHYSIOLOGY |INTERVIEWS AS TOPIC |
METHODS |KENYA |MOTHERS/*PSYCHOLOGY/STATISTICS &
NUMERICAL DATA |PREGNANCY |QUESTIONNAIRES |SOCIAL
DESIRABILITY |SOFTWARE|USER-COMPUTER INTERFACE
Communication for HIV/AIDS prevention in Kenya: social-cultural

considerations.
Author: Muturi N
Source: J Health Commun. 2005 Jan-Feb;10(1):77-98.
Abstract: The acquired immune deficiency syndrome (AIDS) epidemic is spreading fast in
Africa in spite of the various efforts and resources put in place to prevent it.
In Kenya, reproductive health programs have used the mass media and other
communication interventions to inform and educate the public about the disease
and to promote behavior change and healthy sexual practices. This effort has led
to a discrepancy between awareness and behavioral change among people of
reproductive age. In this article I examine the discrepancy in Kenya from a
communications perspective addressing social cultural and related factors
contributing to the lack of change in behavior and sexual practices. I draw on
the theoretical framework of Grunig's model of excellence in communication, the
importance of understanding and relationship building between programs and
their stakeholders. Data were gathered qualitatively using focus groups and in-
depth interviews among men and women in rural Kenya. Key findings indicate
that although awareness of sexually transmitted diseases (STDs) including
human immunodeficiency virus (HIV)/AIDS is high in Kenya, a majority of the
population, particularly those in the rural communities, lack understanding of
the communicated messages. They also lack the knowledge of other ways of
transmitting HIV particularly among those not sexually involved. Cultural
beliefs, values, norms, and myths have played a role in the rapidly increasing
epidemic in the rural communities and yet HIV/AIDS communication programs
have not addressed these factors adequately. I conclude that successful behavior
change communication must include strategies that focus on increasing
understanding of the communicated messages and understanding of the
audience through application of appropriate methodologies. Building a
relationship with the audience or stakeholders through dialogues and two-way
symmetrical communication contributes
toward this understanding and the maintenance of the newly adopted behaviors
and practices.
119
Language: English
Keywords: |ADOLESCENT |ADULT|ATTITUDE TO HEALTH| COMMUNICATION

CULTURE |FEMALE |FOCUS GROUPS |HIV INFECTIONS PREVENTION
& CONTROL |PSYCHOLOGY |TRANSMISSION |HEALTH EDUCATION
|METHODS |HUMANS |KENYA |MALE |MASS MEDIA |MIDDLE
AGED |RURAL POPULATION |SEXUAL BEHAVIOR |PSYCHOLOGY
No HIV stage is dominant in driving the HIV epidemic in sub-Saharan

Africa.
Author: Abu-Raddad LJ, Longini IM Jr
Source: AIDS. 2008 May 31;22(9):1055-61.
To estimate the role of each of the HIV progression stages in fueling
HIV transmission in sub-Saharan Africa by using the recent measurements of
HIV transmission probability per coital per HIV stage in the Rakai study.
Methods:
A mathematical model, parameterized by empirical data from the Rakai, Masaka,
and Four-City studies, was used to estimate the proportion of infections due to
each of the HIV stages in two representative epidemics in sub-Saharan Africa.
The first setting represents a hyperendemic HIV epidemic (Kisumu, Kenya)
whereas the second setting represents a generalized but not hyperendemic HIV
epidemic (Yaounde, Cameroon).
Results:
We estimate that 17, 51, and 32% of HIV transmissions in Kisumu were due to
index cases in their acute, latent, and late stages, respectively. In Yaounde, the
fractions were 25, 44, and 31%. We found that the relative contribution of each
stage varied with the epidemic evolution with the acute stage prevailing early on
when the infection is concentrated in the high-risk groups with the late stage
playing a major role as the epidemic matured and stabilized. The latent stage
contribution remained largely stable throughout the epidemic and contributed
about half of all transmissions.
Conclusion:
No HIV stage dominated the epidemical though the latent stage provided the
largest contribution. The role of each stage depends on the phase of the epidemic
and on the prevailing levels of sexual risk behavior in the populations in which
HIV is spreading. These findings may influence the design and implementation
of different HIV interventions.
Language: English
120
Keywords: |CAMEROON/EPIDEMIOLOGY |CIRCUMCISION, MALE/STATISTICS &

NUMERICAL DATA |DISEASE OUTBREAKS/*STATISTICS &
NUMERICAL DATA |DISEASE PROGRESSION |FEMALE |HIV
INFECTIONS/*EPIDEMIOLOGY/TRANSMISSION |HUMANS
|KENYA/EPIDEMIOLOGY |MALE|MODELS, STATISTICAL
| PROSTITUTION/STATISTICS & NUMERICAL DATA| RISK FACTORS
| RISK-TAKING |SEXUAL BEHAVIOR/STATISTICS & NUMERICAL
DATA |SEXUAL PARTNERS
Selection for human immunodeficiency virus type 1 envelope

glycosylation variants with shorter V1-V2 loop sequences occurs during
transmission of certain genetic subtypes and may impact viral RNA
levels.
Author: Chohan B, Lang D, Sagar M, Korber B, Lavreys L, Richardson B, Overbaugh J
Source: J Virol. 2005 May;79(10):6528-31.
Abstract: Designing an effective human immunodeficiency virus type 1 (HIV-1) vaccine

will rely on understanding which variants, from among the myriad of circulating
HIV-1 strains, are most commonly transmitted and determining whether such
variants have an Achilles heel. Here we show that heterosexually acquired
subtype A HIV-1 envelopes have signature sequences that include shorter V1-V2
loop sequences and fewer predicted N-linked glycosylation sites relative to the
overall population of circulating variants. In contrast, recently transmitted
subtype B variants did not, and this was true for cases where the major risk
factor was homosexual contact, as well as for cases where it was heterosexual
contact. This suggests that selection during HIV-1 transmission may vary
depending on the infecting subtype. There was evidence from 23 subtype A-
infected women for whom there was longitudinal data that those who were
infected with viruses with fewer potential N-linked glycosylation sites in V1-V2
had lower viral set point levels. Thus, our study also suggests that the extent of
glycosylation in the infecting virus could impact disease progression.
Language: English.
Keywords: | DISEASE PROGRESSION| DISEASE TRANSMISSION, HORIZONTAL

|FEMALE |GLYCOSYLATION |HIV ENVELOPE PROTEIN GP120 |
GENETICS |HIV NFECTIONS |DIAGNOSIS |TRANSMISSION |
VIROLOGY |HIV-1 |GENETICS |HETEROSEXUALITY |HUMANS |
KENYA |MALE |MOLECULAR SEQUENCE DATA |PEPTIDE
FRAGMENTS |GENETICS |VARIATION (GENETICS) |VIRAL ENVELOPE
PROTEINS/*GENETICS |VIRAL LOAD
121

Author: Shacham E, Reece M, Ong'or WO, Omollo O, Monahan PO, Ojwang C
Source: AIDS Patient Care STDS. 2008 Jul;22(7):595-601.
in November 2005.
Demographic and HIV-related characteristics, as well as assessments of
psychological distress, were collected from each participant and analyzed by
gender in order to document the characteristics of those seeking psychosocial
care in conjunction with their participation in an HIV-related treatment and
prevention program. Those seeking psychosocial support were primarily female
(72%), living with HIV for an average of 2.5 years, and unemployed (70%).
Women were younger and more likely to be either widowed or never married;
while men were more likely to have advanced HIV disease, including lower CD4
counts and an AIDS diagnosis. Across all participants, HIV serostatus disclosure
was rarely reported to sex partners, family members, and friends. Symptoms of
psychological distress were more prevalent among women on multiple
measures, including depression, anxiety, paranoid ideation, interpersonal
sensitivity, and somatization. An increased understanding of the characteristics
of those likely to seek psychosocial support groups will help HIV program
managers to develop protocols necessary for facilitating linkages to psychosocial
support for those enrolled in HIV-related treatment programs. Patient
engagement in psychosocial support may facilitate improvements in
treatment and prevention behaviors.
Language: English
Keywords: |ADOLESCENT| ADULT |ANTI-HIV AGENTS/THERAPEUTIC USE

|COMMUNITY MENTAL HEALTH SERVICES/UTILIZATION
|CROSS-SECTIONAL STUDIES |FEMALE |HIV INFECTIONS/*DRUG
THERAPY/EPIDEMIOLOGY/*PSYCHOLOGY/VIROLOGY |HUMANS
|KENYA|MALE|MIDDLE AGED|PREVALENCE| QUESTIONNAIRES|
SOCIAL SUPPORT |STRESS,
PSYCHOLOGICAL/EPIDEMIOLOGY/PHYSIOPATHOLOGY
122
No HIV stage is dominant in driving the HIV epidemic in sub-Saharan

Africa.
Author: Abu-Raddad, L. J. and Longini, I. M.
Source: Jr. AIDS. 2008 May 31; 22(9):1055-61.
To estimate the role of each of the HIV progression stages in fueling HIV
transmission in sub-Saharan Africa by using the recent measurements of HIV
transmission probability per coital per HIV stage in the Rakai study.
Methods:
A mathematical model, parameterized by empirical data from the Rakai,
Masaka, and Four-City studies, was used to estimate the proportion of infections
due to each of the HIV stages in two representative epidemics in sub-Saharan
Africa. The first setting represents a hyperendemic HIV epidemic (Kisumu,
Kenya) whereas the second setting represents a generalized but not
hyperendemic HIV epidemic (Yaounde, Cameroon).
Results:
We estimate that 17, 51, and 32% of HIV transmissions in Kisumu were due to
index cases in their acute, latent, and late stages, respectively. In Yaounde, the
fractions were 25, 44, and 31%. We found that the relative contribution of each
stage varied with the epidemic evolution with the acute stage prevailing early on
when the infection is concentrated in the high-risk groups with the late stage
playing a major role as the epidemic matured and stabilized. The latent stage
contribution remained largely stable throughout the epidemic and contributed
about half of all transmissions.
Conclusion:
No HIV stage dominated the epidemical though the latent stage provided the
largest contribution. The role of each stage depends on the phase of the epidemic
and on the prevailing levels of sexual risk behavior in the populations in which
HIV is spreading. These findings may influence the design and implementation
of different HIV interventions
123
Genital herpes has played a more important role than any other sexually
transmitted infection in driving HIV prevalence in Africa.
Author: Abu-Raddad, L. J.; Magaret, A. S.; Celum, C.; Wald, A.; Longini, I. M. Jr; Self, S.
G., and Corey, L
Source: PLoS ONE. 2008; 3(5):e2230.
Extensive evidence from observational studies suggests a role for genital herpes
in the HIV epidemic. A number of herpes vaccines are under development and
several trials of the efficacy of HSV-2 treatment with acyclovir in reducing HIV
acquisition, transmission, and disease progression have just reported their results
or will report their results in the next year. The potential impact of these
interventions requires a quantitative assessment of the magnitude of the synergy
between HIV and HSV-2 at the population level.
Methods and findings:

A deterministic compartmental model of HIV and HSV-2 dynamics and
interactions was constructed. The nature of the epidemiologic synergy was
explored qualitatively and quantitatively and compared to other sexually
transmitted infections (STIs). The results suggest a more substantial role for
HSV-2 in fueling HIV spread in sub-Saharan Africa than other STIs. We estimate
that in settings of high HSV-2 prevalence, such as Kisumu, Kenya, more than a
quarter of incident HIV infections may have been attributed directly to HSV-2.
HSV-2 has also contributed considerably to the onward transmission of HIV by
increasing the pool of HIV positive persons in the population and may explain
one-third of the differential HIV prevalence among the cities of the Four City
study. Conversely, we estimate that HIV had only a small net impact on HSV-2
prevalence.
Conclusions:
HSV-2 role as a biological cofactor in HIV acquisition and transmission may have
contributed substantially to HIV particularly by facilitating HIV spread among
the low-risk population with stable long-term sexual partnerships. This finding
suggests that prevention of HSV-2 infection through a prophylactic vaccine may
be an effective intervention both in nascent epidemics with high HIV incidence
in the high risk groups, and in established epidemics where a large portion of
HIV transmission occurs in stable partnerships.
124
Paediatric HIV and neurodevelopment Saharan Africa: a systematic

review. in sub-Saharan Africa: a systematic review.
Author: Abubakar, A.; Van Baar, A.; Van de Vijver, F. J.; Holding, P., and Newton, C. R.
Source: Trop Med Int Health. 2008 Jul; 13(7):880-7.
To determine the degree of motor, cognitive, language and social-emotional
impairment related to HIV infection in children living in sub-Saharan Africa
(SSA).
Methods:
Literature searches using MEDLINE and PsycINFO. Additionally, the reference
lists of previous reviews were checked to ensure that all eligible studies were
identified. Cohen's d, a measure of effect size, was computed to estimate the
level of impairment.
Results:
Six reports met the inclusion criteria. In infancy a consistent delay in motor
development was observed with a median value of Cohen's d = 0.97 at 18
months, indicating a severe degree of impairment. Mental development showed
a moderate delay at 18 months, with a median value d = 0.67. Language delay
did not appear until 24 months of age, d = 0.91. Less clear findings occurred in
older subjects.
Conclusion:
Although HIV has been shown to affect all domains of child functioning, motor
development is the most apparent in terms of severity, early onset, and
persistence across age groups. However, motor development has been the most
widely assessed domain while language development has been less vigorously
evaluated in SSA, hence an accurate quantitative estimate of the effect cannot yet
be made.
Dual infection with HIV and malaria fuels the spread of both diseases in
sub-Saharan Africa.
Author: Abu-Raddad, L. J.; Patnaik, P., and Kublin, J. G.
Source: Science. 2006 Dec 8; 314(5805):1603-6.
Abstract: Mounting evidence has revealed pathological interactions between HIV and
malaria in dually infected patients, but the public health implications of the
interplay have remained unclear. A transient almost one-log elevation in HIV
viral load occurs during febrile malaria episodes; in addition, susceptibility to
malaria is enhanced in HIV-infected patients. A mathematical model applied to a
125
setting in Kenya with an adult population of roughly 200,000 estimated that,

since 1980, the disease interaction may have been responsible for 8,500 excess
HIV infections and 980,000 excess malaria episodes. Co-infection might also have
facilitated the geographic expansion of malaria in areas where HIV prevalence is
high. Hence, transient and repeated increases in HIV viral load resulting from
recurrent co-infection with malaria may be an important factor in promoting the
spread of HIV in sub-Saharan Africa.
Male circumcision in Siaya and Bondo Districts, Kenya: prospective

cohort study to assess behavioral disinhibition following circumcision.
Author: Agot, K. E.; Kiarie, J. N.; Nguyen, H. Q.; Odhiambo, J. O.; Onyango, T. M., and
Weiss, N. S.
Source: J Acquir Immune Defic Syndr. 2007 Jan 1; 44(1):66-70.
Evidence for efficacy of male circumcision as an HIV prevention measure is
increasing, but there is serious concern that men who are circumcised may
subsequently adopt more risky sexual behaviors.
Methods:
Using a prospective cohort study, we compared sexual behaviors of 324 recently
circumcised and 324 uncircumcised men at 1, 3, 6, 9, and 12 months after
circumcision/study enrollment. The main outcome indicators were incidence of
sexual behaviors known to place men at increased risk of acquiring HIV,
namely, having sex with partners other than their wife/wives for married men
or other than "regular" girlfriends for unmarried men.
Results:
During the first month following circumcision, men were 63% and 61% less
likely to report having 0 to 0.5 and >0.5 risky sex acts/week, respectively, than
men who remained uncircumcised. This difference disappeared during the
remainder of follow-up, with no excess of reported risky sex acts among
circumcised men. Similar results were observed for risky unprotected sex acts,
number of risky sex partners, and condom use.
Discussion:
During the first year post-circumcision, men did not engage in more risky sexual
behaviors than uncircumcised men, suggesting that any protective effect of male
circumcision on HIV acquisition is unlikely to be offset by an adverse behavioral
impact.
126
HLA and T in cross-reactive immune responses to HIV-1 subtype A,

CRF01_AE and CRF02_AG cell elements vaccine sequence in Ivorian
blood donors. Vaccine.
Author: Aidoo, M.; Sawadogo, S.; Bile, E. C.; Yang, C.; Nkengasong, J. N., and McNicholl,
J. M.
Abstract: Comprehensive understanding of the determinants of cross-subtype immune

responses in HIV infection is critical to developing efficacious HIV vaccines
against multiple viral subtypes. Because HIV-1 subtype A or recombinants
comprising subtype A are prevalent in Africa and parts of Asia where HIV is
spreading, we assessed the determinants of cross-subtype immune responses in
HIV-infected blood donors from Cote d'Ivoire to peptides from a candidate
CRF02_AG vaccine sequence, a subtype A sequence from western Kenya and a
CRF01_AE sequence from Thailand. We present evidence that immune
recognition of multiple viral subtypes is maintained by recognition of multiple
epitopes. Our data suggest that complete escape of HIV from immune
recognition is uncommon. Evaluation of these frequently generated cross-
reactive responses should be included in immunogenicity trials of HIV vaccines.
Independent associations of insulin resistance with high whole-body

intermuscular and low leg subcutaneous adipose tissue distribution in
obese HIV- infected women.
Author: J. B.; Kenya, S.; He, Q.; Wainwright, M.; Berk, E. S.; Heshka, S.; Kotler, D. P., and
Engelson, E. S.
Source: Am J Clin Nutr. 2007 Jul; 86(1):100-6.
Obesity and insulin resistance are growing problems in HIV-positive (HIV+)
women receiving highly active antiretroviral therapy (HAART).
Objective:
The objective was to determine the contribution of adipose tissue (AT)
enlargement and distribution to the presence of insulin resistance in obese HIV+
women.
Design:
Whole-body intermuscular AT (IMAT), visceral AT (VAT), subcutaneous AT
(SAT), and SAT distribution (leg versus upper body) were measured by whole-
body magnetic resonance imaging. Insulin sensitivity (S(I)) was measured with
an intravenous glucose tolerance test in obese HIV+ women recruited because of
their desire to lose weight (n=17) and in obese healthy controls (n=32).
Results:
127
The HIV+ women had relatively less whole-body SAT and more VAT and IMAT
than did the controls (P<0.05 for all). A significant interaction by HIV status was
observed for the relation of total SAT with S(I) (P<0.001 for the regression's slope
interactions after adjustment for age, height, and weight). However, relations of
IMAT, VAT, and SAT distribution (leg SAT as a percentage of total SAT; leg SAT
%) with S(I) did not differ significantly between groups. For both groups
combined, the best model predicting a low S(I) included significant contributions
by both high IMAT and low leg SAT%, independent of age, height, and weight,
and no interaction between groups was observed (overall r(2)=0.44, P=0.0003).
Conclusion:
In obese HIV+ women, high whole-body IMAT and low leg SAT% distribution
are independently associated with insulin resistance.
Characterization of CD8 T-cell responses in HIV-1-exposed seronegative

commercial sex workers from Nairobi, Kenya.
Author: Alimonti, J. B.; Kimani, J.; Matu, L.; Wachihi, C.; Kaul, R.; Plummer, F. A., and
Fowke, K. R.
Source: Immunol Cell Biol. 2006 Oct; 84(5):482-5.
Abstract: CD8+ T-lymphocyte responses are crucial to the control of HIV-1; therefore,
studying the CD8+ immune response in a naturally resistant population could
provide valuable insights into an effective anti-HIV response in healthy
uninfected individuals. Approximately 5-10% of the women in the Pumwani
Commercial Sex Worker cohort in Nairobi, Kenya, have been highly exposed to
HIV-1 yet remain HIV-IgG-seronegative and HIV-PCR negative (HIV(ES)). As
IFN-gamma production correlates to cytotoxic function, the CD8+ T-lymphocyte
IFN-gamma response to HIV p24 peptides was compared in HIV(ES) and HIV-
infected (HIV+) individuals. Almost 40% of the HIV(ES) had a CD8+ IFN-
gamma+ response that was five times lower in magnitude than that of the HIV+
group. The breadth of the response in HIV(ES) was very narrow and focused
primarily on one peptide that is similar to the protective KK10 peptide. In the
HIV+ group, low peripheral CD4+ counts negatively influenced the number of
CD8+ cells producing IFN-gamma, which may undermine the ability to control
HIV. Overall, many of the HIV(ES) women possess a HIV-1 p24-specific CD8+
IFN-gamma response, providing evidence to the specificity needed for an
effective HIV vaccine
128
CD4+ T cell responses in HIV-exposed seronegative women are

qualitatively distinct from those in HIV-infected women.
Author: Alimonti, J. B.; Koesters, S. A.; Kimani, J.; Matu, L.; Wachihi, C.; Plummer, F. A.,
and Fowke, K. R.
Source: J Infect Dis. 2005 Jan 1; 191(1):20-4.
Abstract: The immune response of human immunodeficiency virus (HIV)-exposed

seronegative (ESN) women may be qualitatively different from that in those
infected with HIV (HIV(+)). In a cohort of female commercial sex workers in
Nairobi, Kenya, we found significantly lower (P< or =.01) levels of CD4(+)-
specific immune activation and apoptosis in the ESN women compared with
those in the HIV(+) women. Compared with the HIV(+) women, a lower
proportion of the ESN women showed p24 peptide pool responses by the short-
term, CD4(+)-specific, interferon (IFN)- gamma intracellular cytokine staining
assay, whereas the proportion showing responses by the long-term, CD8(+)-
depleted T cell proliferation assay was similar. Interestingly, the ESN responders
had a 4.5-fold stronger proliferation response (P=.002) than the HIV(+) group.
These data suggest that, compared with those in HIV(+) women, CD4(+) T cells
in ESN women have a much greater ability to proliferate in response to p24
peptides.
Widowhood in the era of HIV/AIDS: a case study of Siaya District,

Kenya.
Author: Ambasa-Shisanya, C. R.
Source: SAHARA J. 2007 Aug; 4(2):606-15.
Abstract: Luo women are believed to acquire contagious cultural impurity after the death
of their husbands that is perceived as dangerous to other people. To neutralise
this impure state, a sexual cleansing rite is observed. In the indigenous setting,
the ritual was observed by a brother-in-law or cousin of the deceased husband
through a guardianship institution. However, with the emergence of HIV/AIDS,
many educated brothers-in-law refrain from the practice and instead hire
professional cleansers as substitutes. If the deceased spouses were HIV positive,
the ritual places professional cleansers at risk of infection. Thereafter, they could
act as a bridge for HIV/AIDS transmission to other widows and to the general
population. This paper provides insights into reasons for continuity of
widowhood rites in Siaya District. Twelve focus group discussions and 20 in-
depth interviews were conducted.The cultural violence against Luo widows
could spread HIV/AIDS, but Christianity and condoms act as coping
mechanisms.
129
Evidence for expression of endogenous retroviral sequences on primate

reproductive tissues and detection of cross-reactive ERVS antigens in the
baboon ovary: a review.
Author: Arimi, M. M.; Nyachieo, A.; Langat, D. K.; Abdi, A. M., and Mwenda, J. M..
Source: East Afr Med J. 2006 Feb; 83(2):106-12.
To review recent research findings on the specific expression of endogenous
retroviral sequences (ERVS) in reproductive tissues and their possible
physiological roles. ERVS have been implicated in several biological events such
as induction of resistance to exogenous retrovirus invasion, involvement in
placental trophoblast formation, sperm maturation and differentiation; and
stimulation of local immunosuppression to protect the foetus from
immunological attack.
Data sources:
Critical review of relevant articles and abstracts cited in international and local
journals, literature searches on Medline and Medchem up to 2005.
Data synthesis:
Retroviruses have been implicated in the induction of tumour and
immunological disorders. Over the years, endogenous retroviruses (ERVs) and
retroviral elements have been detected in the genome of many vertebrate species,
including primates. The evidence for the presence of retroviruses in the primate
tissues such as the placenta, ovary, breast, testis and epididymis has been
documented using electron microscopic studies. Retrovirus-like particles were
found budding from the basal membrane of syncytiotrophoblasts, as well as in
tumour cell lines in embryonic carcinoma or teratocarcinomas. Apart from their
pathological effects, recent evidence suggests that these ERVs may play useful
roles in normal physiological events.
Results:
Recent studies indicate the expression of endogenous retroviruses in the testis,
epididymis, placenta and breast. However, limited data exist on the detection of
ERVs in the ovary. Overall, the precise functions for ERVs in these tissues are not
well understood. In the testis and epididymis, speculative functions may include
among others spermatogenesis and/or sperm maturation (differentiation)
whereas in placenta they are possibly associated with trophoblast fusion and
locally induced immunosuppression to protect the foetus from immunological
attack. Experiments in our laboratory have indicated restricted expression of
retroviral antigens including baboon endogenous retroviral proteins (BERV),
ERV-3, HIV-1 gp41 and HERV-K env in the baboon ovary.
130
Conclusion:
ERVs are specifically expressed in different mammalian reproductive tissues and
may have unique physiological roles.
Behaviour change in clients of health centre-based voluntary HIV

counselling and testing services in Kenya.
Author: Arthur, G.; Nduba, V.; Forsythe, S.; Mutemi, R.; Odhiambo, J., and Gilks, C..
Source: Sex Transm Infect. 2007 Dec; 83(7):541-6.
To explore behaviour change, baseline risk behaviour, perception of risk, HIV
disclosure and life events in health centre-based voluntary counselling and
testing (VCT) clients.
Design and setting:

Single-arm prospective cohort with before-after design at three (one urban and
two rural) government health centres in Kenya; study duration 2 years, 1999-
2001.
Subjects: Consecutive eligible adult clients.

Numbers of sexual partners, partner type, condom use, reported symptoms of
sexually transmitted infection, HIV disclosure and life events.
Results:
High rates of enrollment and follow-up provided a demographically
representative sample of 401 clients with mean time to follow-up of 7.5 months.
Baseline indicators showed that clients were at higher risk than the general
population, but reported a poor perception of risk. Clients with multiple partners
showed a significant reduction of sexual partners at follow-up (16% to 6%;
p<0.001), and numbers reporting symptoms of sexually transmitted infection
decreased significantly also (from 40% to 15%; p<0.001). Condom use improved
from a low baseline. Low rates of disclosure (55%) were reported by HIV-
positive clients. Overall, no changes in rates of life events were seen.
Conclusion:
This study suggests that significant prevention gains can be recorded in clients
receiving health centre-based VCT services in Africa. Prevention issues should be
considered when refining counselling and testing policies for expanding
treatment programmes.
131
Potential impact of infant feeding recommendations on mortality and

HIV-infection in children born to HIV-infected mothers in Africa: a
simulation.
Author: Atashili, J.; Kalilani, L.; Seksaria, V., and Sickbert-Bennett, E. E.
Source: BMC Infect Dis. 2008; 8:66.
Although breast-feeding accounts for 15-20% of mother-to-child transmission
(MTCT) of HIV, it is not prohibited in some developing countries because of the
higher mortality associated with not breast-feeding. We assessed the potential
impact, on HIV infection and infant mortality, of a recommendation for shorter
durations of exclusive breast-feeding (EBF) and poor compliance to these
recommendations.
Methods:
We developed a deterministic mathematical model using primarily parameters
from published studies conducted in Uganda or Kenya and took into account
non-compliance resulting in mixed-feeding practices. Outcomes included the
number of children HIV-infected and/or dead (cumulative mortality) at 2 years
following each of 6 scenarios of infant-feeding recommendations in children born
to HIV-infected women: Exclusive replacement-feeding (ERF) with 100%
compliance, EBF for 6 months with 100% compliance, EBF for 4 months with
100% compliance, ERF with 70% compliance, EBF for 6 months with 85%
compliance, EBF for 4 months with 85% compliance.
Results:
In the base model, reducing the duration of EBF from 6 to 4 months reduced HIV
infection by 11.8% while increasing mortality by 0.4%. Mixed-feeding in 15% of
the infants increased HIV infection and mortality respectively by 2.1% and 0.5%
when EBF for 6 months was recommended; and by 1.7% and 0.3% when EBF for
4 months was recommended. In sensitivity analysis, recommending EBF resulted
in the least cumulative mortality when the a) mortality in replacement-fed
infants was greater than 50 per 1000 person-years, b) rate of infection in
exclusively breast-fed infants was less than 2 per 1000 breast-fed infants per
week, c) rate of progression from HIV to AIDS was less than 15 per 1000 infected
infants per week, or d) mortality due to HIV/AIDS was less than 200 per 1000
infants with HIV/AIDS per year.
Conclusion:
Recommending shorter durations of breast-feeding in infants born to HIV-
infected women in these settings may substantially reduce infant HIV infection
but not mortality. When EBF for shorter durations is recommended, lower
mortality could be achieved by a simultaneous reduction in the rate of
progression from HIV to AIDS and or HIV/AIDS mortality, achievable by the
use of HAART in infants.
132
Hormonal contraceptive use, herpes simplex virus infection, and risk of

HIV-1 acquisition among Kenyan women.
Author: Baeten, J. M.; Benki, S.; Chohan, V.; Lavreys, L.; McClelland, R. S.; Mandaliya, K.;
Ndinya-Achola, J. O.; Jaoko, W., and Overbaugh, J. Kenyan women.
Source : AIDS. 2007 Aug 20; 21(13):1771-7.
Studies of the effect of hormonal contraceptive use on the risk of HIV-1
acquisition have generated conflicting results. A recent study from Uganda and
Zimbabwe found that women using hormonal contraception were at increased
risk for HIV-1 if they were seronegative for herpes simplex virus type 2 (HSV-2),
but not if they were HSV-2 seropositive.
Objective:
To explore the effect of HSV-2 infection on the relationship between hormonal
contraception and HIV-1 in a high-risk population. Hormonal contraception has
previously been associated with increased HIV-1 risk in this population.
Methods:
Data were from a prospective cohort study of 1206 HIV-1 seronegative sex
workers from Mombasa, Kenya who were followed monthly. Multivariate Cox
proportional hazards analyses were used to adjust for demographic and
behavioral measures and incident sexually transmitted diseases.
Results:
Two hundred and thirty-three women acquired HIV-1 (8.7/100 person-years).
HSV-2 prevalence (81%) and incidence (25.4/100 person-years) were high. In
multivariate analysis, including adjustment for HSV-2, HIV-1 acquisition was
associated with use of oral contraceptive pills [adjusted hazard ratio (HR), 1.46;
95% confidence interval (CI), 1.00-2.13] and depot medroxyprogesterone acetate
(adjusted HR, 1.73; 95% CI, 1.28-2.34). The effect of contraception on HIV-1
susceptibility did not differ significantly between HSV-2 seronegative versus
seropositive women. HSV-2 infection was associated with elevated HIV-1 risk
(adjusted HR, 3.58; 95% CI, 1.64-7.82).
Conclusions:
In this group of high-risk African women, hormonal contraception and HSV-2
infection were both associated with increased risk for HIV-1 acquisition. HIV-1
risk associated with hormonal contraceptive use was not related to HSV-2
serostatus
133
HIV-1 subtype D infection is associated with faster disease progression

than subtype A in spite of similar plasma HIV-1 loads.
Author: Baeten, J. M.; Chohan, B.; Lavreys, L.; Chohan, V.; McClelland, R. S.; Certain, L.;
Mandaliya, K.; Jaoko, W., and Overbaugh, J.
Source : J Infect Dis. 2007 Apr 15; 195(8):1177-80.
Abstract: We investigated the effect of human immunodeficiency virus type 1 (HIV-1)

subtype on disease progression among 145 Kenyan women followed from the
time of HIV-1 acquisition. Compared with those infected with subtype A,
women infected with subtype D had higher mortality (hazard ratio, 2.3 [95%
confidence interval, 1.0-5.6]) and a faster rate of CD4 cell count decline (P=.003).
The mortality risk persisted after adjustment for plasma HIV-1 load. There were
no differences in plasma viral load by HIV-1 subtype during follow-up. HIV-1
subtype D infection is associated with a >2-fold higher risk of death than subtype
A infection, in spite of similar plasma HIV-1 loads.
Female-to-male infectivity of HIV-1 among circumcised and

uncircumcised Kenyan men.
Author: Baeten, J. M.; Richardson, B. A.; Lavreys, L.; Rakwar, J. P.; Mandaliya, K.; Bwayo,
J. J., and Kreiss, J. K.
Source : J Infect Dis. 2005 Feb 15; 191(4):546-53.
A lack of male circumcision has been associated with increased risk of human
immunodeficiency virus type 1 (HIV-1) acquisition in a number of studies, but
questions remain as to whether confounding by behavioral practices explains
these results. The objective of the present study was to model per-sex act
probabilities of female-to-male HIV-1 transmission (i.e., infectivity) for
circumcised and uncircumcised men, by use of detailed accounts of sexual
behavior in a population with multiple partnerships.
Methods:
Data were collected as part of a prospective cohort study of HIV-1 acquisition
among 745 Kenyan truck drivers. Sexual behavior with wives, casual partners,
and prostitutes was recorded at quarterly follow-up visits. Published HIV-1
seroprevalence estimates among Kenyan women were used to model HIV-1 per-
sex act transmission probabilities.
Results:
The overall probability of HIV-1 acquisition per sex act was 0.0063 (95%
confidence interval, 0.0035-0.0091). Female-to-male infectivity was significantly
higher for uncircumcised men than for circumcised men (0.0128 vs. 0.0051;
134
P=.04). The effect of circumcision was robust in subgroup analyses and across a
wide range of HIV-1 prevalence estimates for sex partners.
Conclusions:
After accounting for sexual behavior, we found that uncircumcised men were at
a >2-fold increased risk of acquiring HIV-1 per sex act, compared with
circumcised men. Moreover, female-to-male infectivity of HIV-1 in the context of
multiple partnerships may be considerably higher than that estimated from
studies of HIV-1-serodiscordant couples. These results may explain the rapid
spread of the HIV-1 epidemic in settings, found throughout much of Africa, in
which multiple partnerships and a lack of male circumcision are common.
Polymorphisms in IRF-1 associated with resistance to HIV-1 infection in

highly exposed uninfected Kenyan sex workers.
Author: Ball, T. B.; Ji, H.; Kimani, J.; McLaren, P.; Marlin, C.; Hill, A. V., and Plummer, F.
A.
Source : AIDS. 2007 May 31; 21(9):1091-101.
To determine the correlation between polymorphisms in the IL-4 gene cluster
and resistance to HIV-1 infection.
Design:
A cross-sectional genetic analysis of polymorphisms within the IL-4 gene cluster
was conducted in a well-described female sex worker cohort from Nairobi,
Kenya, known to exhibit differential susceptibility to HIV-1 infection.
Methods:
Microsatellite genotyping was used to screen six microsatellite markers in the IL-
4 gene cluster for associations with HIV-1 resistance. Further analysis of the
interferon regulatory factor 1 (IRF-1) gene was conducted by genomic
sequencing. Associations between IRF-1 gene polymorphisms and the HIV-1
resistance phenotype were determined using the chi-square test and Kaplan-
Meier survival analysis. The functional consequence of IRF-1 polymorphism was
conducted by quantitative Western blot.
Results:
Three polymorphisms in IRF-1, located at 619, the microsatellite region and 6516
of the gene, showed associations with resistance to HIV-1 infection. The 619A,
179 at IRF-1 microsatellite and 6516G alleles were associated with the HIV-1-
resistant phenotype and a reduced likelihood of seroconversion. Peripheral
blood mononuclear cells from patients with protective IRF-1 genotypes
exhibited significantly lower basal IRF-1 expression and reduced responsiveness
to exogenous IFN-gamma stimulation.
135
Conclusion:
Polymorphisms in the IRF-1 gene are associated with resistance to infection by
HIV-1 and a lowered level of IRF-1 protein expression. This study adds IRF-1, a
transcriptional immunoregulatory gene, to the list of genetic correlates of altered
susceptibility to HIV-1. This is the first report suggesting that a viral
transcriptional regulator might contribute to resistance to HIV-1. Further
functional analysis on the role of IRF-1 polymorphisms and HIV-1 resistance is
underway.
Cost effectiveness and delivery study for future HIV vaccines.

Author: Barth-Jones, D. C.; Cheng, H.; Kang, L. Y.; Kenya, P. R.; Odera, D.; Mosqueira, N.
R.; Mendoza, W.; Portela, M. C.; Brito, C.; Tangcharoensathien, V.; Akaleephan,
C.; Supantamart, S.; Patcharanarumol, W.; de Macedo Brigido, L. F.; Fonseca, M.
G.; Sanchez, M.
Source : AIDS. 2005 Sep 2; 19(13):w1-6. .; Chang, M. L.; Osmanov, S.; Avrett, S.; Esparza,
J., and Griffiths, U.
Abstract: Research teams from five countries, Brazil, China, Kenya, Peru and Thailand,
have initiated a policy-maker survey on vaccine delivery, cost studies for future
HIV vaccination programmes, and associated simulation modeling exercises
analysing the relative cost-effectiveness of potential HIV vaccination strategies.
The survey assesses challenges and opportunities for future country-level HIV
vaccination strategies, providing data on the vaccine characteristics (e.g. vaccine
efficacies for susceptibility, infectiousness and disease progression) and
vaccination programme strategies to be considered in the cost-effectiveness
modeling analyses. The study will provide decision-makers with modeling data
on vaccination policy considerations that will assist in developing country-level
capacities for future HIV vaccine policy adoption and effective delivery systems,
and will help delineate the long-term financial requirements for sustainable HIV
vaccination programmes. The WHO-UNAIDS HIV Vaccine Initiative and the
collaborating researchers welcome comments or questions from policy makers,
health professionals and other stakeholders in the public and private sectors
about this effort to help advance policy and capacity related to future potential
HIV vaccines.
136
HIV/AIDS and cultural practices in western Kenya: the impact of sexual

cleansing rituals on sexual behaviours.
Author: R.; Ngare, D.; Sidle, J.; Ayuku, D.; Baliddawa, J., and Greene, J.
Source : Cult Health Sex. 2008 Aug; 10(6):587-99.
Abstract: This paper reports on an exploratory study examining the role of sexual
cleansing rituals in the transmission of HIV among the Luo community in
western Kenya. Data were collected using both in-depth interviews and focus
group discussions. The study population consisted of 38 widows, 12 community
elders and 44 cleansers. Data were collected on non-behavioural causes,
behavioural causes and behavioural indicators associated with sexual rituals.
Content analysis revealed five central themes: the effect of the ritual on sexual
behaviours; factors contributing to the continued practice of the ritual, including
a sub-theme on the commercialization of the ritual; the inseparable relationship
between the sanctity of sex, prosperity and fertility of the land; and the effects of
modernization on the ritual, including a sub-theme on the effects of mass media
on HIV-prevention awareness campaigns. Causal factors of unchanging sexual
behaviours are deeply rooted in traditional beliefs, which the community uphold
strongly. These beliefs encourage men and women to have multiple sexual
partners in a context where the use of condoms is rejected and little HIV testing
is carried out.
Quantification of genital human immunodeficiency virus type 1 (HIV-1)

DNA in specimens from women with low plasma HIV-1 RNA levels
typical of HIV-1 nontransmitters.
Author: Benki, S.; McClelland, R. S.; Emery, S.; Baeten, J. M.; Richardson, B. A.; Lavreys,
L.; Mandaliya, K., and Overbaugh, J.
Source : J Clin Microbiol. 2006 Dec; 44(12):4357-62.
Abstract: Studies of human immunodeficiency virus type 1 (HIV-1) transmission suggest

that genital HIV-1 RNA and DNA may both be determinants of HIV-1
infectivity. Despite its potential role in HIV-1 transmission, there are limited
quantitative data on genital HIV-1 DNA. Here we validated an in-house real-
time PCR method for quantification of HIV-1 DNA in genital specimens. In
reactions with 100 genomes to 1 genome isolated from a cell line containing one
HIV-1 provirus/cell, this real-time PCR assay is linear and agrees closely with a
commercially available real-time PCR assay specific for a cellular housekeeping
gene. In mock genital samples spiked with low numbers of HIV-1-infected cells
such that the expected HIV-1 DNA copy number/reaction was 100, 10, or 5, the
average copy number/reaction was 80.2 (standard deviation [SD], 28.3), 9.1 (SD,
5.4), or 3.1 (SD, 2.1), respectively. We used this method to examine genital HIV-1
DNA levels in specimens from women whose low plasma HIV-1 RNA levels are
137
typical of HIV-1 nontransmitters. The median HIV-1 DNA copy number in

endocervical secretions from these women (1.8 HIV-1 DNA copies/10,000 cells)
was lower than that for women with higher plasma HIV-1 RNA levels (16.6 HIV-
1 DNA copies/10,000 cells) (P=0.04), as was the median HIV-1 DNA copy
number in vaginal secretions (undetectable versus 1.0 HIV-1 DNA copies/10,000
cells). These data suggest that women with low plasma HIV-1 RNA and thus a
predicted low risk of HIV-1 transmission have low levels of genital HIV-1 cell-
associated virus. The assay described here can be utilized in future efforts to
examine the role of cell-associated HIV-1 in transmission.
Infant feeding practices among HIV infected women receiving

prevention of mother-to-child transmission services at Kitale District
Hospital, Kenya.
Source : East Afr Med J. 2008 Apr; 85(4):156-61.
To determine the types and modes of infant feeding practices among the HIV
infected mothers on prevention of mother-to-child transmission (PMTCT) and
attending MCH-FP clinic at Kitale District Hospital, Kenya.
Design: Descriptive cross-sectional study.
Setting:
Kitale District Hospital in Western Kenya within the maternal and child health
and family planning (MCH-FP) and comprehensive care clinics.
Subjects:
A total of 146 respondents who had delivered 150 babies were recruited for this
study.
Results:
Thirty five percent (52/150) of the babies were exclusively breastfed while 50%
(75/150) were not breastfed at all and 14% (21/150) of the babies received mixed
feeding. The length of exclusive breastfeeding ranged from 1-6 months with most
(53%) women exclusively breastfeeding for two to three months. Only 13% of the
women exclusively breastfed for five to six months. There was a strong
relationship between mode of infant feeding and spouse's awareness of HIV
status. Mothers who had disclosed their HIV status to their spouses were more
likely not to breastfeed than mothers who had not disclosed their status (p <
0.05%). The choice of infant feeding method was also influenced by the socio-
economic status of the mothers and nevirapine uptake. The level of education
did not influence the mode of infant feeding.
Conclusion:
Infant feeding decisions were mainly influenced by the male partner's
involvement and the socio economic status of the mother. Half of the
138
respondents did not breastfeed at all. The duration of exclusive breastfeeding

rarely reached six months. To encourage women to adhere to good infant feeding
practices, involvement of their partners, family members as well as the
community for support should be encouraged.
HIV-1 subtype A envelope variants from early in infection have variable

sensitivity to neutralization and to inhibitors of viral entry.
Author: Blish, C. A.; Nedellec, R.; Mandaliya, K.; Mosier, D. E., and Overbaugh, J.
Source : AIDS. 2007 Mar 30; 21(6):693-702.
An effective HIV-1 vaccine or microbicide must block the transmitted virus
variants that initially establish a new infection; consequently, it is critical that
such viruses be isolated and characterized.
Objective:
To evaluate HIV-1 envelope variants from early in infection from individuals
infected heterosexually with subtype A HIV-1 for their sensitivity to antibody-
mediated neutralization and to inhibitors of viral entry.
Methods:
Full-length subtype A HIV-1 envelope clones from 28-75 days postinfection were
used to generate pseudoviruses for infection studies. The susceptibility of these
pseudoviruses to neutralization by autologous and heterologous plasma and by
monoclonal antibodies was examined. The sensitivity of these pseudoviruses to
PSC-RANTES and TAK-779, inhibitors of CCR5, and to soluble CD4 (sCD4) was
also evaluated. RESULTS: Pseudoviruses with subtype A HIV-1 envelopes from
early in infection demonstrated a broad range of neutralization sensitivities to
both autologous and heterologous plasma. However, neutralization by the
monoclonal antibodies b12, 2G12, 4E10 and 2F5 was generally poor; notably,
none of the 14 early virus variants were neutralized by 2G12 and only one was
neutralized by b12. Viruses bearing these early CCR5-using envelopes were
generally sensitive to the CCR5 inhibitors PSC-RANTES and TAK-779, but they
demonstrated more variable sensitivity to sCD4.
Conclusions:
These subtype A HIV-1 variants, representing the viruses that must be blocked
by antibody-based prevention strategies, vary in their susceptibility to
neutralization. A subset of these HIV-1 variants from early in infection will be
useful for screening candidate vaccines and microbicides.
Enhancing exposure of HIV-1 neutralization epitopes through mutations

in gp41.
139
Author: Blish, C. A.; Nguyen, M. A., and Overbaugh, J. Enhancing exposure of HIV-1
neutralization epitopes through mutations in gp41
Source : PLoS Med. 2008 Jan 3; 5(1):e9.
The generation of broadly neutralizing antibodies is a priority in the design of
vaccines against HIV-1. Unfortunately, most antibodies to HIV-1 are narrow in
their specificity, and a basic understanding of how to develop antibodies with
broad neutralizing activity is needed. Designing methods to target antibodies to
conserved HIV-1 epitopes may allow for the generation of broadly neutralizing
antibodies and aid the global fight against AIDS by providing new approaches to
block HIV-1 infection. Using a naturally occurring HIV-1 Envelope (Env) variant
as a template, we sought to identify features of Env that would enhance exposure
of conserved HIV-1 epitopes.

Within a cohort study of high-risk women in Mombasa, Kenya, we previously
identified a subtype A HIV-1 Env variant in one participant that was unusually
sensitive to neutralization. Using site-directed mutagenesis, the unusual
neutralization sensitivity of this variant was mapped to two amino acid
mutations within conserved sites in the transmembrane subunit (gp41) of the
HIV-1 Env protein. These two mutations, when introduced into a neutralization-
resistant variant from the same participant, resulted in 3- to >360-fold enhanced
neutralization by monoclonal antibodies specific for conserved regions of both
gp41 and the Env surface subunit, gp120, >780-fold enhanced neutralization by
soluble CD4, and >35-fold enhanced neutralization by the antibodies found
within a pool of plasmas from unrelated individuals. Enhanced neutralization
sensitivity was not explained by differences in Env infectivity, Env concentration,
Env shedding, or apparent differences in fusion kinetics. Furthermore,
introduction of these mutations into unrelated viral Env sequences, including
those from both another subtype A variant and a subtype B variant, resulted in
enhanced neutralization susceptibility to gp41- and gp120-specific antibodies,
and to plasma antibodies. This enhanced neutralization sensitivity exceeded
1,000-fold in several cases.
Conclusions:
Two amino acid mutations within gp41 were identified that expose multiple
discontinuous neutralization epitopes on diverse HIV-1 Env proteins. These
exposed epitopes were shielded on the unmodified viral Env proteins, and
several of the exposed epitopes encompass desired target regions for protective
antibodies. Env proteins containing these modifications could act as a scaffold
for presentation of such conserved domains, and may aid in developing methods
to target
Late marriage and the HIV epidemic in sub-Saharan Africa.
140
Source : Popul Stud (Camb). 2007 Mar; 61(1):73-83.
Abstract: The causes of large variation in the sizes of HIV epidemics among countries in
sub-Saharan Africa are not well understood. Here we assess the potential roles of
late age at marriage and a long period of premarital sexual activity as population
risk factors, using ecological data from 33 sub-Saharan African countries and
with individual-level data from Demographic and Health Surveys (DHS) in
Kenya and Ghana in 2003. The ecological analysis finds a significant positive
correlation between HIV prevalence and median age at first marriage, and
between HIV prevalence and interval between first sexual intercourse and first
marriage. The individual-level analysis shows that HIV infection per year of
exposure is higher before than after first marriage. These findings support the
hypothesis of a link between a high average age at marriage and a long period of
premarital intercourse during which partner changes are relatively common and
facilitate the spread of HIV.
Tuberculosis after HAART initiation in HIV-positive patients from five

countries with a high tuberculosis burden. Tuberculosis after HAART
initiation in HIV-positive patients from five countries with a high
tuberculosis burden.
Author: Bonnet, M. M.; Pinoges, L. L.; Varaine, F. F.; Oberhauser, B. B.; O'Brien, D. D.;
Kebede, Y. Y.; Hewison, C. C.; Zachariah, R. R., and Ferradini, L. L.
Source : AIDS. 2006 Jun 12; 20(9):1275-9.
HAART reduces tuberculosis (TB) incidence in people living with HIV/AIDS but
those starting HAART may develop active TB or subclinical TB may become
apparent in the immune reconstitution inflammatory syndrome.
Objective:
To measure the incidence rate of notified TB in people receiving HAART in five
HIV programmes occurring in low-resource countries with a high TB/HIV
burden.
141
Methods:
A retrospective review in five Medecins Sans Frontieres programmes (Cambodia,
Thailand, Kenya, Malawi and Cameroon) allowed incidence rates of notified TB
to be calculated based on follow-up time after HAART initiation.
Result:
Among 3151 patients analysed, 90% had a CD4 cell count of < 200 cells/mul.
Median follow-up time ranged from 3.7 months in Thailand or Kenya to 11.1
months in Cambodia. Incidence rates were 7.6, 10.4, 17.6, 14.3 and 4.8/100
person-years for pulmonary TB and 12.7, 4.3, 6.9, 2.1 and 0/100 person-years for
extra-pulmonary TB in the programmes in Cambodia, Thailand, Kenya, Malawi
and Cameroon, respectively. Overall, 62.3% of pulmonary TB and 54.9% of extra-
pulmonary TB were diagnosed within 3 months after HAART initiation.
Conclusion:
High incidence rates of notified TB under HAART in programmes held in poor-
resource countries were observed; these were likely to include both undiagnosed
prevalent TB at HAART initiation and subclinical TB developing during the
immune reconstitution inflammatory syndrome. This raises operational issues
concerning TB diagnosis and treatment of TB/HIV-coinfected patients and
prompts for urgent TB and HIV care integration.
Longitudinal comparison of chemokines in breastmilk early postpartum

among HIV-1-infected and uninfected Kenyan women.
Author: Bosire, R.; Guthrie, B. L.; Lohman-Payne, B.; Mabuka, J.; Majiwa, M.; Wariua, G.;
Mbori-Ngacha, D.; Richardson, B.; John-Stewart, G., and Farquhar, C
Source : Breastfeed Med. 2007 Sep; 2(3):129-38.
Abstract: Breastmilk chemokines have been associated with increased HIV-1 RNA levels in
breastmilk and altered risk of mother-to-child HIV-1 transmission. To
characterize CC and CXC chemokines in breastmilk postpartum, we collected
breastmilk specimens at regular intervals for 6 months after delivery from
women with and without HIV-1 infection and used commercial ELISA kits to
measure breastmilk concentrations of MIP-1alpha, MIP-1beta, RANTES, and
SDF-1alpha. Among 54 HIV-1-infected and 26 uninfected women, mean
chemokine levels were compared cross-sectionally and longitudinally at days 5
and 10, and months 1 and 3 postpartum. For both HIV-1-infected and uninfected
women, breastmilk chemokine levels were highest at day 5 for MIP-1alpha, MIP-
1beta, and SDF-1alpha, and subsequently decreased. RANTES levels remained
constant over the follow-up period among HIV-1-uninfected women, and
increased moderately among HIV-1-infected women. For MIP-1beta and
RANTES, breastmilk levels were significantly higher among HIV-1-infected
women compared to uninfected women early postpartum. In addition, HIV-1-
infected women transmitting HIV-1 to their infant had consistently higher
breastmilk RANTES levels than those who did not transmit, with the greatest
142
difference observed at 1 month (2.68 vs. 2.21 log10 pg/mL, respectively; p =

0.007). In summary, all four chemokines were most elevated within the first
month postpartum, a period of high transmission risk via breastmilk. MIP-1beta
and RANTES levels in breastmilk were higher among HIV-1-infected women
than among uninfected women, and breastmilk RANTES was positively
associated with vertical transmission in this study, consistent with results from
our earlier cohort.
Effect of CCR2 chemokine receptor polymorphism on HIV type 1

mother-to-child transmission and child survival in Western Kenya. AIDS
Res Hum Retroviruses.
Author: Brouwer, K. C.; Yang, C.; Parekh, S.; Mirel, L. B.; Shi, Y. P.; Otieno, J.; Lal, A. A.,
and Lal, R. B.
Source : AIDS Res Hum Retroviruses. 2005 May; 21(5):358-62.
Abstract: The effect of CCR2 polymorphism on HIV-1 mother-to-child transmission and

disease progression has not been explored in depth within Africa. As the CCR2-
64I variant of this putative HIV coreceptor has been associated with slower
progression to AIDS in adults, the current study was undertaken to examine the
relationship between CCR2 polymorphism and HIV-1 perinatal transmission and
child survival in western Kenya. CCR2 genotype was determined for 445 HIV-
seropositive mothers and their infants. The CCR2-64I allele frequency of both
mothers and children did not differ by HIV-1 transmission status, regardless of
maternal viral load, viral subtype, immune status, or placental malaria status.
For infants who acquired HIV perinatally (n = 78), there was no association
between CCR2 genotype and viral load upon infection or survival rate over the
2-year follow-up. Our results do not indicate an effect of CCR2-64I on perinatal
HIV transmission and survival in Kenyan children.
Identification of differentially expressed proteins in the cervical mucosa

of HIV-1-resistant sex workers.
Author: Burgener, A.; Boutilier, J.; Wachihi, C.; Kimani, J.; Carpenter, M.; Westmacott, G.;
Cheng, K.; Ball, T. B., and Plummer, F.
Source : J Proteome Res. 2008 Oct; 7(10):4446-54.
Abstract: Novel tools are necessary to understand mechanisms of altered susceptibility to

HIV-1 infection in women of the Pumwani Sex Worker cohort, Kenya. In this
cohort, more than 140 of the 2000 participants have been characterized to be
relatively resistant to HIV-1 infection. Given that sexual transmission of HIV-1
occurs through mucosal surfaces such as that in the cervicovaginal environment,
143
our hypothesis is that innate immune factors in the genital tract may play a role
in HIV-1 infection resistance. Understanding this mechanism may help develop
microbicides and/or vaccines against HIV-1. A quantitative proteomics
technique (2D-DIGE: two-dimensional difference in-gel electrophoresis) was
used to examine cervical mucosa of HIV-1 resistant women ( n = 10) for
biomarkers of HIV-1 resistance. Over 15 proteins were found to be differentially
expressed between HIV-1-resistant women and control groups ( n = 29), some
which show a greater than 8-fold change. HIV-1-resistant women overexpressed
several antiproteases, including those from the serpin B family, and also cystatin
A, a known anti-HIV-1 factor. Immunoblotting for a selection of the identified
proteins confirmed the DIGE volume differences. Validation of these results on a
larger sample of individuals will provide further evidence these biomarkers are
associated with HIV-1 resistance and could help aid in the development of
effective microbicides against HIV-1.
Correlation of CD4 counts and CD4/CD8 ratio with HIV-infection

Author: Butt, F. M.; Vaghela, V. P., and Chindia, M. L. Correlation of CD4 counts and
CD4/CD8 ratio with HIV-infection associated oral manifestations.
Source : East Afr Med J. 2007 Aug; 84(8):383-8.
Objective:
Design: A cross-sectional study.
Setting: Kenyatta National Hospital, Nairobi, Kenya.
Subjects:
in the study.
Results:
73 years (mean=34.81 years). Oral manifestations encountered with highest
simplex (corner of the mouth) 0.5%, persistent oral ulceration (labial mucosa)
0.5%, Parotid enlargement 2% and Kaposis sarcoma (hard/soft palate) 2.9%.
144
Conclusion:
cell/mm3 and mean CD4/CD8<0.39(95%CI 0.32-0.48).
Integrating nutrition security with treatment of people living with HIV:

lessons from Kenya.
Author: Byron, E.; Gillespie, S., and Nangami, M
Source : Food Nutr Bull. 2008 Jun; 29(2):87-97.
The increased caloric requirements of HIV-positive individuals, undesirable side
effects of treatment that may be worsened by malnutrition (but alleviated by
nutritional support), and associated declines in adherence and possible increased
drug resistance are all justifications for developing better interventions to
strengthen the nutrition security of individuals receiving antiretroviral
treatment.
Objective:
To highlight key benefits and challenges relating to interventions aimed at
strengthening the nutrition security of people living with HIV who are receiving
antiretroviral treatment.
Methods:
Qualitative research was undertaken on a short-term nutrition intervention
linked to the provision of free antiretroviral treatment for people living with HIV
in western Kenya in late 2005 and early 2006.
Results:
Patients enrolled in the food program while on treatment regimens self-reported
greater adherence to their medication, fewer side effects, and a greater ability to
satisfy increased appetite. Most clients self-reported weight gain, recovery of
physical strength, and the resumption of labor activities while enrolled in dual
(food supplementation and treatment) programs. Such improvements were seen
to catalyze increased support from family and community.
Conclusions:
These findings provide further empirical support to calls for a more holistic and
comprehensive response to the coexistence of AIDS epidemics with chronic
nutrition insecurity. Future work is needed to clarify ways of bridging the gap
between short-term nutritional support to individuals and longer-term
livelihood security programming for communities affected by AIDS. Such
interdisciplinary research will need to be matched by intersectoral action on the
part of the agriculture and health sectors in such environments.
145

Author: Calleja, J. M.; Marum, L. H.; Carcamo, C. P.; Kaetano, L.; Muttunga, J., and Way,
A.
Source : AIDS. 2005 May; 19 Suppl 2:S9-S17.
populations over 50 000.The household response rate was above 90% in all
from each survey.These population-based HIV seroprevalence surveys
elements to validate survey results.This review was initiated through an
international meeting on 'New strategies for HIV/AIDS Surveillance in
Resource-constrained Countries' held in Addis Ababa on 26-30 January 2004 to
share and develop recommendations to guide future surveys.
National scale-up of HIV testing and provision of HIV care to

tuberculosis patients in Kenya.
Author: Chakaya, J. M.; Mansoer, J. R.; Scano, F.; Wambua, N.; L'Herminez, R.;
Odhiambo, J.; Mohamed, I.; Kangangi, J.; Ombeka, V.; Akeche, G.; Adala, S.;
Gitau, S.; Maina, J.; Kibias, S.; Langat, B.; Abdille, N.; Wako, I.; Kimuu, P., and
Sitienei, J.
Source : Int J Tuberc Lung Dis. 2008 Apr; 12(4):424-9.
Abstract: Setting:
Kenya, one of the 22 tuberculosis (TB) high-burden countries, whose TB burden
is fuelled by the human immunodeficiency virus (HIV).
146
Objective:
To monitor and evaluate the implementation of HIV testing and provision of
HIV care to TB patients in Kenya through the establishment of a routine TB-HIV
integrated surveillance system.
Design:
A descriptive report of the status of implementation of HIV testing and provision
of HIV interventions to TB patients one year after the introduction of the revised
TB case recording and reporting system.
Results:
From July 2005 to June 2006, 88% of 112835 TB patients were reported to the
National Leprosy and TB Control Programme, 98773 (87.9%) of whom were
reported using a revised recording and reporting system that included TB-HIV
indicators. HIV testing of TB patients increased from 31.5% at the beginning of
this period to 59% at the end. Of the 46428 patients tested for HIV, 25558 (55%)
were found to be HIV-positive, 85% of whom were provided with cotrimoxazole
preventive treatment and 28% with antiretroviral treatment.
Conclusion:
A country-wide integrated TB-HIV surveillance system in TB patients can be
implemented and provides essential data to monitor and evaluate TB-HIV
related interventions.
Correlates of delayed disease progression in HIV-1-infected Kenyan

children. Correlates of delayed disease progression in HIV-1-infected
Kenyan children.
Author: Author: Chakraborty, R.; Morel, A. S.; Sutton, J. K.; Appay, V.; Ripley, R. M.;
Dong, T.; Rostron, T.; Ogola, S.; Palakudy, T.; Musoke, R.; D'Agostino, A.; Ritter,
M., and Rowland-Jones, S. L.
Source : J Immunol. 2005 Jun 15; 174(12):8191-9.
Abstract: Without treatment most HIV-1-infected children in Africa die before their third
birthday (>89%) and long-term nonprogressors are rare. The mechanisms
underlying nonprogression in HIV-1-infected children are not well understood.
In the present study, we examined potential correlates of delayed HIV disease
progression in 51 HIV-1-infected African children. Children were assigned to
progression subgroups based on clinical characterization. HIV-1-specific
immune responses were studied using a combination of ELISPOT assays,
tetramer staining, and FACS analysis to characterize the magnitude, specificity,
and functional phenotype of HIV-1-specific CD8(+) and CD4(+) T cells. Host
genetic factors were examined by genotyping with sequence-specific primers.
HIV-1 nef gene sequences from infecting isolates from the children were
examined for potential attenuating deletions. Thymic output was measured by T
147
cell rearrangement excision circle assays. HIV-1-specific CD8(+) T cell responses

were detected in all progression groups. The most striking attribute of long-term
survivor nonprogressors was the detection of HIV-1-specific CD4(+) Th
responses in this group at a magnitude substantially greater than previously
observed in adult long-term nonprogressors. Although long-term survivor
nonprogressors had a significantly higher percentage of CD45RA(+)CD4(+) T
cells, nonprogression was not associated with higher thymic output. No
protective genotypes for known coreceptor polymorphisms or large sequence
deletions in the nef gene associated with delayed disease progression were
identified. In the absence of host genotypes and attenuating mutations in HIV-1
nef, long-term surviving children generated strong CD4(+) T cell responses to
HIV-1. As HIV-1-specific helper cells support anti-HIV-1 effector responses in
active disease, their presence may be important in delaying disease progression.
nef gene sequence variation among HIV-1-infected African children nef

gene sequence variation among HIV-1-infected African children.
Author: Chakraborty, R.; Reinis, M.; Rostron, T.; Philpott, S.; Dong, T.; D'Agostino, A.;
Musoke, R.; Silva, E.; Stumpf, M.; Weiser, B.; Burger, H., and Rowland-Jones, S.
L. nef gene sequence variation among HIV-1-infected African children.
Source : HIV Med. 2006 Mar; 7(2):75-84.
There are few data on African children infected with nonclade B HIV-1 in
endemic settings, which limits generalizations about pathogenesis and
progression. Genotypic and phenotypic variations in host immunogenetics and
HIV-1 negative factor (nef) accessory protein may influence disease progression
and have frequently been characterized in subjects infected with clade B HIV-1.
Methods:
In this descriptive study, we report nef gene sequence variation and host genetic
polymorphisms in 32 Kenyan children, including 12 slow progressors.
Results:
Phylogenetic analysis identified HIV-1 clades A, C and D and a recombinant
A/D subtype. Grossly defective nef genes or significant changes from relevant
clade reference sequences were not identified in children with delayed disease
progression.
Conclusions:
nef sequence variations may not be common in perinatally infected African
children. Further studies are warranted in HIV-1-infected subjects in settings
where infection is endemic.
148
HIV testing and counselling for women attending child health clinics: an
opportunity for entry to prevent mother-to-child transmission and HIV
treatment.
Author: Author: Chersich, M. F.; Luchters, S. M.; Othigo, M. J.; Yard, E.; Mandaliya, K.,
and Temmerman, M.
Source : Int J STD AIDS. 2008 Jan; 19(1):42-6.
counselling and family planning services.
Optimizing paediatric HIV care in Kenya: challenges in early infant

diagnosis. Bull World Health Organ.
Author: Cherutich, P.; Inwani, I.; Nduati, R., and Mbori-Ngacha, D.
Source : Bull World Health Organ. 2008 Feb; 86(2):155-60.
Abstract: Problem:
In 2003, the goal of the Kenyan Ministry of Health was to avail antiretroviral
treatment (ART) to 50% of the estimated 250 000 eligible individuals by the end
of 2005. By July 2005, 45 000 adults and more than 2000 children were on
treatment. A study was conducted to determine the barriers to identification of
HIV-infected children.
Approach:
Existing government policies were reviewed and the ART register of the Kenya
National AIDS Control Programme was used to identify facilities providing
ART. This paper reports the findings around diagnosis and staging of HIV
infection in children.
Local setting:
149
At the time of the study, 58 health facilities were providing ART to children.
Only one institution had achieved universal HIV testing in the antenatal clinics.
Six facilities systematically followed up HIV-exposed children. HIV antibody
testing was not readily available to the children. Although four research centres
were capable of carrying out diagnostic HIV polymerase chain reaction (PCR),
the services were restricted to research purposes. Other constraints were
inadequate physical infrastructure, inadequate systems for quality control in the
laboratories and shortage of staff.
Lessons learnt:
The policy framework to support identification of HIV-infected children had
been established, albeit with narrow focus on sick children. The assessment
identified the weaknesses in the structures for systematic diagnosis of HIV
through laboratory or clinical-based algorithms. The researchers concluded that
health staff training and implementation of a systematic standard approach to
identification of HIV-infected children is urgently required

levelsSelection for human immunodeficiency virus type 1 envelope
levels.
Author: Chohan, B.; Lang, D.; Sagar, M.; Korber, B.; Lavreys, L.; Richardson, B., and
Overbaugh, J
Source : Virol. 2005 May; 79(10):6528-31.

150
Infant feeding in the time of HIV: rapid assessment of infant feeding

policy and programmes in four African countries scaling up prevention
of mother to child transmission programmes.
Author: Chopra, M. and Rollins, N.
Source : Arch Dis Child. 2008 Apr; 93(4):288-91.
To assess the infant feeding components of prevention of mother to child HIV
transmission (PMTCT) programmes.
Methods:
Assessments were performed across Botswana, Kenya, Malawi and Uganda. 29
districts offering PMTCT were selected by stratified random sampling with rural
and urban strata. All health facilities in the selected PMTCT district were
assessed. The facility level manager and the senior nurse in charge of maternal
care were interviewed. 334 randomly selected health workers involved in the
PMTCT programme completed self-administered questionnaires. 640 PMTCT
counselling observations were carried out and 34 focus groups were conducted
amongst men and women.
Results:
Most health workers (234/334, 70%) were unable to correctly estimate the
transmission risks of breastfeeding irrespective of exposure to PMTCT training.
Infant feeding options were mentioned in 307 of 640 (48%) observations of
PMTCT counselling sessions, and in only 35 (5.5%) were infant feeding issues
discussed in any depth; of these 19 (54.3%) were rated as poor. Several health
workers also reported receiving free samples of infant formula in contravention
of the International Code on Breastmilk Substitutes. National HIV managers
stated they were unsure about infant feeding policy in the context of HIV.
Finally, there was an almost universal belief that an HIV positive mother who
breastfeeds her child will always infect the child and intentional avoidance of
breastfeeding by the mother indicates that she is HIV positive.
151
Conclusion:
These findings underline the need to implement and support systematic infant
feeding policies and programme responses in the context of HIV programmes
Independent effects of nevirapine prophylaxis and HIV-1 RNA

suppression in breast milk on early perinatal HIV-1 transmission.
Author: Chung, M. H.; Kiarie, J. N.; Richardson, B. A.; Lehman, D. A.; Overbaugh, J.;
Njiri, F., and John-Stewart, G. C.
Source : Defic Syndr. 2007 Dec 1; 46(4):472-8.
The mechanism of action of single-dose nevirapine on reducing mother-to-child
transmission of HIV-1 may involve reduction of maternal HIV-1 or prophylaxis
of infants.
Methods:
In a study that randomized pregnant mothers to HIVNET 012 nevirapine versus
short-course antenatal zidovudine, we compared breast milk HIV-1 RNA viral
shedding and administration of single-dose nevirapine between mothers who
transmitted HIV-1 to their infants at 6 weeks postpartum and those who did not.
Results:
In multivariate analyses, maximum breast milk HIV-1 RNA levels (hazard ratio
[HR] = 2.50, 95% confidence interval [CI]: 1.25 to 4.99; P = 0.01) and nevirapine
use (HR = 0.12, 95% CI: 0.02 to 0.97; P = 0.05) were each independently associated
with perinatal transmission at 6 weeks postpartum. Mothers who transmitted
HIV-1 to their infants had significantly higher HIV-1 RNA levels in their breast
milk between the second day and sixth week postpartum. Among mothers with
maximum breast milk virus levels less than a median of 3.5 log(10) copies/mL,
the administration of nevirapine further decreased HIV-1 transmission risk from
22.2% to 0.0% (P = 0.04).
Conclusions:
Peripartum administration of single-dose nevirapine to mother and infant
decreases early perinatal HIV-1 transmission by means of breast milk HIV-1
RNA suppression and, independently, by providing the infant with exposure
prophylaxis.
152
Mandatory neonatal male circumcision in Sub-Saharan Africa: medical

and ethical analysis.
Author: Clark, P. A.; Eisenman, J., and Szapor, S.
Source : Med Sci Monit. 2007 Dec; 13(12):RA205-13.
Abstract: The majority of those infected with HIV in sub-Saharan Africa do not have access
to antiretroviral therapy, which is known to prolong the lives of HIV-positive
persons in industrialized countries. Although the availability of antiretroviral
therapy for those infected with HIV has increased worldwide, the infection rate
out surpasses those started on such treatment. Without an AIDS vaccine or
curative treatment, and given the difficulty in getting persons at risk to adopt
healthy sexual behaviors, alternative approaches to decrease the spread of HIV
infection are urgently needed. Three recent randomized controlled trials
undertaken in Kisumu, Kenya, Raki District, Uganda and Orange Farm, South
Africa have confirmed that male circumcision reduces the risk of heterosexually
acquired HIV infection in men by approximately 51% to 60%. These three studies
provide a solid evidence-base for future health policy. The procedure for
adolescents and adults is expensive compared to abstinence, condoms or other
methods; and the surgery is not without serious risks if performed by traditional
healers using unsterilized blades as often happens in rural Africa. However,
neonatally, the procedure is relatively inexpensive and the risks diminish
considerably. Mandating neonatal male circumcision is an effective therapy that
has minimal risks, is cost efficient and will save human lives. To deny
individuals access to this effective therapy is to deny them the dignity and
respect all persons deserve. Neonatal male circumcision is medically necessary
and ethically imperative.
Immunoepidemiologic profile of Chlamydia trachomatis infection:

importance of heat-shock protein 60 and interferon- gamma.
Author: Cohen, C. R.; Koochesfahani, K. M.; Meier, A. S.; Shen, C.; Karunakaran, K.;
Ondondo, B.; Kinyari, T.; Mugo, N. R.; Nguti, R., and Brunham, R. C.
Source : J Infect Dis. 2005 Aug 15; 192(4):591-9.
Abstract: Epidemiological, animal, and in vitro investigations suggest that Chlamydia

trachomatis infection engenders acquired immunity, the basis for which is
incompletely defined, especially in humans. In a prospective cohort study of
women at high risk for C. trachomatis infection, we found that, at baseline and
after adjustment for age and other potential confounding variables, production
of interferon- gamma by peripheral-blood mononuclear cells (PBMCs)
stimulated with chlamydia heat-shock protein 60 strongly correlated with
protection against incident C. trachomatis infection. This investigation supports a
direct role for C. trachomatis-specific immune responses in altering the risk of
153
infection and suggests immune correlates of protection that are potentially useful
in vaccine development.
AIDS-affected children face systemic discrimination in accessing

education.
Author: Cohen, J. Southern Africa:
Source : HIV AIDS Policy Law Rev. 2005 Dec; 10(3):24-5.
Abstract: In June 2005, Human Rights Watch (HRW) conducted an investigation in Kenya,
South Africa and Uganda to document AIDS-affected children's experiences of
inequality and neglect in the school system. HRW found, consistent with
previous research, that the sickness of one or both parents due to HIV/AIDS led
many children withdraw from school to perform household labour or offset lost
family income. Parental death often led to abandonment, discrimination within
extended and foster families, and emotional trauma that interfered with school
performance.
Market incentives, human lives, and AIDS vaccines.

Author: Craddock, S. Market incentives, human lives, and AIDS vaccines.
Source : Soc Sci Med. 2007 Mar; 64(5):1042-56.
Abstract: For many, an AIDS vaccine holds the promise of intervening in a widespread
epidemic because it is not predicated on changing economic structures and social
contexts underlying vulnerability to HIV for millions of individuals. Yet 20 years
into the AIDS epidemic, there is still no vaccine. Based on interviews of AIDS
vaccine researchers, watchdog organizations, and ethics groups from the United
States, South Africa, and Kenya conducted between August and December of
2003, this paper explores possible answers to the question of why there is no
vaccine, looking in particular at contradictions between a biomedical research
industry increasingly driven by market incentives and a disease that primarily
affects individuals living in low-income countries with little vaccine purchasing
power. Producing a vaccine that could be effective in low-income regions
requires new kinds of initiatives that can coordinate research nationally and
globally, and circumvent current regulatory mechanisms that dictate against the
development and dissemination of low-profit medical technologies. Until such
initiatives are supported, however, vaccine research will continue at a
devastatingly slow pace at the cost of millions of lives annually.

154
Author: Currie, C. S.; Floyd, K.; Williams, B. G., and Dye, C
Source : BMC Public Health. 2005; 5:130.
and southern Africa. Several strategies have the potential to reduce the burden
of TB in high HIV prevalence settings, and cost and cost-effectiveness analyses
can help to prioritize them when budget constraints exist. However, published
cost and cost-effectiveness studies are limited.
Methods:
Results:
The three lowest cost and most cost-effective strategies were improving TB cure
rates, improving TB case detection rates, and improving both together. The
incremental cost of combined improvements to case detection and cure was
below USD 15 million per year (7.5% of year 2000 government health
Conclusion:
155
Microcredit for people affected by HIV and AIDS: insights from Kenya.
Author: Datta, D. and Njuguna, J.
Source : SAHARA J. 2008 Jul; 5(2):94-1
Abstract: Consequences of HIV and AIDS are exponential in Kenya, touching not only the
health of those infected, but also depleting socioeconomic resources of entire
families. Access to financial services is one of the important ways to protect and
build economic resources. Unfortunately, the norm of financial viability
discourages microfinance institutions from targeting people severely impacted
by HIV and AIDS. Thus, HIV and AIDS service NGOs have been increasingly
getting involved in microcredit activity in recent years for economic
empowerment of their clients. Despite limited human resources and funding in
the area of microcredit activity, these NGOs have demonstrated that nearly 50%
of their microcredit beneficiaries invested money in income-generating activities,
resulting in enhancement to their livelihood security. In the short term these
NGOs need to improve their current practices. However, this does not mean
launching microfinance initiatives within their AIDS-focused programmes, as
financial services are best provided by specialised institutions. Longer-term
cooperation between microfinance institutions and other AIDS service
organisations and donors is necessary to master appropriate and rapid responses
in areas experiencing severe impacts of HIV and AIDS.
Do unsafe tetanus toxoid injections play a significant role in the

transmission of HIV/AIDS? Evidence from seven African countries.
Author: de Walque, D.
Source : Sex Transm Infect. 2008 Apr; 84(2):122-5.
Although sexual transmission is generally considered to be the main factor
driving the HIV/AIDS epidemic in Africa, recent studies have claimed that
iatrogenic transmission should be considered as an important source of HIV
infection. In particular, receipt of tetanus toxoid injections during pregnancy has
been reported to be associated with HIV infection in Kenya. The objective of this
paper is to assess the robustness of this association among women in nationally
representative HIV surveys in seven African countries.
Methods:
The association between prophylactic tetanus toxoid injections during pregnancy
and HIV infection was analysed, using individual-level data from women who
gave birth in the past five years. These data are from the nationally
representative Demographic and Health Surveys, which included HIV testing in
seven African countries: Burkina Faso 2003 (N = 2424), Cameroon 2004 (N =
156
2600), Ethiopia 2005 (N = 2886), Ghana 2003 (N = 2560), Kenya 2003 (N = 1617),
Lesotho 2004 (N = 1278) and Senegal 2005 (N = 2126).
Results:
Once the odds ratios (OR) were adjusted for five-year age groups and for ethnic,
urban and regional indicators, the association between prophylactic tetanus
toxoid injections during pregnancy and HIV infection was never statistically
significant in any of the seven countries. Only in Cameroon was there an
association between previous tetanus toxoid injection and HIV positivity but it
became weaker (OR 1.53, 95% CI 0.91 to 2.57) once urban location and ethnic
group were adjusted for.
Conclusions:
Although the risk of HIV infection through unsafe injections and healthcare
should not be ignored and should be reduced, it does not seem that there is, at
present and in the seven countries studied, strong evidence supporting the claim
that unsafe tetanus toxoid injections are a major factor driving the HIV epidemic.
Quality and quantity of antenatal HIV counselling in a PMTCT

programme in Mombasa, Kenya.
Author: Delva, W.; Mutunga, L.; Quaghebeur, A., and Temmerman, M.
Source : AIDS Care. 2006 Apr; 18(3):189-93.
Abstract: A recent report from a PMTCT implementation study in Mombasa, Kenya,

points at an important gap between the efficacy in clinical trial circumstances
and the effectiveness of PMTCT programmes when implemented in real life.
Hence, the quality and quantity of antenatal HIV counselling in a routine setting
were appraised. The counsellors' social and communicative skills, duration and
topics covered during pre- and post-test counselling sessions were assessed by
means of the VCT assessment tools published by UNAIDS. A total of 14 group
educational sessions, 66 pre-test counselling sessions and 50 post-test counselling
sessions were observed and assessed. In general, the frequency and duration of
the counselling was low. Crucial topics such as window period and partner
involvement and follow-up support were covered haphazardly. The counsellor's
social and communicative skills were given high marks, yet information was
rarely repeated or summarized. The limited time dedicated to women receiving
antenatal VCT contrasts with the heavy and comprehensive load of health
information and advice they are supposed to receive. Ample pre- and post-test
counselling including follow-up should be pursued for optimal effectiveness of
PMTCT. We propose a number of health system interventions preceded and
guided by ongoing audit.
157
The role of sexually transmitted infections in male circumcision

effectiveness against HIV--insights from clinical trial simulation.
Author: Desai, K.; Boily, M. C.; Garnett, G. P.; Masse, B. R.; Moses, S., and Bailey, R. C.
Source : Emerg Themes Epidemiol. 2006; 3:19.
A landmark randomised trial of male circumcision (MC) in Orange Farm, South
Africa recently showed a large and significant reduction in risk of HIV infection,
reporting MC effectiveness of 61% (95% CI: 34%-77%). Additionally, two further
randomised trials of MC in Kisumu, Kenya and Rakai, Uganda were recently
stopped early to report 53% and 48% effectiveness, respectively. Since MC may
protect against both HIV and certain sexually transmitted infections (STI), which
are themselves cofactors of HIV infection, an important question is the extent to
which this estimated effectiveness against HIV is mediated by the protective
effect of circumcision against STI. The answer lies in the trial data if the
appropriate statistical analyses can be identified to estimate the separate
efficacies against HIV and STI, which combine to determine overall effectiveness.
Objectives and methods:

Focusing on the MC trial in Kisumu, we used a stochastic prevention trial
simulator (1) to determine whether statistical analyses can validly estimate
efficacy, (2) to determine whether MC efficacy against STI alone can produce
large effectiveness against HIV and (3) to estimate the fraction of all HIV
infections prevented that are attributable to efficacy against STI when both
efficacies combine. RESULTS: Valid estimation of separate efficacies against HIV
and STI as well as MC effectiveness is feasible with available STI and HIV trial
data, under Kisumu trial conditions. Under our parameter assumptions, high
overall effectiveness of MC against HIV was observed only with a high MC
efficacy against HIV and was not possible on the basis of MC efficacy against STI
alone. The fraction of all HIV infections prevented which were attributable to MC
efficacy against STI was small, except when efficacy of MC specifically against
HIV was very low. In the three MC trials which reported between 48% and 61%
effectiveness (combining STI and HIV efficacies), the fraction of HIV infections
prevented in circumcised males which were attributable to STI was unlikely to be
more than 10% to 20%.
Conclusion:
Estimation of efficacy, attributable fraction and effectiveness leads to improved
understanding of trial results, gives trial results greater external validity and is
essential to determine the broader public health impact of circumcision to men
and women.
158
Urban-rural differences in the socioeconomic deprivation--sexual

behavior link in Kenya.
Author: Dodoo, F. N.; Zulu, E. M., and Ezeh, A. C.
Source : Soc Sci Med. 2007 Mar; 64(5):1019-31.
Abstract: We compare the impact of socioeconomic deprivation on risky sexual outcomes

in rural and urban Kenya. Quantitative data are drawn from the Demographic &
Health Surveys (DHS) and qualitative data from the Sexual Networking and
Associated Reproductive and Social Health Concerns study. Using two separate
indicators of deprivation we show that, although poverty is significantly
associated with the examined sexual outcomes in all settings, the urban poor are
significantly more likely than their rural counterparts to have an early sexual
debut and a greater incidence of multiple sexual partnerships. The disadvantage
of the urban poor is accentuated for married women; those in Nairobi's slums
are at least three times as likely to have multiple sexual partners as their rural
counterparts. The implications of these findings are discussed.
Health workforce issues and the Global Fund to fight AIDS,

Tuberculosis and Malaria: an analytical review.
Author: rager, S.; Gedik, G., and Dal Poz, M. R.
Source : um Resour Health. 2006; 4:23.
Abstract: Recent studies have shown evidence of a direct and positive causal link between
the number of health workers and health outcomes. Several studies have
identified an adequate health workforce as one of the key ingredients to
achieving improved health outcomes. Global health initiatives are faced with
human resources issues as a major, system-wide constraint. This article explores
how the Global Fund addresses the challenges of a health workforce bottleneck
to the successful implementation of priority disease programmes. Possibilities for
investment in human resources in the Global Fund's policy documents and
guidelines are reviewed. This is followed by an in-depth study of 35 Global Fund
proposals from five African countries: Ethiopia, Ghana, Kenya, Malawi and
Tanzania. The discussion presents specific human resources interventions that
can be found in proposals. Finally, the comments on human resources
interventions in the Global Fund's Technical Review Panel and the budget
allocation for human resources for health were examined. Policy documents and
guidelines of the Global Fund foster taking account of human resources
constraints in recipient countries and interventions to address them. However,
the review of actual proposals clearly shows that countries do not often take
advantage of their opportunities and focus mainly on short-term, in-service
training in their human resources components. The comments of the Technical
Review Panel on proposed health system-strengthening interventions reveal a
159
struggle between the Global Fund's goal to fight the three targeted diseases, on
the one hand, and the need to strengthen health systems as a prerequisite for
success, on the other. In realizing the opportunities the Global Fund provides for
human resources interventions, countries should go beyond short-term
objectives and link their activities to a long-term development of their human
resources for health.
Herpes simplex virus type 2 and risk of intrapartum human

immunodeficiency virus transmission.
Author: rake, A. L.; John-Stewart, G. C.; Wald, A.; Mbori-Ngacha, D. A.; Bosire, R.;
Wamalwa, D. C.; Lohman-Payne, B. L.; Ashley-Morrow, R.; Corey, L., and
Farquhar, C.
Source : Obstet Gynecol. 2007 Feb; 109(2 Pt 1):403-9.
To determine whether herpes simplex virus type 2 (HSV-2) infection was
associated with risk of intrapartum human immunodeficiency virus type 1 (HIV-
1) transmission and to define correlates of HSV-2 infection among HIV-1-
seropositive pregnant women.
Methods:
We performed a nested case control study within a perinatal cohort in Nairobi,
Kenya. Herpes simplex virus type 2 serostatus and the presence of genital ulcers
were ascertained at 32 weeks of gestation. Maternal cervical and plasma HIV-1
RNA and cervical HSV DNA were measured at delivery.
Results:
One hundred fifty-two (87%) of 175 HIV-1-infected mothers were HSV-2-
seropositive. Among the 152 HSV-2-seropositive women, nine (6%) had genital
ulcers at 32 weeks of gestation, and 13 (9%) were shedding HSV in cervical
secretions. Genital ulcers were associated with increased plasma HIV-1 RNA
levels (P=.02) and an increased risk of intrapartum HIV-1 transmission (16% of
transmitters versus 3% of nontransmitters had ulcers; P = .003), an association
which was maintained in multivariable analysis adjusting for plasma HIV-1
RNA levels (P=.04). We found a borderline association for higher plasma HIV-1
RNA among women shedding HSV (P=.07) and no association between cervical
HSV shedding and either cervical HIV-1 RNA levels or intrapartum HIV-1
transmission (P=.4 and P=.5, [corrected] respectively).
Conclusion:
Herpes simplex virus type 2 is the leading cause of genital ulcers among women
in sub-Saharan Africa and was highly prevalent in this cohort of pregnant
women receiving prophylactic zidovudine. After adjusting for plasma HIV-1
RNA levels, genital ulcers were associated with increased risk of intrapartum
HIV-1 transmission. These data suggest that management of HSV-2 during
160
pregnancy may enhance mother-to-child HIV-1 prevention efforts. LEVEL OF

EVIDENCE: II.
Severe gynecomastia in an African boy with perinatally acquired human

immunodeficiency virus infection receiving highly active antiretroviral
therapy.
Author: Author: Dzwonek, A.; Clapson, M.; Withey, S.; Bates, A., and Novelli, V.
Source : Pediatr Infect Dis J. 2006 Feb; 25(2):183-4.
Abstract: Highly active antiretroviral therapy (HAART) slows the progression of human
immunodeficiency virus (HIV) disease and lowers mortality and morbidity in
children. Coincident with these advances, an increasing number of side effects
are being reported. We describe an adolescent boy with perinatally acquired HIV
infection who developed significant bilateral breast enlargement as a result of
HAART. He required bilateral mastectomies. Pediatricians need to be aware of
less common side effects of HAART.
Responding to the HIV pandemic: the power of an academic medical

partnership.
Author: Einterz, R. M.; Kimaiyo, S.; Mengech, H. N.; Khwa-Otsyula, B. O.; Esamai, F.;
Quigley, F., and Mamlin, J. J.
Source : Acad Med. 2007 Aug; 82(8):812-8.
Abstract: Partnerships between academic medical center (AMCs) in North America and
the developing world are uniquely capable of fulfilling the tripartite needs of
care, training, and research required to address health care crises in the
developing world. Moreover, the institutional resources and credibility of AMCs
can provide the foundation to build systems of care with long-term
sustainability, even in resource-poor settings. The authors describe a partnership
between Indiana University School of Medicine and Moi University and Moi
Teaching and Referral Hospital in Kenya that demonstrates the power of an
academic medical partnership in its response to the HIV/AIDS pandemic in
sub-Saharan Africa. Through the Academic Model for the Prevention and
Treatment of HIV/AIDS, the partnership currently treats over 40,000 HIV-
positive patients at 19 urban and rural sites in western Kenya, now enrolls nearly
2,000 new HIV positive patients every month, feeds up to 30,000 people weekly,
enables economic security, fosters HIV prevention, tests more than 25,000
pregnant women annually for HIV, engages communities, and is developing a
robust electronic information system.The partnership evolved from a program of
limited size and a focus on general internal medicine into one of the largest and
most comprehensive HIV/AIDS-control systems in sub-Saharan Africa. The
161
partnership's rapid increase in scale, combined with the comprehensive and

long-term approach to the region's health care needs, provides a twinning model
that can and should be replicated to address the shameful fact that millions are
dying of preventable and treatable diseases in the developing world.
The STARK study: a cross-sectional study of adherence to short-term

drug regiments in urban Kenya.
Author: Ellis, A. E.; Gogel, R. P.; Roman, B. R.; Watson, J. B.; Indyk, D., and Rosenberg, G.
Source : Soc Work Health Care. 2006; 42(3-4):237-50.
Abstract: The purpose of the STARK study (Short-Term Adherence Research in Kenya)
was to identify factors that predict adherence to short-term drug regimens in
Nairobi, Kenya. The participants (N = 357) in the study were recruited from the
RAFIKI Foundation Clinic, a free primary healthcare clinic in Kibera, Nairobi's
largest slum. Quantitative surveys were administered to all the participants
regarding their adherence patterns and to a subgroup of mothers (N = 233)
regarding their adherence in giving medicine to their children. 40 participated in
four focus groups. 52% of participants reported taking all of their prescribed
medication and 47% took it until they felt better. Over 65% of mothers reported
giving all prescribed medication to their children. The most frequently cited
barriers to adherence included lack of food and clean water, stress, and financial
problems. By identifying obstacles to adherence and strategies to overcome
them, this study showed that a community- based clinic with committed
healthcare workers in Kenya can empower an economically disadvantaged
population to be adherent.
Orphans and schooling in Africa: a longitudinal analysis. Demography.

Author: Evans, D. K. and Miguel, E.
Source : Demography. 2007 Feb; 44(1):35-57.
academic performance.
162
Pediatric HIV type 1 vaccine trial acceptability among mothers in Kenya.

Author: Author: Farquhar, C.; John-Stewart, G. C.; John, F. N.; Kabura, M. N., and Kiarie,
J. N.
Source : AIDS Res Hum Retroviruses. 2006 Jun; 22(6):491-5.
Abstract: Vaccination of infants against human immunodeficiency virus type 1 (HIV-1)

may prevent mother-to-child HIV-1 transmission. Successful trials and
immunization efforts will depend on the willingness of individuals to participate
in pediatric vaccine research and acceptance of infant HIV-1 vaccines. In a cross-
sectional study, pregnant women presenting to a Nairobi antenatal clinic for
routine care were interviewed regarding their attitudes toward participation in
research studies and HIV-1 vaccine acceptability for their infants. Among 805
women, 782 (97%) reported they would vaccinate their infant against HIV-1 and
729 (91%) reported willingness to enroll their infant in a research study.
However, only 644 (80%) would enroll their infants if HIV- 1 testing was
required every 3 months and 513 (64%) would agree to HIV-1 vaccine trial
participation. Reasons for not wanting to enroll in a pediatric HIV-1 vaccine trial
included concerns about side effects (75%), partner objection (34%), and fear of
discrimination (10%), HIV-1 acquisition (8%), or false-positive HIV-1 results
(5%). The strongest correlate of pediatric vaccine trial participation was maternal
willingness to be a vaccine trial participant herself; in univariate and multivariate
models this was associated with a 17-fold increased likelihood of participation
(HR 17.1; 95% CI 11.7-25; p < 0.001). We conclude from these results that
immunizing infants against HIV-1 and participation in pediatric vaccine trials
are generally acceptable to women at high risk for HIV-1 infection. It will be
important to address barriers identified in this study and to include male
partners when mobilizing communities for pediatric HIV-1 vaccine trials and
immunization programs.
Salivary human immunodeficiency virus (HIV)-1-specific

immunoglobulin A in HIV-1-exposed infants in Kenya.
Author: Farquhar, C.; VanCott, T.; Bosire, R.; Bermudez, C.; Mbori-Ngacha, D.; Lohman-
Payne, B.; Nduati, R.; Otieno, P., and John-Stewart, G
Source: Clin Exp Immunol. 2008 Jul; 153(1):37-43.
Abstract: Humoral immunity, and specifically immunoglobulin A (IgA) that is directed

against human immunodeficiency virus (HIV)-1, may contribute to protection
against HIV-1 acquisition at mucosal surfaces. HIV-1-specific IgA has been
detected in genital tract secretions of HIV-1-uninfected commercial sex workers
with HIV-1 exposure, and may be produced in parotid saliva by infants exposed
orally to HIV-1 during delivery and breastfeeding. To explore this hypothesis,
we collected saliva from 145 infants aged < or = 6 months enrolled in a perinatal
HIV-1 transmission study in Nairobi and from 55 control infants without HIV-1
163
exposure who were born to HIV-1-seronegative mothers. Among the 145 infants,
115 (79%) remained uninfected during the 12-month study period and 30 (21%)
became HIV-1-infected during follow-up. Nine (8%) of the 115 HIV-1-exposed,
uninfected infants had detectable levels of HIV-1 gp160-specific IgA compared
with four (13%) of 30 infected infants and none of 55 control infants (P = 0.47 and
P = 0.03 respectively). Among the nine HIV-1-exposed, uninfected infants with
positive assays, median age was 1 month and none acquired HIV-1 during
follow-up. We conclude that HIV-1-specific salivary IgA responses may be
generated by very young infants exposed perinatally to maternal HIV-1. Mucosal
responses would be an appropriate target for paediatric vaccines against breast
milk HIV-1 transmission.
Mapping transactional sex on the Northern Corridor highway in Kenya.

Health Place.
Author: Ferguson, A. G. and Morris, C. N.
Source : 2007 Jun; 13(2):504-19.
Abstract: Even in generalized HIV/AIDS epidemics, vulnerable populations such as sex

workers and truckers require special attention in programming. Combining a
number of elicitation methods, centred on Geographical Information Systems
(GIS) mapping, the Kenyan section of the Northern Corridor highway was
studied to characterize the 'hot spots' where transactional sex is concentrated and
to provide estimates of numbers of truckers and sex workers and the volumes of
transactional sex taking place on the highway. An average of 2400 trucks park
overnight at the 39 hot spots identified. These spots have an estimated sex
worker population of 5600 women. Analysis of 403 sex worker diaries shows an
average of 13.6 different clients and 54.2 sex acts in a month. Condom use is 69%
in liaisons with regular clients and 90% with casual clients. The use of GIS is
demonstrated at regional and local scales. The 'bridge population' of clients of
sex workers, containing a wide rage of occupations, supports the concept of
programming for 'vulnerable places' as well as vulnerable groups
Using diaries to measure parameters of transactional sex: an example

from the Trans-Africa highway in Kenya.
Author: Ferguson, A. G.; Morris, C. N., and Kariuki, C. W.
Source : Cult Health Sex. 2006 Mar-2006 Apr 30; 8(2):175-85.
Abstract: Conventional methods of elicitation have severe limitations where sensitive

information is being sought, resulting from both self-disclosure and recall bias.
The use of diaries largely circumvents both of these problems. Four hundred and
three female sex workers based on a section of the Trans-Africa Highway in
164
Kenya completed standard diaries for consecutive 28-day periods. Variables

measured included numbers and types of different clients, condom use,
occupation of client, movement patterns and days of menses. Mean numbers of
sexual partners, liaisons and sex acts and inter-relationships between the
variables measured are analysed. The study affirms the value of diaries as an
elicitation method for studying transactional sex in a resource-poor setting.
Usable diaries were received from 70% of those who had agreed to participate in
the study. The diaries yield detailed quantitative data that describe the
characteristics and dynamics of transactional sex on a major highway in Africa
and provide information that may be used to estimate HIV transmission rates.
The gradient in sub-Saharan Africa: socioeconomic status and

HIV/AIDS.
Author: Fortson, J. G.
Source : Demography. 2008 May; 45(2):303-22.
Abstract: Using data from the Demographic and Health Surveys (DHS) for Burkina Faso
(2003), Cameroon (2004), Ghana (2003), Kenya (2003), and Tanzania (2003), I
investigate the cross-sectional relationship between HIV status and
socioeconomic status. I find evidence of a robust positive education gradient in
HIV infection, showing that, up to very high levels of education, better-educated
respondents are more likely to be HIV-positive. Adults with six years of
schooling are as much as three percentage points more likely to be infected with
HIV than adults with no schooling. This gradient is not an artifact of age, sector
of residence, or region of residence. With controls for sex, age, sector of
residence, and region of residence, adults with six years of schooling are as
much as 50% more likely to be infected with HIV than those with no schooling.
Education is positively related to certain risk factors for HIV including the
likelihood of having premarital sex. Estimates of the wealth gradient in HIV, by
contrast, vary substantially across countries and are sensitive to the choice of
measure of wealth.
165
Proportion of new HIV infections attributable to herpes simplex 2

increases over time: simulations of the changing role of sexually
transmitted infections in sub-Saharan African HIV epidemics.
Author: Freeman, E. E.; Orroth, K. K.; White, R. G.; Glynn, J. R.; Bakker, R.; Boily, M. C.;
Habbema, D.; Buve, A., and Hayes, R.
Source : Sex Transm Infect. 2007 Aug; 83 Suppl 1:i17-24.
To understand the changing impact of herpes simplex 2 (HSV-2) and other
sexually transmitted infections (STIs) on HIV incidence over time in four sub-
Saharan African cities, using simulation models.
Methods:
An individual-based stochastic model was fitted to demographic, behavioural
and epidemiological data from cross-sectional population-based surveys in four
African cities (Kisumu, Kenya; Ndola, Zambia; Yaounde, Cameroon; and
Cotonou, Benin) in 1997. To estimate the proportion of new HIV infections
attributable to HSV-2 and other STIs over time, HIV incidence in the fitted model
was compared with that in model scenarios in which the cofactor effect of the
STIs on HIV susceptibility and infectivity were removed 5, 10, 15, 20 and 25 years
into the simulated HIV epidemics.
Results:
The proportion of incident HIV attributable to HSV-2 infection (the model
estimated population attributable fraction (PAF(M))) increased with maturity of
the HIV epidemic. In the different cities, the PAF(M) was 8-31% 5 years into the
epidemic, but rose to 35-48% 15 years after the introduction of HIV. In contrast,
the proportion of incident HIV attributable to chancroid decreased over time
with strongest effects five years after HIV introduction, falling to no effect 15
years after. Sensitivity analyses showed that, in the model, recurrent HSV-2
ulcers had more of an impact on HIV incidence than did primary HSV-2 ulcers,
and that the effect of HSV-2 on HIV infectivity may be more important for HIV
spread than the effect on HIV susceptibility, assuming that HSV-2 has similar
cofactor effects on HIV susceptibility and infectivity. The overall impact of other
curable STIs on HIV spread (syphilis, gonorrhoea and chlamydia) remained
relatively constant over time.
Conclusions:
Although HSV-2 appears to have a limited impact on HIV incidence in the early
stages of sub-Saharan African HIV epidemics when the epidemic is concentrated
in core groups, it has an increasingly large impact as the epidemic progresses. In
generalised HIV epidemics where control programmes for curable STIs are
already in place, interventions against HSV-2 may have a key role in HIV
prevention.
166
Factors associated with self-reported unprotected anal sex among male

sex workers in Mombasa, Kenya.
Author: Geibel, S.; Luchters, S.; King'Ola, N.; Esu-Williams, E.; Rinyiru, A., and Tun, W.
Source : Sex Transm Dis. 2008 Aug; 35(8):746-52.
To identify social and behavioral characteristics associated with sexual risk
behaviors among male sex workers who sell sex to men in Mombasa, Kenya.
Methods:
Using time-location sampling, 425 men who had recently sold, and were
currently willing to sell sex to men were invited to participate in a cross-sectional
survey. A structured questionnaire was administered using handheld computers.
Factors associated with self-reported unprotected anal sex with male clients in
the past 30 days were identified and subjected to multivariate analysis.
Results:
Thirty-five percent of respondents did not know HIV can be transmitted via anal
sex, which was a significant predictor of unprotected anal sex [adjusted odds
ratio (AOR) 1.92; 95% confidence interval (95% CI), 1.16-3.16]. Other associated
factors included drinking alcohol 3 or more days per week (AOR, 1.63; 95% CI,
1.05-2.54), self-report of burning urination within the past 12 months (AOR, 2.07;
95% CI, 1.14-3.76), and having never been counseled or tested for HIV (AOR,
1.66; 95% CI, 1.07-2.57). Only 21.2% of respondents correctly knew that a water-
based lubricant should be used with latex condoms.
Conclusions:
Male sex workers who sell sex to men in Mombasa are in acute need of targeted
prevention information on anal HIV and STI transmission, consistent condom
use, and correct lubrication use with latex condoms. HIV programs in Africa
need to consider and develop specific prevention strategies to reach this
vulnerable population.
'Are you on the market?': a capture-recapture enumeration of men who

sell sex to men in and around Mombasa, Kenya.
Author: Geibel, S.; van der Elst, E. M.; King'ola, N.; Luchters, S.; Davies, A.; Getambu, E.
M.; Peshu, N.; Graham, S. M.; McClelland, R. S., and Sanders, E. J.
Source : AIDS. 2007 Jun 19; 21(10):1349-54.
167
Men who have sex with men (MSM) are highly vulnerable to HIV infection, but
this population can be particularly difficult to reach in sub-Saharan Africa. We
aimed to estimate the number of MSM who sell sex in and around Mombasa,
Kenya, in order to plan HIV prevention research.
Methods:
We identified 77 potential MSM contact locations, including public streets and
parks, brothels, bars and nightclubs, in and around Mombasa and trained 37
MSM peer leader enumerators to extend a recruitment leaflet to MSM who were
identified as 'on the market', that is, a man who admitted to selling sex to men.
We captured men on two consecutive Saturdays, 1 week apart. A record was
kept of when, where and by whom the invitation was extended and received,
and of refusals. The total estimate of MSM who sell sex was derived from
capture-recapture calculation.
Results:
Capture 1 included 284 men (following removal of 15 duplicates); 89 men
refused to participate. Capture 2 included 484 men (following removal of 35
duplicates); 75 men refused to participate. Of the 484 men in capture 2, 186 were
recaptures from capture 1, resulting in a total estimate of 739 (95% confidence
interval, 690-798) MSM who sell sex in the study area.
Conclusions:
We estimated that 739 MSM sell sex in and around Mombasa. Of these, 484 were
contacted through trained peer enumerators in a single day. MSM who sell sex in
and around Mombasa represent a sizeable population who urgently need to be
targeted by HIV prevention strategies.
Acceptability of human immunodeficiency virus testing in patients with

invasive cervical cancer in Kenya.
Author: Gichangi, P.; Estambale, B.; Bwayo, J.; Rogo, K.; Ojwang, S.; Njuguna, E., and
Temmerman, M.
Source : Int J Gynecol Cancer. 2006 Mar-2006 Apr 30; 16(2):681-5.
Abstract: Invasive cervical cancer (ICC) is common in areas where human

immunodeficiency virus (HIV) is also prevalent. Currently, HIV seroprevalence
as well as acceptability of HIV testing in ICC patients in Kenya is unknown. The
objective of this study was to determine the acceptability of HIV testing among
patients with ICC. Women with histologically verified ICC at Kenyatta National
Hospital participated in the study. A structured questionnaire was administered
to patients who gave informed consent. HIV pre- and posttesting counseling was
done. Blood was tested for HIV using enzyme-linked immunosorbent assay.
Overall, 11% of ICC patients were HIV seropositive. The acceptance rate of HIV
testing was 99%; yet, 5% of the patients did not want to know their HIV results.
168
Patients less than 35 years old were two times more likely to refuse the result of
the HIV test (odds ratio [OR] 2.2). Patients who did not want to know their HIV
results were three times more likely to be HIV seropositive (OR 3.1). Eighty four
percent of the patients were unaware of their HIV seropositive status. The HIV-1
seroprevalence in ICC patients was comparable to the overall seroprevalence in
Kenya. ICC patients were interested in HIV testing following pretest counseling.
Offering routine HIV testing is recommended in ICC patients.
Predictors of mortality in HIV-1 exposed uninfected post-neonatal

infants at the Kenyatta National Hospital, Nairobi.
Author: Gichuhi, C.; Obimbo, E.; Mbori-Ngacha, D.; Mwatha, A.; Otieno, P.; Farquhar, C.;
Wariua, G.; Wamalwa, D.; Bosire, R., and John-Stewart,
Source: G. East Afr Med J. 2005 Sep; 82(9):447-51.
To identify potential predictors of mortality, to determine mortality rate and to
identify prevalent causes of death in a cohort of HIV-1 exposed uninfected
infants.
Design: Prospective cohort study.
Subjects:
Three hundred and fifty one HIV-1 exposed uninfected post-neonatal infants
who survived to one year of age.
Results:
Sixteen infants died (post-neonatal mortality rate of 47/1000 live births), 14 (88%)
before six months of age. The most frequently identified medical conditions at
death included bronchopneumonia, diarrhoea and failure to thrive. In
multivariate analysis, prematurity (RR=10.5, 95%CI 3.8-29.1, p<0.001), teenage
motherhood (RR=3.6, Cl 1.0-13.2, p=0.05) and symptomatic maternal HIV-1
disease (RR=2.7, CI 0.9-7.7, p=0.06) were associated with infant mortality.
Conclusion:
Prematurity, teenage motherhood and symptomatic HIV-1 maternal disease
were important predictors for post-neonatal mortality in this cohort of HIV-1
exposed uninfected infants. These factors should be considered in monitoring
and follow up in prevention of mother-to-child HIV-1 transmission (PMTCT)
programs.
169
Total lymphocyte count as a surrogate marker for CD4+ t cell count in

Author: Gitura, B.; Joshi, M. D.; Lule, G. N., and Anzala, O
Source : East Afr Med J. 2007 Oct; 84(10):466-72.
Design: Cross-sectional descriptive study.
Setting:
Kenyatta National Hospital, HIV treatment and follow-up outpatient facility;
Comprehensive Care Centre, Nairobi, Kenya.
Subjects:
Two hundred and twenty five HIV Elisa positive, ARV naive patients visiting the
Comprehensive Care Centre between January 2006 to March 2006.
Results:
minority of patients who despite a TLC > or = 1900 cells/mm3 are, on basis of
settings.
Conclusion:
however the WHO recommended TLC cuto-ff of 1200/mm3 was found to be of
to start antiretroviral therapy.
170
Short term estimates of adult HIV incidence by mode of transmission:

Kenya and Thailand as examples.
Author: Gouws, E.; White, P. J.; Stover, J., and Brown, T.
Source : Sex Transm Infect. 2006 Jun; 82 Suppl 3:iii51-55.
Patterns of transmission of HIV are different among different regions of the
world and change over time within regions. In order to adapt prevention
strategies to changing patterns of risk, we need to understand the behaviours
that put people at risk of infection and how new infections are distributed among
risk groups.
Methods:
A model is described to calculate the expected incidence of HIV infections in the
adult population by mode of exposure using the current distribution of prevalent
infections and the patterns of risk within different populations. For illustration
the model is applied to Thailand and Kenya.
Results:
New infections in Kenya were mainly transmitted through heterosexual contact
(90%), while a small but significant number were related to injecting drug use
(4.8%) and men who have sex with men (4.5%). In Thailand, the epidemic has
spread over time to the sexual partners of vulnerable groups and in 2005 the
majority of new infections occurred among the low risk heterosexual population
(43%). Men having sex with men accounted for 21% and sex work (including sex
workers, clients, and partners of clients) for 18% of new infections. Medical
interventions did not contribute significantly to new infections in either Kenya
or Thailand.
Conclusions:
The model provides a simple tool to inform the planning of effective,
appropriately targeted, country specific intervention programmes. However,
better surveillance systems are needed in countries to obtain more reliable
biological and behavioural data in order to improve the estimates of incidence by
risk group.
171
Higher pre-infection vitamin E levels are associated with higher

mortality in HIV-1-infected Kenyan women: a prospective study.
Author: Graham, S. M.; Baeten, J. M.; Richardson, B. A.; Bankson, D. D.; Lavreys, L.;
Ndinya-Achola, J. O.; Mandaliya, K.; Overbaugh, J., and McClelland, R. S.
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 <200 cells/muL, and
mortality.
Results:
After controlling for potential confounding factors, each 1 mg/L increase in pre-
infection vitamin E was associated with 0.08 log10 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 pre-infection 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.
A decrease in albumin in early HIV type 1 infection predicts subsequent

disease progression.
Author: Graham, S. M.; Baeten, J. M.; Richardson, B. A.; Wener, M. H.; Lavreys, L.;
Mandaliya, K.; Ndinya-Achola, J. O.; Overbaugh, J., and McClelland, R. S.
Source: AIDS Res Hum Retroviruses. 2007 Oct; 23(10):1197-200.
Abstract: We investigated the association between albumin levels and HIV-1 disease
progression among 78 Kenyan women followed from before infection through a
median of 70 months. With HIV-1 acquisition, median albumin decreased from
38.5 g/liter to 36.8 g/liter (p = 0.07) and the prevalence of hypoalbuminemia
172
increased from 16% to 32% (p = 0.02). Each 1 g/liter decrease in albumin with
HIV-1 acquisition was associated with a 13% increase (p = 0.01) in the risk of
progressing to a CD4 count <200 cells/mul, after adjustment for set point plasma
viral load. A decrease in albumin of over 10% was associated with a 3.5-fold
increase in the risk of progressing to a CD4 count <200 cells/mul (95% CI 1.4-9.0,
p = 0.008). Trends for an increased risk of mortality were also seen. A greater
decrease in albumin levels accompanying HIV-1 acquisition may be a marker for
changes in early infection associated with more rapid disease progression.
Screening for genital and anorectal sexually transmitted infections in

HIV prevention trials in Africa.
Author: Grijsen, M. L.; Graham, S. M.; Mwangome, M.; Githua, P.; Mutimba, S.;
Wamuyu, L.; Okuku, H.; Price, M. A.; McClelland, R. S.; Smith, A. D., and
Sanders, E. J.
Source: Sex Transm Infect. 2008 Oct; 84(5):364-70.
To demonstrate the value of routine, basic sexually transmitted infection (STI)
screening at enrolment into an HIV-1 vaccine feasibility cohort study and to
highlight the importance of soliciting a history of receptive anal intercourse
(RAI) in adults identified as "high risk".
Methods:
Routine STI screening was offered to adults at high risk of HIV-1 upon
enrolment into a cohort study in preparation for HIV-1 vaccine trials. Risk
behaviours and STI prevalence were summarised and the value of microscopy
assessed. Associations between prevalent HIV-1 infection and RAI or prevalent
STI were evaluated with multiple logistic regression.
Results:
Participants had a high burden of untreated STI. Symptom-directed management
would have missed 67% of urethritis cases in men and 59% of cervicitis cases in
women. RAI was reported by 36% of male and 18% of female participants. RAI
was strongly associated with HIV-1 in men (adjusted odds ratio (aOR) 3.8; 95%
CI 2.0 to 6.9) and independently associated with syphilis in women (aOR 12.9;
95% CI 3.4 to 48.7).
Conclusions:
High-risk adults recruited for HIV-1 prevention trials carry a high STI burden.
Symptom-directed treatment may miss many cases and simple laboratory-based
screening can be done with little cost. Risk assessment should include questions
about anal intercourse and whether condoms were used. STI screening,
including specific assessment for anorectal disease, should be offered in African
research settings recruiting participants at high risk of HIV-1 acquisition.
173

Author: Hallett, T. B.; Aberle-Grasse, J.; Bello, G.; Boulos, L. M.; Cayemittes, M. P.;
Cheluget, B.; Chipeta, J.; Dorrington, R.; Dube, S.; Ekra, A. K.; Garcia-Calleja, J.
M.; Garnett, G. P.; Greby, S.; Gregson, S.; Grove, J. T.; Hader, S.; Hanson, J.;
Hladik, W.; Ismail, S.; Kassim, S.; Kirungi, W.; Kouassi, L.; Mahomva, A.;
Marum, L.; Maurice, C.; Nolan, M.; Rehle, T.; Stover, J., and Walker, N.
Source: Sex Transm Infect. 2006 Apr; 82 Suppl 1:i1-8.
generalised HIV epidemics are associated with changes in sexual risk behaviour.
Methods:
A mathematical model was developed to explore the relation between
prevalence recorded at antenatal clinics (ANCs) and the pattern of incidence of
infection throughout the population. To create a null model a range of
assumptions about sexual behaviour, natural history of infection, and sampling
biases in ANC populations were explored to determine which factors maximised
declines in prevalence in the absence of behaviour change. Modelled prevalence,
where possible based on locally collected behavioural data, was compared with
the observed prevalence data in urban Haiti, urban Kenya, urban Cote d'Ivoire,
Malawi, Zimbabwe, Rwanda, Uganda, and urban Ethiopia.
Results:
show no signs of changed sexual behaviour.
Conclusions:
Changes in patterns of HIV prevalence in urban Kenya, Zimbabwe, and urban
Haiti are quite recent and caution is required because of doubts over the
accuracy and representativeness of these estimates. Nonetheless, the observed
changes are consistent with behaviour change and not the natural course of the
HIV epidemic.
174
Does cotrimoxazole prophylaxis for the prevention of HIV-associated

Author: Hamel, M. J.; Greene, C.; Chiller, T.; Ouma, P.; Polyak, C.; Otieno, K.;
Williamson, J.; Shi, Y. P.; Feikin, D. R.; Marston, B.; Brooks, J. T.; Poe, A.; Zhou,
Z.; Ochieng, B.; Mintz, E., and Slutsker, L.
Source: Am J Trop Med Hyg. 2008 Sep; 79(3):320-30.
multivitamins. Specimens were collected at baseline, 2 weeks, monthly, and at
sick visits during 6 months of follow-up to compare changes in resistance, with
higher-CD4 as referent. P. falciparum parasitemia incidence density was 16 and
156/100 person-years in lower-CD4 and higher-CD4, respectively (adjusted rate
ratio [ARR] = 0.11; 95% confidence interval [CI] = 0.06-0.15; P < 0.001) and 97/100
Incidence density of triple and quintuple dihydrofolate-
reductase/dihydropteroate-synthetase mutations was 90% reduced in lower-
CD4 compared with referent. Overall, cotrimoxazole non-susceptibility was high
among isolated pneumococcus (92%) and E. coli (76%) and increased
significantly in lower-CD4 subjects by Week 2 (P < 0.005). Daily cotrimoxazole
prevented malaria and reduced incidence of antifolate-resistant P. falciparum but
resistance
Potential for abuse in the VCT counselling room: service provider's

perceptions in Kenya.
Author: Hamilton, C.; Okoko, D.; Tolhurst, R.; Kilonzo, N.; Theobald, S., and Taegtmeyer,
M
Source: Health Policy Plan. 2008 Nov; 23(6):390-6.
Abstract: The rapid scale-up of HIV counselling and testing programmes in Kenya has led
to quality concerns, including the potential for abuse within the private,
confidential setting of client-initiated voluntary counselling and testing (VCT). A
qualitative study was conducted in three provinces of Kenya, involving 26 VCT
service providers and 13 key informants. First and second hand accounts of
emotional, physical and sexual abuse emerged in all three study sites in spite of
measures to mitigate such occurrences. Whilst uncommon, abuse was perceived
by service providers to be serious and sufficiently widespread to raise significant
175
concerns. Abuse occurred client to counsellor, from counsellor to client and from
counsellor to counsellor. In all cases the person suffering the abuse was female.
While the potential for abuse was demonstrated in VCT sites, we argue that
experiences of abuse are not confined to VCT and are largely shaped by gender
and power relations within the Kenyan cultural context. The international
impetus for scale-up of HIV services provides an urgent rationale for the need to
address and highlight these difficult issues at multiple levels. International
guidelines, policy and methods need adapting in recognition of the potential for
abuse. Systems for investigating and deregistering counsellors have been
developed in Kenya but require formalizing. Institutions providing VCT should
consider unlocked doors, semi-opaque windows and the use of 'mystery clients'
as a quality assurance measure.
The relationship between expressed HIV/AIDS-related stigma and

beliefs and knowledge about care and support of people living with
AIDS in families caring for HIV-infected children in Kenya.
Author: Hamra, M.; Ross, M. W.; Karuri, K.; Orrs, M., and D'Agostino, A.
Source: AIDS Care. 2005 Oct; 17(7):911-22.
Abstract: At the end of 2001, AIDS-related deaths had left an estimated 900,000 living
orphans in Kenya (UNAIDS/WHO Epidemiology fact sheet, Kenya report, 2004).
Many of those orphans are also HIV+. In Eastern Kenya, the Lea Toto Kangemi
Outreach Program provides support to families caring for HIV+ children, many
of whom are orphaned or soon to be orphaned. A major challenge for these
families is the stigma attached to the family. In 2003, the Kangemi Program
conducted a household survey of client families. We examined markers of
expressed stigma and the association between expressed stigma and other
demographic and belief/knowledge domains. The focus of the present study was
the specific belief/knowledge domain surrounding care/support of HIV+
persons. Our goal was to explore this domain in the Kangemi families and to
examine its relationship to expressed stigma. We created an AIDS-related stigma
scale from selected items in the household survey and cross-tabulated stigma
scores with care/support knowledge items. We found significant associations
between less expressed stigma and greater care/support knowledge. Our results
have implications for interventions that reduce expressed stigma and/or
improve quality of care.
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HIV, hepatitis B and hepatitis C coinfection in Kenya.

Author: Harania, R. S.; Karuru, J.; Nelson, M., and Stebbing, J.
Source: AIDS. 2008 Jun 19; 22(10):1221-2.
Abstract: There are few data regarding hepatitis and HIV coinfection in Africa. In 378 HIV
seropositive individuals in Nairobi, 23 (6%) were hepatitis B virus (HBV) and
HIV coinfected, four (1%) were hepatitis C virus (HCV) and HIV coinfected and
one patient was infected with all three viruses. Coinfected individuals were more
likely to be men and older; a lack of HBV vaccination was a risk factor for
HIV/HBV coinfection (P = 0.001) and tenofovir containing regimens appeared
most effective at reducing HBV viral load.
Human leukocyte antigen-DQ alleles and haplotypes and their

associations with resistance and susceptibility to HIV-1 infection.
Author: Hardie, R. A.; Luo, M.; Bruneau, B.; Knight, E.; Nagelkerke, N. J.; Kimani, J.;
Wachihi, C.; Ngugi, E. N., and Plummer, F. A.
Source: AIDS. 2008 Apr 23; 22(7):807-16.
To determine the association of DQ antigens with resistance and susceptibility to
HIV-1.
Design:
Despite repeated exposure to HIV-1, a subset of women in the Pumwani Sex
Worker cohort established in Nairobi, Kenya in 1985 have remained HIV-1
negative for at least 3 years and are classified as resistant. Differential
susceptibility to HIV-1 infection is associated with HIV-1 specific CD4 and CD8
T cell responses. As human leukocyte antigen-DQ antigens present viral peptides
to CD4 cells, we genotyped human leukocyte antigen -DQ alleles for 978 women
enrolled in the cohort and performed cross-sectional and longitudinal analyses to
identify associations of human leukocyte antigen -DQ with
resistance/susceptibility to HIV-1.
Methods:
QA1 and DQB1 were genotyped using taxonomy-based sequence analysis. SPSS
13.0 was used to determine associations of DQ alleles/haplotypes with HIV-1
resistance, susceptibility, and seroconversion rates.
Results:
Several DQB1 alleles and DQ haplotypes were associated with resistance to HIV-
1 infection. These included DQB1*050301 (P = 0.055, Odds Ratio = 12.77, 95%
Confidence Interval = 1.44-112), DQB1*0603 and DQB1*0609 (P = 0.037, Odds
Ratio = 3.25, 95% Confidence Interval = 1.12-9.47), and DQA1*010201-DQB1*0603
177
(P = 0.044, Odds Ratio = 17.33, 95% Confidence Interval = 1.79-168). Conversely,

DQB1*0602 (P = 0.048, Odds Ratio = 0.68, 95% Confidence Interval = 0.44-1.05)
and DQA1*010201-DQB1*0602 (P = 0.039, Odds Ratio = 0.64, 95% Confidence
Interval = 0.41-1.03) were overrepresented in the HIV-1 infected population.
DQA1*0504-DQB1*0201, DQA1*010201-DQB1*0201, DQA1*0402-DQB1*0402 and
DQA1*0402-DQB1*030101 genotypes were only found in HIV-1 positive subjects
(Odds Ratio = 0.30-0.31, 95% Confidence Interval = 0.03-3.70), and these women
seroconverted rapidly. The associations of these DQ alleles and haplotypes with
resistance and susceptibility to HIV-1 were independent of the previously
reported human leukocyte antigen-DRB*01, human leukocyte antigen A2/6802,
and human leukocyte antigen-A*2301.
Conclusion:
The associations of DQ alleles and haplotypes with resistance and susceptibility
to HIV-1 emphasize the importance of human leukocyte antigen-DQ and CD4 in
anti-HIV-1 immunity.
Antiretroviral durability and tolerability in HIV-infected adults living in

urban Kenya.
Author: Hawkins, C.; Achenbach, C.; Fryda, W.; Ngare, D., and Murphy, R.
Source: J Acquir Immune Defic Syndr. 2007 Jul 1; 45(3):304-10.
Insufficient data exist on the durability and tolerability of first-line antiretroviral
therapy (ART) regimens provided by HIV treatment programs implemented in
developing countries.
Methods:
Longitudinal observation of clinical, immunologic, and treatment parameters of
all HIV-infected adult patients initiated on ART was performed at Saint Mary's
Mission Hospital in Nairobi, Kenya from September 2004 until August 2006.
Results:
A total of 1286 patients were analyzed (59.1% female). Initial ART regimens were
primarily stavudine, lamivudine, and nevirapine (62.1%). Median ART duration
was 350 days (11.6 months). Significant improvements in clinical and
immunologic status were noted after 12 months of therapy. ART switches
occurred in 701 (54.5%) patients. The cumulative incidence of ART switch at 12
months was 78.4%. Concurrent ART-related toxicities (40.6%) and tuberculosis
treatment interactions (28.1%) were the most frequent reasons for ART switch.
Baseline AIDS symptoms (hazard rate [HR]=1.59, 95% confidence interval [CI]:
1.28 to 1.98; P<0.01) and a CD4 count<or=100 cells/mm3 (HR=1.20, CI: 1.01 to
1.43; P=0.04) were independent predictors of ART switch. ART-related clinical
toxicity occurred in 341 (26.5%) patients. Peripheral neuropathy was reported
178
most frequently (20.7%). A CD4 count<or=100 cells/mm3 was an independent

predictor of clinical toxicity.
Conclusions:
Excellent clinical and immunologic responses to ART were observed in this
urban Kenyan population; however, frequent switches in ART among
medication classes because of toxicity or drug interactions may limit the
durability of these responses.

workers.
Author: Hirbod, T.; Kaul, R.; Reichard, C.; Kimani, J.; Ngugi, E.; Bwayo, J. J.; Nagelkerke,
N.; Hasselrot, K.; Li, B.; Moses, S.; MacDonald, K. S., and Broliden, K.
Source: AIDS. 2008 Mar 30; 22(6):727-35.
HIV-neutralizing immunoglobulin A (IgA) and HIV-specific cellular immunity
a prospective, nested case-control study to examine the association of genital
IgA and systemic cellular immune responses with subsequent HIV acquisition in
high-risk Kenyan female sex workers (FSWs).
Design and methods:

A randomized trial of monthly antibiotic prophylaxis to prevent sexually
transmitted disease/HIV infection was performed from 1998 to 2002 in HIV-
uninfected Kenyan FSWs. After the completion of trial, FSWs who had acquired
HIV (cases) were matched 1: 4 with persistently uninfected controls based on
study arm, duration of HIV-seronegative follow-up, and time of cohort
enrolment. Blinded investigators assayed the ability at enrolment of genital IgA
to neutralize primary HIV isolates as well as systemic HIV-specific cellular
IFNgamma-modified enzyme-linked immunospot and proliferative responses.
Results:
The study cohort comprised 113 FSWs: 24 cases who acquired HIV and 89
matched controls. Genital HIV-neutralizing IgA was associated with reduced
HIV acquisition (P = 0.003), as was HIV-specific proliferation (P = 0.002), and
these associations were additive. HIV-specific IFNgamma production did not
differ between case and control groups. In multivariable analysis, HIV-
neutralizing IgA and HIV-specific proliferation each remained independently
associated with lack of HIV acquisition. Genital herpes (HSV2) was associated
with increased HIV risk and with reduced detection of HIV-neutralizing IgA.
Conclusion:
179
Genital HIV-neutralizing IgA and systemic HIV-specific proliferative responses,

assayed by blinded investigators, were prospectively associated with HIV
nonacquisition. The induction of these immune responses may be an important
goal for HIV vaccines.
Prevention of mother-to-child transmission and voluntary counseling

and testing programme data: what is their utility for HIV surveillance?
Author: Hladik, W.; Masupu, K.; Roels, T.; Plipat, T.; Kaharuza, F.; Bunnell, R.; Seguy, N.,
and Marum, L. H.
Source: AIDS. 2005 May; 19 Suppl 2:S19-24.
Antenatal clinic (ANC)-based surveillance through unlinked anonymous testing
(UAT) for HIV without informed consent provides solid long-term trend data in
resource-constrained countries with generalized epidemics. The rapid expansion
of the prevention of mother-to-child transmission (PMTCT) and voluntary
counseling and testing (VCT) programmes prompts the question regarding their
utility for HIV surveillance and their potential to replace UAT-based ANC
surveillance.
Methods:
Four presentations on the use of PMTCT or VCT data for HIV surveillance were
presented at a recent international conference. The main findings are presented
in this paper, and the operational and epidemiological aspects of using PMTCT
or VCT data for surveillance are considered.
Results:
VCT data in Uganda confirm the falling trend in HIV prevalence observed in
ANC surveillance. Thailand, a country with nationwide PMTCT coverage and a
very high acceptance of HIV testing, has replaced UAT data in favor of PMTCT
data for surveillance. Studies from Botswana and Kenya showed that PMTCT-
based HIV prevalences was similar, but the quality and availability of the
PMTCT data varied.
Conclusion:
The strength of UAT lies in the absence of selection bias and the availability of
individual data. Conversely, the quantity of VCT and PMTCT programme
testing data often exceed those in UAT, but may be subject to bias due to self-
selection or test refusal. When using VCT or PMTCT data for surveillance,
investigators must consider these caveats, as well as their varying data quality,
accessibility, and availability of individual records
AMPATH: living proof that no one has to die from HIV.
180
Author: Inui, T. S.; Nyandiko, W. M.; Kimaiyo, S. N.; Frankel, R. M.; Muriuki, T.; Mamlin,
J. J.; Einterz, R. M., and Sidle, J. E.
Source: J Gen Intern Med. 2007 Dec; 22(12):1745-50.
Abstract: Background and objective:

The HIV/AIDS epidemic in sub-Saharan Africa is decimating populations,
deteriorating economies, deepening poverty, and destabilizing traditional social
orders. The advent of the U.S. President's Emergency Plan for AIDS Relief
(PEPFAR) made significant supplemental resources available to sub-Saharan
national programs for the prevention and treatment of HIV/AIDS, but few
programs have demonstrated the capacity to use these resources to increase
rapidly in size. In this context, AMPATH, a collaboration of Indiana University
School of Medicine, the Moi University School of Medicine, and the Moi
Teaching and Referral Hospital in Eldoret, Kenya, is a stunning exception. This
report summarizes findings from an assessment of AMPATH staff perceptions of
how and why this has happened.
Participants and approach:

Semistructured, in-depth, individual interviews of 26 AMPATH workers were
conducted and recorded. Field notes from these interviews were generated by
independent reviewers and subjected to close-reading qualitative analysis for
themes.
Results:
The themes identified were as follows: creating effectively, connecting with
others, making a difference, serving those in great need, providing
comprehensive care to restore healthy lives, and growing as a person and a
professional.
Conclusion:
Inspired personnel are among the critical assets of an effective program. Among
the reasons for success of this HIV/AIDS program are a set of work values and
motivations that would be helpful in any setting, but perhaps nowhere more
critical than in the grueling work of making a complex program work
spectacularly well in the challenging setting of a resource-poor country.
Sometimes, even in the face of long odds, the human spirit prevails.
181
Elevated T cell counts and RANTES expression in the genital mucosa of

HIV-1-resistant Kenyan commercial sex workers.
Author: Iqbal, S. M.; Ball, T. B.; Kimani, J.; Kiama, P.; Thottingal, P.; Embree, J. E.; Fowke,
K. R., and Plummer, F. A.
Source: J Infect Dis. 2005 Sep 1; 192(5):728-38.
Abstract: The initial site of exposure to human immunodeficiency virus (HIV)-1 during
heterosexual transmission occurs in the genital tract. Although the majority of
immunological studies have focused on the immune response to HIV-1 at the
systemic level, our understanding of tissue-specific immunity is deficient. The
goal of the present study was to characterize T cell populations found in the
cervix of women shown to be resistant to infection by HIV-1. Levels of both
systemic and cervical mucosal lymphocytes were compared between HIV-1-
resistant, HIV-1-uninfected, and HIV-1-infected commercial sex workers (CSWs)
as well as HIV-1-uninfected non-CSW control subjects at low risk for exposure.
The HIV-1-resistant CSWs had increased cervical CD4+ and CD8+ T cell counts,
compared with the HIV-1-uninfected CSWs; importantly, these increases were
not reflected in the systemic lymphocyte compartment. There was a 2-fold
increase in CD4+ T cell counts in the HIV-1-resistant CSWs, compared with both
the HIV-1-infected and the HIV-1-uninfected CSWs. Expression of the HIV-1
coreceptors CCR5 and CXCR4 was also determined, and cytokine and beta
chemokine levels in the genital mucosa were assessed. The HIV-1-resistant CSWs
had a 10-fold increase in RANTES expression, compared with the HIV-1-
uninfected CSWs. This is the first study to show elevated levels of beta
chemokines and CD4+ T cells in the genital tracts of women who are exposed to
HIV-1 and yet are uninfected.
HIV voluntary counselling and testing in Nakuru, Kenya: findings from

a community survey.
Author: Irungu, T. K.; Varkey, P.; Cha, S., and Patterson, J. M.
Source: HIV Med. 2008 Feb; 9(2):111-7.
HIV voluntary counselling and testing (VCT) is important for prevention,
detection and treatment of HIV infection. A study was conducted to determine
the extent of utilization of VCT, and to study the attitudes and preferences of the
community regarding VCT.
Methods:
A total of 301 adults, aged 18-49 years, residing in Nakuru, Kenya were
randomly selected using a two-stage sampling process. A self-administered
182
questionnaire delivered during home visits was used to collect data over a 4-
week period.
Results:
The majority of study participants (184 of 287; 64.1%) had never been tested for
HIV; 77 (26.8%) had received VCT, and 26 (9.1%) had received HIV testing
without counselling. A total of 219 (78.2%) of the 280 responding participants
expressed readiness to have VCT. The majority of participants (216 of 296; 73%)
preferred VCT, while 46 (15.5%) preferred testing without counselling. The
majority (227; 76.7%) preferred couple testing and dedicated clinics and private
doctors' offices as testing facilities. The choice of a nearby facility was ranked
above the provision of anonymity by most participants (162 of 298; 54.4%; vice
versa for 136 of 298; 45.6%).
Conclusions:
With HIV/AIDS continuing to be a major public health concern in Kenya, the
issues surrounding acceptance and use of VCT need to be addressed. Enhancing
community awareness of the benefits of early HIV diagnosis, providing couple-
based VCT as an integral part of VCT and increasing access to VCT testing sites
may enhance utilization of VCT.
Safety and immunogenicity of recombinant low-dosage HIV-1 A vaccine

candidates vectored by plasmid pTHr DNA or modified vaccinia virus
Ankara (MVA) in humans in East Africa.
Author: Jaoko, W.; Nakwagala, F. N.; Anzala, O.; Manyonyi, G. O.; Birungi, J.; Nanvubya,
A.; Bashir, F.; Bhatt, K.; Ogutu, H.; Wakasiaka, S.; Matu, L.; Waruingi, W.; Odada,
J.; Oyaro, M.; Indangasi, J.; Ndinya-Achola, J.; Konde, C.; Mugisha, E.; Fast, P.;
Schmidt, C.; Gilmour, J.; Tarragona, T.; Smith, C.; Barin, B.; Dally, L.; Johnson, B.;
Muluubya, A.; Nielsen, L.; Hayes, P.; Boaz, M.; Hughes, P.; Hanke, T.;
McMichael, A.; Bwayo, J., and Kaleebu, P.
Source: Vaccine. 2008 May 23; 26(22):2788-95.
Abstract: The safety and immunogenicity of plasmid pTHr DNA, modified vaccinia virus
Ankara (MVA) human immunodeficiency virus type 1 (HIV-1) vaccine
candidates were evaluated in four Phase I clinical trials in Kenya and Uganda.
Both vaccines, expressing HIV-1 subtype A gag p24/p17 and a string of CD8 T-
cell epitopes (HIVA), were generally safe and well-tolerated. At the dosage levels
and intervals tested, the percentage of vaccine recipients with HIV-1-specific cell-
mediated immune responses, assessed by a validated ex vivo interferon gamma
(IFN-gamma) ELISPOT assay and Cytokine Flow Cytometry (CFC), did not
significantly differ from placebo recipients. These trials demonstrated the
feasibility of conducting high-quality Phase 1 trials in Africa.
183
Cost effectiveness of couple counselling to enhance infant HIV-1

prevention.
Author: John, F. N.; Farquhar, C.; Kiarie, J. N.; Kabura, M. N., and John-Stewart, G. C.
Source: Int J STD AIDS. 2008 Jun; 19(6):406-9.
Abstract: Data collected in the years 2001--2003 from an antenatal clinic in Nairobi, Kenya,
were used to assess the benefit of couple counselling and test it as a way of
increasing the uptake of interventions in the prevention of mother-to-child
transmission of HIV-1. Among 2833 women enrolled, 311 (11%) received couple
pretest counselling and 2100 (74%) accepted HIV-1 testing. Among those tested
314 (15%) were HIV-1 seropositive. We incorporated these and other data from
the cohort study into a spreadsheet-based model and costs associated with
couple counselling were compared with individual counselling in a theoretical
cohort of 10,000 women. Voluntary couple counselling and testing (VCT),
although more expensive, averted a greater number of infant infections when
compared with individual VCT. Cost per disability-adjusted life year was similar
to that of individual VCT. Sensitivity analyses found that couple VCT was more
cost-effective in scenarios with increased uptake of couple counselling and
higher HIV-1 prevalence.
Risk factors for HIV infection in a national adult population: evidence

from the 2003 Kenya Demographic and Health Survey.
Author: Johnson, K. and Way, A.
Source: J Acquir Immune Defic Syndr. 2006 Aug 15; 42(5):627-36.
To study demographic, social, behavioral, and biological variables as risk factors
for HIV infection among men and women in Kenya.
Methods:
Data from the cross-sectional, population-based 2003 Kenya Demographic and
Health Survey were used. During the course of survey fieldwork, 3,273 women
aged 15 to 49 years and 2,941 men aged 15 to 54 years gave consent to have a few
drops of blood taken for anonymous testing. HIV serostatus data for men and
women were analyzed for their relationships to key characteristics using
bivariate and multivariate techniques to determine factors associated with being
HIV-positive.
Results:
National HIV prevalence in Kenya was found to be 6.7%. In the analysis of the
study sample, uncircumcised men were 4 times more likely to be HIV-positive
than those who were not. Compared with nonpolygynously married women,
184
widowed women (odds ratio [OR] = 10.9), divorced women (OR = 2.3), and
women who were 1 of 3 or more wives (OR = 3.4) were all at higher risk for
being HIV-positive. Both men and women from Nyanza province were at a
significantly higher risk for infection with HIV (OR = 2.9 and 2.3, respectively)
than were the men and women from Nairobi. Men aged 35 to 44 years had the
highest risk of being HIV-positive, whereas the ages of highest risk for women
were 25 to 29 years. Increased wealth was positively related to risk for HIV: the
wealthiest women were 2.6 times more likely than the poorest women to be
HIV-positive. A key finding was that both men and women who considered
themselves to be at low risk for contracting HIV were, in fact, the most likely to
be HIV-positive.
Conclusions:
This analysis demonstrates that HIV is a multidimensional epidemic, with
demographic, residential, social, biological, and behavioral factors all exerting
influence on individual probability of becoming infected with HIV. Although all
of these factors contribute to the risk profile for a given individual, the results
suggest that differences in biological factors such as circumcision and sexually
transmitted infections may be more important in assessing risk for HIV than
differences in sexual behavior.
The impact of maternal HIV status on infant feeding patterns in Nakuru,

Kenya.
Author: Kamau-Mbuthia, E.; Elmadfa, I., and Mwonya, R.
Source: J Hum Lact. 2008 Feb; 24(1):34-41.
Abstract: The aim of the study was to assess the impact of maternal HIV status on infant
(younger mothers, P < .05) was associated with exclusive breastfeeding in the 6th
week and infant birth weight (> mean birth weight, P < .05) in the 10th week. The
results indicate a need to reassess adherence to infant feeding recommendations
irrespective of maternal HIV status and also the infant feeding counseling
process in the hospital. J Hum Lact . 24(1):34-41.
185
Anti-HIV-1 activities in extracts from some medicinal plants as assessed

in an in vitro biochemical HIV-1 reverse transcriptase assay.
Author: Kanyara, J. N. and Njagi, E. N.
Source: Phytother Res. 2005 Apr; 19(4):287-90.
Abstract: An in vitro HIV-1 reverse transcriptase (RT) assay was used for screening of anti-
HIV activity of extracts obtained from some Kenyan medicinal plants. The assay
utilises [3H]-methyl thymidine triphosphate (dTTP) as the enzyme substrate and
polyadenylic acid.oligodeoxythymidylic acid [poly(rA).p(dT)(12-18)] as the
template-primer dimmer. This assay was optimised and standardised with
respect to the various experimental parameters in a microtiter plate
methodology. The assay was then applied to test for potential antiviral activities
of several Kenyan medicinal plant extracts and the concentrations producing
50% inhibition (IC50) of the HIV-1 RT were determined. This assay is described
in this report and results obtained with some of the extracts are presented.
Knowledge, attitude and practice towards HIV/AIDS in a rural Kenyan

community.
Author: Karama, M.; Yamamoto, T.; Shimada, M.; Orago, S. S., and Moji, K.
Source: J Biosoc Sci. 2006 Jul; 38(4):481-90.
Abstract: The aim of this research was to explore people's knowledge, attitude, behaviour
and practice towards HIV/AIDS and sexual activity in rural Kenya, where HIV
is widespread. The study community was located in south-eastern Kenya, 50 km
north of Mombassa, and had an estimated population of 1500. Subjects aged
between 16 and 49 were recruited using a stratified cluster-sampling method and
they completed self-administered questionnaires.Almost all respondents knew
the word 'IV' Around 50% knew of a person living with HIV. About 80% gave
'death' or 'fear' as words representing their image of AIDS. With regard to sexual
activity, the distribution of answers to the question 'how many partners have you
ever had in your life' was bimodal in males but had only one peak in females,
indicating that some men have a large number of sexual partners in their
lifetime. First sexual intercourse was at around 12-13 years for both sexes, but
female teenagers were more sexually experienced than their male counterparts.
186
Risk factors for treatment denial and loss to follow-up in an

antiretroviral treatment cohort in Kenya.
Author: Karcher, H.; Omondi, A.; Odera, J.; Kunz, A., and Harms, G.
Source: Trop Med Int Health. 2007 May; 12(5):687-94.
To evaluate risk factors for treatment denial and loss to follow-up in an
antiretroviral treatment (ART) cohort in a rural African setting in western Kenya.
Method:
Sociodemographic and clinical data of patients enrolled in an ART cohort were
collected within 18 months of an observational longitudinal study and analysed
by logistic and Cox regression models.
Results:
Of 159 patients with treatment indication 35 (22%) never started ART. Pregnancy
[adjusted odds ratio (AOR) 3.60, 95% confidence interval (CI) 1.10-11.8; P = 0.035]
and lower level of education (AOR 3.80, 95% CI 1.14-12.7; P = 0.03) were
independently associated with treatment denial. The incidence of total loss of
patients under therapy was 43.2 per 100 person years (pys) (mortality rate 19.2
per 100 pys plus drop out rate 24 per 100 pys). Older age [adjusted hazard ratio
(AHR) 1.06, 95% CI 1.01-1.12; P = 0.04], AIDS before starting treatment (AHR
5.83, 95% CI 1.15-29.5; P = 0.03) and incomplete adherence to treatment (AHR
1.05, 95% CI 1.03-1.07; P < 0.001) were independent risk factors for death.
Incomplete adherence also independently predicted drop out because of other
reasons (AHR 1.06, 95% CI 1.04-1.09; P < 0.001).
Conclusion:
Pregnancy and lower level of education, higher age, advanced AIDS stage and
impaired compliance to ART were identified as risk factors for treatment denial
and death, respectively. Adequate counselling strategies for patients with these
characteristics could help to improve adherence and outcome of treatment
programmes in resource-limited settings.
Prevalence of HCV and HCV/HIV co-infection among in-patients at the

Kenyatta National Hospital.
Author: Karuru, J. W.; Lule, G. N.; Joshi, M., and Anzala, O.
Source: East Afr Med J. 2005 Apr; 82(4):170-2.
187
To determine the prevalence of HCV and HCV/HIV co-infection among medical
in-patients at the Kenyatta National Hospital. DESIGN: Prospective cross-
sectional descriptive study.
Setting:
Kenyatta National Hospital, a tertiary referral and teaching hospital, in-patient
department
Subjects:
HIV/AIDS and HIV negative in-patients at KNH medical wards. RESULTS:
Among 458 HIV/AIDS medical in-patients, the prevalence of HCV was 3.7%
while in the 518 HIV negative patients, it was 4.4%. The prevalence of co-
infection with HCV and HIV was 3.7%. The incidence of risk factors in persons
with HCV and/or HIV infection(s) was low.
Conclusion:
This study found the prevalence of HCV infection among medical in-patients to
be similar in HIV positive and HIV negative group of patients. The co-infection
rates were low, as were the risk factors for transmission of these infections.
Prevalent herpes simplex virus type 2 infection is associated with altered

vaginal flora and an increased susceptibility to multiple sexually
transmitted infections.
Author: Kaul, R.; Nagelkerke, N. J.; Kimani, J.; Ngugi, E.; Bwayo, J. J.; Macdonald, K. S.;
Rebbaprgada, A.; Fonck, K.; Temmerman, M.; Ronald, A. R., and Moses, S.
Source: J Infect Dis. 2007 Dec 1; 196(11):1692-7.
Prevalent herpes simplex virus type 2 (HSV-2) infection increases human
immunodeficiency virus acquisition. We hypothesized that HSV-2 infection
might also predispose individuals to acquire other common sexually transmitted
infections (STIs).
Methods:
We studied the association between prevalent HSV-2 infection and STI incidence
in a prospective, randomized trial of periodic STI therapy among Kenyan female
sex workers. Participants were screened monthly for infection with Neisseria
gonorrhoeae and Chlamydia trachomatis, and at least every 6 months for
bacterial vaginosis (BV) and infection with Treponema pallidum, Trichomonas
vaginalis, and/or HSV-2.
188
Results:
Increased prevalence of HSV-2 infection and increased prevalence of BV were
each associated with the other; the direction of causality could not be
determined. After stratifying for sexual risk-taking, BV status, and antibiotic use,
prevalent HSV-2 infection remained associated with an increased incidence of
infection with N. gonorrhoeae (incidence rate ratio [IRR], 4.3 [95% confidence
interval {CI}, 1.5-12.2]), T. vaginalis (IRR, 2.3 [95% CI, 1.3-4.2]), and syphilis (IRR,
4.7 [95% CI, 1.1-19.9]). BV was associated with increased rates of infection with C.
trachomatis (IRR, 2.1 [95% CI, 1.1-3.8]) and T. vaginalis (IRR, 8.0 [95% CI, 3.2-
19.8]).
Conclusion:
Increased prevalences of HSV-2 infection and BV were associated with each
other and also associated with enhanced susceptibility to an overlapping
spectrum of other STIs. Demonstration of causality will require clinical trials that
suppress HSV-2 infection, BV, or both.
Drug evaluation: DNA/MVA prime-boost HIV vaccine.

Author: Kent, S.; De Rose, R., and Rollman, E.
Source: Curr Opin Investig Drugs. 2007 Feb; 8(2):159-67.
Abstract: Oxford University and Nairobi University are jointly developing a

HIVA.DNA/modified vaccinia Ankara (MVA) prime-boost vaccine for the
potential prevention of infection with HIV subtype A. The vaccination strategy
consists of priming with a DNA vaccine made from HIV-1 clade A gag p24/p17
consensus sequence (pTHr.HIVA) then boosting with a MVA virus expressing
HIVA (MVA.HIVA). Phase II clinical trials of the vaccine are underway in Kenya
and the UK.
Rapid Identification of Infants for Antiretroviral Therapy in a Resource

Poor Setting: The Kenya Experience.
Author: Khamadi, S.; Okoth, V.; Lihana, R.; Nabwera, J.; Hungu, J.; Okoth, F.; Lubano, K.,
and Mwau, M.
Source: J Trop Pediatr. 2008 May 29.
Abstract: In Kenya, HIV diagnosis is not routinely carried out in infants, and yet rapid
diagnosis could improve access to lifesaving interventions. A cheap and readily
accessible service can resolve this problem, if feasible. In this pilot study the
feasibility and costs of provision of an infant HIV diagnosis service in Kenya are
evaluated. Dried blood spots (DBS) were collected from infants exposed to HIV,
sent to a central testing laboratory and tested using the Roche Amplicor v. 1.5
DNA PCR kit. The results were then dispatched to health facilities within a week.
189
A total of 15.4% of the samples tested HIV+ despite the widespread access to
prevention of mother to child transmission (PMTCT) programs in Kenya. The
cost per test at 21.50 USD is prohibitive and will limit access to diagnosis. It
remains to be seen whether the increase in testing will immediately lead to an
increase in access to antiretroviral therapy (ART) services for infants.

Author: Khamadi, S. A.; Ochieng, W.; Lihana, R. W.; Kinyua, J.; Muriuki, J.; Mwangi, J.;
Lwembe, R.; Kiptoo, M.; Osman, S.; Lagat, N.; Pelle, R.; Muigai, A.; Carter, J. Y.;
Oishi, I.; Ichimura, H.; Mwaniki, D. L.; Okoth, F. A.; Mpoke, S., and Songok, E.
M.
Source: AIDS Res Hum Retroviruses. 2005 Sep; 21(9):810-4.
Kenya, which borders Ethiopia50% were subtype A, 39% subtype C, and 11%
subtype D. This shows that in the northern border region of Kenya subtypes A
and C are the dominant HIV-1 subtypes in circulation. Ethiopia is dominated
mainly by HIV-1 subtype C, which incidentally is the dominant subtype in the
town of Moyale, which borders Ethiopia. These results show that cross-border
movements play an important role in the circulation of subtypes in Northern
Kenya., Somalia, and Sudan. From the analysis of partial env sequences, it was
determined that
Genetic analysis of HIV-1 subtypes in Nairobi, Kenya.

Author: Khoja, S.; Ojwang, P.; Khan, S.; Okinda, N.; Harania, R., and Ali, S.
Genetic analysis of a viral infection helps in following its spread in a given
population, in tracking the routes of infection and, where applicable, in vaccine
design. Additionally, sequence analysis of the viral genome provides information
about patterns of genetic divergence that may have occurred during viral
evolution.
190
Objective:
In this study we have analyzed the subtypes of Human Immunodeficiency Virus
-1 (HIV-1) circulating in a diverse sample population of Nairobi, Kenya.
Methodology:
69 blood samples were collected from a diverse subject population attending the
Aga Khan University Hospital in Nairobi, Kenya. Total DNA was extracted from
peripheral blood mononuclear cells (PBMCs), and used in a Polymerase Chain
Reaction (PCR) to amplify the HIV gag gene. The PCR amplimers were partially
sequenced, and alignment and phylogenetic analysis of these sequences was
performed using the Los Alamos HIV Database.
Results:
Blood samples from 69 HIV-1 infected subjects from varying ethnic backgrounds
were analyzed. Sequence alignment and phylogenetic analysis showed 39
isolates to be subtype A, 13 subtype D, 7 subtype C, 3 subtype AD and
CRF01_AE, 2 subtype G and 1 subtype AC and 1 AG. Deeper phylogenetic
analysis revealed HIV subtype A sequences to be highly divergent as compared
to subtypes D and C.
Conclusion:
Our analysis indicates that HIV-1 subtypes in the Nairobi province of Kenya are
dominated by a genetically diverse clade A. Additionally, the prevalence of
highly divergent, complex subtypes, intersubtypes, and the recombinant forms
indicates viral mixing in Kenyan population, possibly as a result of dual
infections.
Reference ranges for the clinical laboratory derived from a rural

population in Kericho, Kenya.
Author: Kibaya, R. S.; Bautista, C. T.; Sawe, F. K.; Shaffer, D. N.; Sateren, W. B.; Scott, P.
T.; Michael, N. L.; Robb, M. L.; Birx, D. L., and de Souza, M. S.
Source: PLoS ONE. 2008; 3(10):e3327.
Abstract: The conduct of Phase I/II HIV vaccine trials internationally necessitates the
development of region-specific clinical reference ranges for trial enrollment and
participant monitoring. A population based cohort of adults in Kericho, Kenya, a
potential vaccine trial site, allowed development of clinical laboratory reference
ranges. Lymphocyte immunophenotyping was performed on 1293 HIV
seronegative study participants. Hematology and clinical chemistry were
performed on up to 1541 cohort enrollees. The ratio of males to females was 1.9:1.
Means, medians and 95% reference ranges were calculated and compared with
those from other nations. The median CD4+ T cell count for the group was 810
cells/microl. There were significant gender differences for both red and white
blood cell parameters. Kenyan subjects had lower median hemoglobin
concentrations (9.5 g/dL; range 6.7-11.1) and neutrophil counts (1850
191
cells/microl; range 914-4715) compared to North Americans. Kenyan clinical

chemistry reference ranges were comparable to those from the USA, with the
exception of the upper limits for bilirubin and blood urea nitrogen, which were
2.3-fold higher and 1.5-fold lower, respectively. This study is the first to assess
clinical reference ranges for a highland community in Kenya and highlights the
need to define clinical laboratory ranges from the national community not only
for clinical research but also care and treatment.
Adverse Events in HIV-Infected Persons Receiving Antiretroviral Drug

Regimens in a Large Urban Slum in Nairobi, Kenya, 2003-2005.
Author: Kim, A. A.; Wanjiku, L.; Macharia, D. K.; Wangai, M.; Isavwa, A.; Abdi, H.;
Marston, B. J.; Ilako, F.; Kjaer, M.; Chebet, K.; De Cock, K. M., and Weidle, P. J.
Source: J Int Assoc Physicians AIDS Care (Chic Ill). 2007 Sep; 6(3):206-9.
This article describes toxicities to antiretroviral therapy (ART) among HIV-
infected patients receiving care at a clinic in a large urban slum in Nairobi,
Kenya.
Methods:
Patients were treated with nonnucleoside reverse transcriptase inhibitor-based
ART and followed at scheduled intervals. Frequencies and cumulative
probabilities of toxicities were calculated.
Results:
Among 283 patients starting ART, any and severe clinical toxicity were recorded
as 65% and 6%, respectively. Cumulative probabilities for remaining free of any
and severe clinical toxicities at 6, 12, and 18 months, were 0.47, 0.26, and 0.17,
respectively and 0.98, 0.95, and 0.89, respectively. The probability of remaining
free from elevated and grade 3 or 4 serum aminotransferase (AST) at 6, 12, and
18 months were 0.62, 0.42, and 0.21, respectively, and 0.99 at 6, 12, and 18
months.
Conclusions:
ART toxicities were frequent, but severe toxicities were less common. In
resource-limited settings, ART toxicity should not represent a barrier to care.
192
IL-7Ralpha expression on CD4+ T lymphocytes decreases with HIV

disease progression and inversely correlates with immune activation.
Author: Koesters, S. A.; Alimonti, J. B.; Wachihi, C.; Matu, L.; Anzala, O.; Kimani, J.;
Embree, J. E.; Plummer, F. A., and Fowke, K. R.
Source: Eur J Immunol. 2006 Feb; 36(2):336-44.
Abstract: Many factors can influence the rate of HIV disease progression, including those
that maintain T cell homeostasis. One key homeostatic regulator is the IL-7
receptor (IL-7R). Previous studies have shown IL-7R expression levels decrease
in HIV infection, but effects on memory subtypes, CD4(+) T cells, and cell
function have not been explored. The present study examined the expression of
the IL-7Ralpha chain on naive and memory T lymphocyte subsets of both HIV-
positive and HIV-negative individuals from Nairobi, Kenya to assess the role of
IL-7Ralpha in HIV disease. Expression of IL-7Ralpha was significantly reduced
in all CD4(+) and CD8(+) T cell subsets in HIV-positive individuals. This
reduction was further enhanced in those with advanced HIV progression.
Expression of IL-7Ralpha was inversely correlated to immune activation, and
apoptosis, and was positively correlated with CD4 count in both bivariate and
multivariate analysis. Expression of IL-7Ralpha did not correlate with HIV viral
loads, indicating the elevated immune activation seen in HIV-infected
individuals may be impacting expression of IL-7Ralpha, independent of viral
loads. Signaling via the IL-7R is essential for T cell homeostasis and maintenance
of T cell memory. Reduction of this receptor may contribute to the homeostatic
disruption seen in HIV.
Social networks and HIV/AIDs risk perceptions.

Author: Kohler, H. P.; Behrman, J. R., and Watkins, S. C.
Source: Demography. 2007 Feb; 44(1):1-33.

193
control for unobserved factors.
Etiology and resistance patterns of respiratory isolates in Kenyan adults

with AIDS from slum population.
Author: Krcmery, V.; Benca, J.; Liskova, A.; Mitterpachova, E.; Kolenova, A.; Sladeckova,
V.; Horvathova, D., and Kiwou, M.
Source: Neuro Endocrinol Lett. 2007 Nov; 28 Suppl 3:37-9.
Abstract: We investigated regularly swabs of adults dispenzarised at Mary Immaculate

Clinic of Trnava University in Nairobi providing free health care for about 50 000
population of Mukuru Slums. 20 patients who were treated for AIDS by our
clinic (those who started HAART before Free National AIDS Cooperation
Programme - NASCOP) were assessed after 1, 2 and 3 years (18 of 20 completed
the survey, other 2 loss of follow up, probably died. Exposure to other molecules
can select resistant mutants. Previous exposure to TMP/SMX was similar in
both groups and therefore was not responsible for the difference between
resistance patterns.

District, Kenya.
Author: Krieger, J. N.; Bailey, R. C.; Opeya, J.; Ayieko, B.; Opiyo, F.; Agot, K.; Parker, C.;
Ndinya-Achola, J. O.; Magoha, G. A., and Moses, S.
Source: BJU Int. 2005 Nov; 96(7):1109-13.
controlled trial with the incidence of human immunodeficiency virus (HIV) as
the main outcome, as studies suggest that circumcision is associated with a lower
incidence of HIV and other sexually transmitted infections in high-risk
populations.

additional visits if necessary. Healing, satisfaction and resumption of activities
were assessed at these visits and 3 months from randomization.
194
Results:
Conclusion:
Associations of human leukocyte antigen DRB with resistance or

susceptibility to HIV-1 infection in the Pumwani Sex Worker Cohort.
Author: Lacap, P. A.; Huntington, J. D.; Luo, M.; Nagelkerke, N. J.; Bielawny, T.; Kimani,
J.; Wachihi, C.; Ngugi, E. N., and Plummer, F. A.
Source: AIDS. 2008 May 31; 22(9):1029-38.
A group of commercial sex workers in the Pumwani Sex Worker Cohort,
established in 1985 in Nairobi, Kenya, remain HIV-1 uninfected despite heavy
exposure to HIV-1 through active sex work. Previous studies showed that this
resistance is associated with a strong CD4+ T-cell response, which suggested that
human leukocyte antigen class II antigens are important in
resistance/susceptibility to HIV-1 infection. DRB1 is the most polymorphic locus
among class II genes and forms haplotypes with DRB3, DRB4 and DRB5. The
aim of this study is to investigate the role of DRB alleles/haplotypes on
resistance/susceptibility to HIV-1 infection.
Design:
In total, 1090 women enrolled in the Pumwani cohort were genotyped for DRB1,
DRB3, DRB4 and DRB5 using a high-resolution sequence-based method.
Allele/haplotype frequencies were compared between HIV-positive women and
women who have remained HIV negative for more than 3 years despite frequent
exposure.
195
Methods:
Human leukocyte antigen DRB genes were amplified, sequenced and genotyped
using a two-step sequence-based method. Allele/haplotype frequencies were
determined using PyPop32-0.6.0. Statistical analysis was conducted using SPSS
11.0 for Windows.
Results:
Three DRB1 alleles were associated with resistance: DRB1*010101 (P = 0.016; odd
ratio (OR): 2.55; 95% confidence interval (CI): 1.16-5.61), DRB1*010201 (P = 0.019;
OR: 1.86; 95% CI: 1.10-3.15), and DRB1*1102 (P = 0.025; OR: 1.72; 95% CI: 1.07-
2.78). DRB1*030201 (P = 0.038; OR: 0.48; 95% CI: 0.23-0.98), DRB1*070101 (P =
0.035; OR: 0.54; 95% CI: 0.30-0.97), DRB1*1503 (P = 0.0004; OR: 0.34; 95% CI: 0.19-
0.64), and DRB5*010101 (P = 0.001; OR: 0.37; 95% CI: 0.20-0.67) were associated
with susceptibility. The haplotype DRB1*1102-DRB3*020201 was associated with
HIV-1 resistance (P = 0.041; OR: 1.68; 95% CI: 1.02-2.78), whereas the haplotypes
DRB1*070101-DRB4*01010101 (P = 0.041; OR: 0.52; 95% CI: 0.28-0.98) and
DRB1*1503-DRB5*01010101 (P = 0.0002; OR: 0.30; 95% CI: 0.15-0.58) were
associated with susceptibility. These associations with resistance/susceptibility
to HIV-1 were independent of previously reported alleles HLA-DRB1*01 and
HLA-A*2301.
Conclusion:
Our findings indicate that human leukocyte antigen DRB-specific CD4+ T-cell
responses are an important factor in resistance/susceptibility to HIV-1 infection.

Author: Land, A. M.; Ball, T. B.; Luo, M.; Pilon, R.; Sandstrom, P.; Embree, J. E.; Wachihi,
C.; Kimani, J., and Plummer, F. A.
Source: J Virol. 2008 Aug; 82(16):8172-82.

196
purposes.
Full-length HIV type 1 proviral sequencing of 10 highly exposed women

from Nairobi, Kenya reveals a high proportion of intersubtype
recombinants.
Author: Land, A. M.; Ball, T. B.; Luo, M.; Rutherford, J.; Sarna, C.; Wachihi, C.; Kimani, J.,
and Plummer, F. A.
Source: AIDS Res Hum Retroviruses. 2008 Jun; 24(6):865-72.
Abstract: Phylogenetic analysis has revealed that the current HIV/AIDS pandemic consists
of a multitude of different viral clades and recombinant viruses. The
predominant circulating HIV-1 clade in Kenya is A1; however, Kenya borders
countries where different subtypes are prominent, making Kenya a likely
location for recombination. Previous studies have reported significant differences
in the proportions of sequences in Kenya that are intersubtype recombinants.
Studies that performed sequence-based typing on multiple HIV-1 genomic
regions or full-length sequences found higher rates of recombination than those
that examined a single gene or gene fragment. In this study, we describe full-
length HIV-1 proviral sequence-based genotyping after limited peripheral blood
mononuclear cell (PBMC) coculture. Ten subjects from a highly exposed cohort
located in Nairobi, Kenya were examined. Pairwise comparison found minimal
difference between sequences generated directly from patient PBMC DNA
compared to sequences from cocultured PBMC DNA. Of the 10 full-length HIV-1
sequences examined, five were nonrecombinant clade A1, while the other five
were unique intersubtype recombinants. Although this frequency of
recombination is higher than previously described in Kenya, this finding is in
agreement with previous full-length sequence data. Interestingly, although all
the nonrecombinant sequences were clade A1, not all the recombinant sequences
contained a clade A1 sequence.
197
Effects of antiretroviral therapy on work performance: preliminary

results from a cohort study of Kenyan agricultural workers.
Author: Larson, B. A.; Fox, M. P.; Rosen, S.; Bii, M.; Sigei, C.; Shaffer, D.; Sawe, F.;
Wasunna, M., and Simon, J. L.
Source: AIDS. 2008 Jan 30; 22(3):421-5.
This paper estimates the impact of antiretroviral therapy (ART) on days
harvesting tea per month for tea-estate workers in Kenya. Such information is
needed to assess the potential economic benefits of providing treatment to
working adults.
Methods:
Data for this analysis come from company payroll records for 59 HIV-infected
workers and a comparison group of all workers assigned to the same work teams
(reference group, n = 1992) for a period covering 2 years before and 1 year after
initiating ART. Mean difference tests were used to obtain overall trends in days
harvesting tea by month. A difference in difference approach was used to
estimate the impact of HIV/AIDS on days working in the pre-ART period.
Information on likely trends in the absence of the therapy was used to estimate
the positive impacts on days harvesting tea over the initial 12 months on ART.
Results:
No significant difference existed in days plucking tea each month until the ninth
month before initiating ART, when workers worked -2.79 fewer days than
references (15% less). This difference grew to 5.09 fewer days (27% less) in the
final month before initiating ART. After 12 months on ART, we conservatively
estimate that workers worked at least twice as many days in the month than they
would have in the absence of ART.
Conclusions:
Treatment had a large, positive impact on the ability of workers to undertake
their primary work activity, harvesting tea, in the first year on ART.
Higher set point plasma viral load and more-severe acute HIV type 1
(HIV-1) illness predict mortality among high-risk HIV-1-infected African
women.
Author: Lavreys, L.; Baeten, J. M.; Chohan, V.; McClelland, R. S.; Hassan, W. M.;
Richardson, B. A.; Mandaliya, K.; Ndinya-Achola, J. O., and Overbaugh, J.
Source: Clin Infect Dis. 2006 May 1; 42(9):1333-9.
198
There is limited information on the natural history of human immunodeficiency

virus type 1 (HIV-1) infection in Africa, especially from individuals with well-
defined dates of infection. We used data from a prospective cohort study of
female sex workers in Mombasa, Kenya, who were followed up monthly from
before the date of HIV-1 infection.
Methods:
Antiretroviral-naive women who had a well-defined date of HIV-1 infection
were included in this analysis. The effects of set point plasma viral load
(measured 4-24 months after infection), early CD4+ cell count, and symptoms of
acute HIV-1 infection on mortality were assessed using Cox proportional hazards
analysis.
Results:
Among 218 women, the median duration of follow-up after HIV-1 infection was
4.6 years. Forty women died, and at 8.7 years (the time of the last death), the
cumulative survival rate was 51% by Kaplan-Meier analysis. Higher set point
viral load, lower early CD4+ cell count, and more-symptomatic acute HIV-1
illness each predicted death. In multivariate analysis, set point viral load (hazard
ratio [HR], 2.28 per 1 log10 copies/mL increase; P=.001) and acute HIV-1 illness
(HR, 1.14 per each additional symptom; P=.05) were independently associated
with higher mortality.
Conclusion:
Among this group of African women, the survival rate was similar to that for
HIV-1-infected individuals in industrialized nations before the introduction of
combination antiretroviral therapy. Higher set point viral load and more-severe
acute HIV-1 illness predicted faster progression to death. Early identification of
individuals at risk for rapid disease progression may allow closer clinical
monitoring, including timely initiation of antiretroviral treatment.
Commercial sex and HIV transmission in mature epidemics: a study of

five African countries.
Author: Leclerc, P. M. and Garenne, M.
Source: Int J STD AIDS. 2008 Oct; 19(10):660-4.
Abstract: The study compares the association between using the services of commercial sex
workers and male HIV seroprevalence in five African countries: Ghana, Kenya,
Lesotho, Malawi and Rwanda. The HIV seroprevalence among men who 'ever
paid for sex' was compared with controls who 'never paid for sex'. Results were
based on 12,929 eligible men, aged 15-59 years, interviewed in Demographic and
Health Surveys. The odds ratio of HIV seroprevalence associated with ever
paying for sex was 1.89 (95% confidence interval = 1.57-2.28), with only minor
differences by country. The results were stable in multivariate analysis after
controlling for available potential cofactors (data on non-sexual routes of
199
transmission were not available). Given the relatively small proportion of men
involved, the risk attributable to 'ever paying for sex' remained low: 7.1% in
univariate analysis and 4.4% after adjustment, and it varied among countries
(range 1.3-9.4%). These results match previous observations that commercial sex
seems to play a minor role in the spread of HIV in mature epidemics.
Toll-like receptor expression and responsiveness are increased in

viraemic HIV-1 infection.
Author: Lester, R. T.; Yao, X. D.; Ball, T. B.; McKinnon, L. R.; Kaul, R.; Wachihi, C.; Jaoko,
W.; Plummer, F. A., and Rosenthal, K. L.
Source: AIDS. 2008 Mar 30; 22(6):685-94.
Toll-like receptors (TLR) are important in pathogen recognition and may play a
role in HIV disease. We evaluated the effect of chronic untreated and treated
HIV-1 infection on systemic TLR expression and TLR signalling. METHODS:
Two hundred HIV-infected and uninfected women from a Kenya cohort
participated in the studies. TLR1 to TLR10 messenger RNA expression was
determined by quantitative reverse transcriptase polymerase chain reaction in
peripheral blood mononuclear cells (PBMC). TLR ligand responsiveness was
determined in or using ex-vivo PBMC by cytokine production in culture
supernatants.
Results:
Chronic, untreated HIV-1 infection was significantly associated with increased
mRNA expression of TLR6, TLR7, and TLR8 and when analysis was limited to
those with advanced disease (CD4 cell count < 200 cells/ml) TLR2, TLR3, and
TLR4 were additionally elevated. TLR expression correlated with the plasma
HIV-RNA load, which was significant for TLR6 and TLR7. In vitro HIV single-
stranded RNA alone could enhance TLR mRNA expression. PBMC of HIV-
infected subjects also demonstrated profoundly increased proinflammatory
responsiveness to TLR ligands, suggesting sensitization of TLR signalling in
HIV. Finally, viral suppression by HAART was associated with a normalization
of TLR levels.
Conclusion:
Together, these data indicate that chronic viraemic HIV-1 is associated with
increased TLR expression and responsiveness, which may perpetuate innate
immune dysfunction and activation that underlies HIV pathogenesis, and thus
reveal potential new targets for therapy
HIV type 1 subtypes among STI patients in Nairobi: a genotypic study

based on partial pol gene sequencing.
200
Author: Lihana, R. W.; Khamadi, S. A.; Kiptoo, M. K.; Kinyua, J. G.; Lagat, N.; Magoma,
G. N.; Mwau, M. M.; Makokha, E. P.; Onyango, V.; Osman, S.; Okoth, F. A., and
Songok, E. M.
Source: IDS Res Hum Retroviruses. 2006 Nov; 22(11):1172-7.
Abstract: Circulating strains of human immunodeficiency virus (HIV) exhibit an

extraordinary degree of genetic diversity and have been classified on the basis of
relationships into distinct lineages called groups, types, subtypes, and
subsubtypes. Sexually transmitted infections (STIs) are known to be a risk factor
for HIV infection. To establish HIV-1 subtype diversity among STI patients in
Nairobi, 140 samples were collected and partial pol gene sequencing done. From
the analysis it was established that subtype A1 was the major subtype (64%)
followed by D (17%), C (9%), G (1%), and recombinants AD (4%), AC (3%),
CRF02()AG (1%), and CRF16()A2D (1%). These results suggest that the HIV-1
epidemic may be evolving toward more virulent and complex subtypes through
transmission of complex recombinants due to viral mixing. Any use of ARVs
may therefore require initial testing for de novo resistance before commencement
of treatment and/or management.
Longitudinal assessment of human immunodeficiency virus type 1 (HIV-

1)-specific gamma interferon responses during the first year of life in
HIV-1-infected infants.
Author: Lohman, B. L.; Slyker, J. A.; Richardson, B. A.; Farquhar, C.; Mabuka, J. M.;
Crudder, C.; Dong, T.; Obimbo, E.; Mbori-Ngacha, D.; Overbaugh, J.; Rowland-
Jones, S., and John-Stewart, G.
Source: J Virol. 2005 Jul; 79(13):8121-30.
Abstract: Human immunodeficiency virus type 1 (HIV-1) infection results in different

patterns of viral replication in pediatric compared to adult populations. The role
of early HIV-1-specific responses in viral control has not been well defined,
because most studies of HIV-1-infected infants have been retrospective or cross-
sectional. We evaluated the association between HIV-1-specific gamma
interferon (IFN-gamma) release from the cells of infants of 1 to 3 months of age
and peak viral loads and mortality in the first year of life among 61 Kenyan HIV-
1-infected infants. At 1 month, responses were detected in 7/12 (58%) and 6/21
(29%) of infants infected in utero and peripartum, respectively (P = 0.09), and in
approximately 50% of infants thereafter. Peaks of HIV-specific spot-forming
units (SFU) increased significantly with age in all infants, from 251/10(6)
peripheral blood mononuclear cells (PBMC) at 1 month of age to 501/10(6)
PBMC at 12 months of age (P = 0.03), although when limited to infants who
survived to 1 year, the increase in peak HIV-specific SFU was no longer
significant (P = 0.18). Over the first year of life, infants with IFN-gamma
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responses at 1 month had peak plasma viral loads, rates of decline of viral load,
and mortality risk similar to those of infants who lacked responses at 1 month.
The strength and breadth of IFN-gamma responses at 1 month were not
significantly associated with viral containment or mortality. These results
suggest that, in contrast to HIV-1-infected adults, in whom strong cytotoxic T
lymphocyte responses in primary infection are associated with reductions in
viremia, HIV-1-infected neonates generate HIV-1-specific CD8+-T-cell responses
early in life that are not clearly associated with improved clinical outcomes.
Impact of five years of peer-mediated interventions on sexual behavior

and sexually transmitted infections among female sex workers in
Mombasa, Kenya.
Author: Luchters, S.; Chersich, M. F.; Rinyiru, A.; Barasa, M. S.; King'ola, N.; Mandaliya,
K.; Bosire, W.; Wambugu, S.; Mwarogo, P., and Temmerman, M.
Source: BMC Public Health. 2008; 8:143.
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.
Methods:
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.
Results:
Over five years, sex work became predominately a full-time activity, with
increased mean sexual partners (2.8 versus 4.9/week; P < 0.001). Consistent
condom use with clients increased from 28.8% (145/503) to 70.4% (356/506; P <
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 > or = 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 (P = 0.36).
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Conclusion:
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.
Safer sexual behaviors after 12 months of antiretroviral treatment in

Mombasa, Kenya: a prospective cohort.
Author: Luchters, S.; Sarna, A.; Geibel, S.; Chersich, M. F.; Munyao, P.; Kaai, S.;
Mandaliya, K. N.; Shikely, K. S.; Rutenberg, N., and Temmerman, M.
Source: AIDS Patient Care STDS. 2008 Jul; 22(7):587-94.
Abstract: Roll-out of antiretroviral treatment (ART) raises concerns about the potential for
unprotected sex if sexual activity increases with well-being, resulting in
continued HIV spread. Beliefs about reduced risk for HIV transmission with
ART may also influence behavior. From September 2003 to November 2004, 234
adults enrolled in a trial assessing the efficacy of modified directly observed
therapy in improving adherence to ART. Unsafe sexual behavior (unprotected
sex with an HIV-negative or unknown status partner) before starting ART and 12
months thereafter was compared. Participants were a mean 37.2 years (standard
deviation [SD] = 7.9 years) and 64% (149/234) were female. Nearly half
(107/225) were sexually active in the 12 months prior to ART, the majority
(96/107) reporting one sexual partner. Unsafe sex was reported by half of those
sexually active in the 12 months before ART (54/107), while after 12 months
ART, this reduced to 28% (30/107). Unsafe sex was associated with
nondisclosure of HIV status to partner; recent HIV diagnosis; not being married
or cohabiting; stigma; depression and body mass index <18.5 kg/m(2). ART
beliefs, adherence, and viral suppression were not associated with unsafe sex.
After adjusting for gender and stigma, unsafe sex was 0.59 times less likely after
12 months ART than before initiation (95% confidence interval [CI] = 0.37-0.94; p
= 0.026). In conclusion, although risky sexual behaviors had decreased, a
considerable portion do not practice safe sex. Beliefs about ART's effect on
transmission, viral load, and adherence appear not to influence sexual behavior
but require long-term surveillance. Positive prevention interventions for those
receiving ART must reinforce safer sex practices and partner disclosure
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Challenges of a pandemic: HIV/AIDS-related problems affecting Kenyan

widows.
Author: Luginaah, I.; Elkins, D.; Maticka-Tyndale, E.; Landry, T., and Mathui, M.
Source: Soc Sci Med. 2005 Mar; 60(6):1219-28.
Abstract: The paper reports the findings of a qualitative study using focus group
discussions and in-depth interviews about the challenges faced by widows as
they confront the direct and indirect impacts of HIV/AIDS in Nyanza, Kenya.
Two focus groups were conducted with widows from two community-based
organizations. This was followed by in-depth interviews with four members and
two leaders from each of the community-based organizations. The contents were
analysed using grounded theory. The findings reveal several challenges
encountered by widows in their struggles with the direct and indirect impacts of
HIV/AIDS. Widows who know or do not know their HIV status are conscious
about the possibility of contracting or transmitting the virus. Wife inheritance (a
Luo custom), emerged as an outstanding issue for the widows in the context of
HIV/AIDS transmission. The widows employ various strategies to resist being
inherited. Widows in the current epidemic navigate issues of sexuality in various
ways, such as insisting their partners use condoms or permanently abstaining
from sexual intercourse.
Confronting the 'sugar daddy' stereotype: age and economic asymmetries

and risky sexual behavior in urban Kenya.
Author: Luke, N.
Source: Int Fam Plan Perspect. 2005 Mar; 31(1):6-14.
Abstract: Context:
"Sugar daddy" relationships, which are characterized by large age and economic
asymmetries between partners, are believed to be a major factor in the spread of
HIV in Sub-Saharan Africa. Information is needed about sugar daddy
partnerships-and about age and economic asymmetries more generally-to
determine how common they are and whether they are related to unsafe sexual
behavior.
Methods:
The sample comprised 1,052 men aged 21-45 who were surveyed in Kisumu,
Kenya, in 2001. Data on these men and their 1,614 recent non-marital
partnerships were analyzed to calculate the prevalence of sugar daddies and
sugar daddy relationships, as well as a range of age and economic disparities
within non-marital partnerships. Logistic regression models were constructed to
assess relationships between condom use at last sexual intercourse and various
measures of age and economic asymmetry.
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Results:
The mean age difference between non-marital sexual partners was 5.5 years, and
47% of men's female partners were adolescents. Fourteen percent of partnerships
involved an age difference of at least 10 years, and 23% involved more than the
mean amount of male-to-female material assistance. Men who reported at least
one partnership with both these characteristics were defined as sugar daddies
and made up 5% of the sample; sugar daddy relationships accounted for 4% of
partnerships. Sugar daddy partnerships and the largest age and economic
asymmetries we constructed were associated with decreased odds of condom
use.
Conclusions:
Although sugar daddy relationships are not as pervasive as generally assumed,
age and economic asymmetries in non-marital partnerships are relatively
common. All these types of asymmetries are associated with nonuse of condoms.
Increasing women's power within asymmetric sexual relationships could
improve their ability to negotiate safer sexual behaviors, such as condom use.
Anti-retroviral drug resistance-associated mutations among non-subtype

B HIV-1-infected Kenyan children with treatment failure.
Author: Lwembe, R.; Ochieng, W.; Panikulam, A.; Mongoina, C. O.; Palakudy, T.;
Koizumi, Y.; Kageyama, S.; Yamamoto, N.; Shioda, T.; Musoke, R.; Owens, M.;
Songok, E. M.; Okoth, F. A., and Ichimura, H.
Source: J Med Virol. 2007 Jul; 79(7):865-72.
Abstract: Recently increased availability of anti-retroviral therapy (ART) has mitigated

HIV-1/AIDS prognoses especially in resource poor settings. The emergence of
ART resistance-associated mutations from non-suppressive ART has been
implicated as a major cause of ART failure. Reverse transcriptase inhibitor (RTI)-
resistance mutations among 12 non-subtype B HIV-1-infected children with
treatment failure were evaluated by genotypically analyzing HIV-1 strains
isolated from plasma obtained between 2001 and 2004. A region of pol-RT gene
was amplified and at least five clones per sample were analyzed. Phylogenetic
analysis revealed HIV-1 subtype A1 (n = 7), subtype C (n = 1), subtype D (n = 3),
and CRF02_AG (n = 1). Before treatment, 4 of 12 (33.3%) children had primary
RTI-resistance mutations, K103N (n = 3, ages 5-7 years) and Y181C (n = 1, age 1
year). In one child, K103N was found as a minor population (1/5 clones) before
treatment and became major (7/7 clones) 8 months after RTI treatment. In 7 of 12
children, M184V appeared with one thymidine-analogue-associated mutation
(TAM) as the first mutation, while the remaining 5 children had only TAMs
appearing either individually (n = 2), or as TAMs 1 (M41L, L210W, and T215Y)
and 2 (D67N, K70R, and K219Q/E/R) appearing together (n = 3). These results
suggest that "vertically transmitted" primary RTI-resistance mutations, K103N
and Y181C, can persist over the years even in the absence of drug pressure and
205
impact RTI treatment negatively, and that appearing patterns of RTI-resistance

mutations among non-subtype B HIV-1-infected children could possibly be
different from those reported in subtype B-infected children.
Prevalence of dyslipidemia and dysglycaemia in HIV infected patients.

Author: Manuthu, E. M.; Joshi, M. D.; Lule, G. N., and Karari, E.
Source: East Afr Med J. 2008 Jan; 85(1):10-7.
Highly active antiretroviral therapy (HAART) has dramatically reduced AIDS
morbidity and mortality, however long-term metabolic consequences including
dysglycaemia and dyslipidemia have raised concern regarding accelerated
cardiovascular disease risk.
Objective:
To determine the period prevalence of dyslipidemia and dysglycaemia in HIV-
infected patients. DESIGN: Cross-sectional comparative group study.
Setting:
Kenyatta National Hospital, a tertiary HIV dedicated out-patient facility.
Subjects: Consecutive HIV- positive adult patients.

Dyslipidemia: presence of raised total or LDL cholesterol or low HDL
cholesterol, or raised triglycerides. Dysglycaemia: presence of impaired fasting
glucose or impaired glucose tolerance, or diabetes mellitus. Results: Between
January and April 2006, out of 342 screened patients, 295 were recruited and
58% were females. One hundred and thirty four (45%) were on HAART, 82% of
whom were on stavudine, lamivudine and either nevirapine or efavirenz.
Overall prevalence of dyslipidemiawas 63.1% and dysglycaemia was 20.7%.
High total cholesterol occurred in 39.2% of HAART and 10.0% HAART naive
patients (p<0.0001, OR 5.18, CI 3.11-10.86), whereas high LDL cholesterol
occurred in 40.8% and in 11.2% respectively (p<0.0001, OR 5.43, CI 2.973-9.917).
HDL levels were low in 14.6% and 51.3% among HAART and HAART naive
patients, respectively, (p<0.0001, OR 0.16, CI 0.091-0.29) while high triglycerides
occurred in 25.6% and 22.5% respectively (p=0.541 OR 1.184 CI 0.688-2.037).
Among patients on HAART compared to HAART naive patients, diabetes was
found in 1.5% against 1.2% (p=0.85), impaired fasting in 2.2% against 0.6%
(p=0.30) and impaired glucose tolerance in 16.4% against 21.1% (p=0.22),
respectively.
Conclusions:
HIV- infected patients demonstrated a high prevalence of dyslipidemia. HAART
use was associated with high levels of total, and LDL cholesterol and high
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triglyceride levels, an established athrogenic lipid profile. However, HAART was

not associated with low HDL cholesterol and had no significant effect on
dysglycaemia.
A program to provide antiretroviral therapy to residents of an urban

slum in nairobi, kenya.
Author: Marston, B. J.; Macharia, D. K.; Nga'nga, L.; Wangai, M.; Ilako, F.; Muhenje, O.;
Kjaer, M.; Isavwa, A.; Kim, A.; Chebet, K.; Decock, K. M., and Weidle, P. J.
Source: J Int Assoc Physicians AIDS Care (Chic Ill). 2007 Jun; 6(2):106-12.
To evaluate retention in care and response to therapy for patients enrolled in an
antiretroviral treatment program in a severely resource-constrained setting.
Methods:
We evaluated patients enrolled between February 26, 2003, and February 28,
2005, in a community clinic in Kibera, an informal settlement, in Nairobi, Kenya.
Midlevel providers offered simplified, standardized antiretroviral therapy (ART)
regimens and monitored patients clinically and with basic laboratory tests.
Clinical, immunologic, and virologic indicators were used to assess response to
ART; adherence was determined by 3-day recall. A total of 283 patients (70%
women; median baseline CD4 count, 157 cells/ mm(3); viral load, 5.16 log
copies/mL) initiated ART and were followed for a median of 7.1 months (n =
2384 patient-months).
Results:
At 1 year, the median CD4 count change was +124.5 cells/mm(3) (n = 74;
interquartile range, 42 to 180), and 71 (74%) of 96 patients had viral load <400
copies/mL. The proportion of patients reporting 100% adherence over the 3 days
before monthly clinic visits was 94% to 100%. As of February 28, 2005, a total of
239 patients (84%) remained in care, 22 (8%) were lost to follow-up, 12 (4%) were
known to have died, 5 (2%) had stopped ART, 3 (1%) moved from the area, and
2 (< 1% ) transferred care.
Conclusions:
Response to ART in this slum population was comparable to that seen in
industrialized settings. With government commitment, donor support, and
community involvement, it is feasible to implement successful ART programs in
extremely challenging social and environmental conditions.
Using mass media campaigns to promote voluntary counseling and HIV-

testing services in Kenya.
Author: Marum, E.; Morgan, G.; Hightower, A.; Ngare, C., and Taegtmeyer, M.
207
Source: AIDS. 2008 Oct 1; 22(15):2019-24.
Kenya, a country with high HIV prevalence, has seen a rapid scale-up of
voluntary counseling and HIV-testing (VCT) services from three sites in 2000 to
585 by June 2005. From 2002 onwards, services were promoted by a four-phase
professionally designed mass media campaign.
Objective:
To assess the impact of a mass media campaign on VCT services. DESIGN:
Observational data from client records.
Methods:
VCT client data from 131 voluntary counseling and testing sites were included.
Descriptive statistics and Poisson regression were used to assess the impact of
campaign phases.
Results:
Client records (381,160) from 131 sites were analyzed. A linear increase in new
sites and an exponential increase in client utilization were observed. Regression
analysis revealed that the first phase of the campaign increased attendance by
28.5% (95% confidence interval = 15.9, 42.5%) and the fourth by 42.5% (95%
confidence interval = 28.4, 64.1%). These two phases, which directly mentioned
HIV, had more impact on utilization than the second and third phases, which did
not have a significant effect.
Conclusion:
The Kenyan experience suggests that a professional, intensive mass media
campaign is likely to contribute to increases in utilization of testing. Expansion of
programs for counseling and HIV testing in developing countries is likely to be
facilitated by mass media promotion of these services.
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Acceptability of male circumcision and predictors of circumcision

preference among men and women in Nyanza Province, Kenya.
Author: Mattson, C. L.; Bailey, R. C.; Muga, R.; Poulussen, R., and Onyango, T.
Source: AIDS Care. 2005 Feb; 17(2):182-94.
Abstract: Numerous epidemiologic studies report significant associations between lack of

male circumcision and HIV-1 infection, leading some to suggest that male
circumcision be added to the limited armamentarium of HIV prevention
strategies in areas where HIV prevalence is high and the mode of transmission is
primarily heterosexual. This cross-sectional survey of 107 men and 110 women in
Nyanza Province, Kenya, assesses the attitudes, beliefs, and predictors of
circumcision preference among men and women in a traditionally non-
circumcising region. Sixty per cent (n=64) of uncircumcised men and 69% (n=68)
of women who had uncircumcised regular partners reported that they would
prefer to be circumcised or their partners to be circumcised. Men's circumcision
preference was associated with the belief that it is easier for uncircumcised men
to get penile cancer, sexually transmitted diseases, and HIV/AIDS, and that
circumcised men have more feeling in their penises, enjoy sex more, and confer
more pleasure to their partners. Women with nine or more years of school were
more likely to prefer circumcised partners. Men who preferred to remain
uncircumcised were concerned about the pain and cost of the procedure, and
pain was a significant deterrent for women to agree to circumcision for their
sons. If clinical trials prove circumcision to be efficacious in reducing risk of HIV
infection, it is likely that the procedure will be sought by a significant proportion
of the population, especially if it is affordable and minimally painful.
Risk compensation is not associated with male circumcision in Kisumu,

Kenya: a multi-faceted assessment of men enrolled in a randomized
controlled trial.
Author: Mattson, C. L.; Campbell, R. T.; Bailey, R. C.; Agot, K.; Ndinya-Achola, J. O., and
Moses, S.
Three randomized controlled trials (RCTs) have confirmed that male
circumcision (MC) significantly reduces acquisition of HIV-1 infection among
men. The objective of this study was to perform a comprehensive, prospective
evaluation of risk compensation, comparing circumcised versus uncircumcised
controls in a sample of RCT participants.
209

Between March 2004 and September 2005, we systematically recruited men
enrolled in a RCT of MC in Kenya. Detailed sexual histories were taken using a
modified Timeline Followback approach at baseline, 6, and 12 months.
Participants provided permission to obtain circumcision status and laboratory
results from the RCT. We evaluated circumcised and uncircumcised men's
sexual behavior using an 18-item risk propensity score and acquisition of
incident infections of gonorrhea, chlamydia, and trichomoniasis. Of 1780 eligible
RCT participants, 1319 enrolled (response rate = 74%). At the baseline RCT visit,
men who enrolled in the sub-study reported the same sexual behaviors as men
who did not. We found a significant reduction in sexual risk behavior among
both circumcised and uncircumcised men from baseline to 6 (p<0.01) and 12 (p =
0.05) months post-enrollment. Longitudinal analyses indicated no statistically
significant differences between sexual risk propensity scores or in incident
infections of gonorrhea, chlamydia, and trichomoniasis between circumcised and
uncircumcised men. These results are based on the most comprehensive analysis
of risk compensation yet done.
Conclusion:
In the context of a RCT, circumcision did not result in increased HIV risk
behavior. Continued monitoring and evaluation of risk compensation associated
with circumcision is needed as evidence supporting its' efficacy is disseminated
and MC is widely promoted for HIV prevention.
Scaling Sexual Behavior or "Sexual Risk Propensity" Among Men at Risk

for HIV in Kisumu, Kenya.
Author: Mattson, C. L.; Campbell, R. T.; Karabatsos, G.; Agot, K.; Ndinya-Achola, J. O.;
Moses, S., and Bailey, R. C.
Source: AIDS Behav. 2008 Jul 24.
Abstract: We present a scale to measure sexual risk behavior or "sexual risk propensity" to
evaluate risk compensation among men engaged in a randomized clinical trial of
male circumcision. This statistical approach can be used to represent each
respondent's level of sexual risk behavior as the sum of his responses on multiple
dichotomous and rating scale (i.e. ordinal) items. This summary "score" can be
used to summarize information on many sexual behaviors or to evaluate changes
in sexual behavior with respect to an intervention. Our 18 item scale
demonstrated very good reliability (Cronbach's alpha of 0.87) and produced a
logical, unidimensional continuum to represent sexual risk behavior. We found
no evidence of differential item function at different time points (except for
reporting a concurrent partners when comparing 6 and 12 month follow-up
visits) or with respect to the language with which the instrument was
administered. Further, we established criterion validity by demonstrating a
statistically significant association between the risk scale and the acquisition of
incident sexually transmitted infections (STIs) at the 6 month follow-up and HIV
210
at the 12 month follow-up visits. This method has broad applicability to evaluate
sexual risk behavior in the context of other HIV and STI prevention interventions
(e.g. microbicide or vaccine trials), or in response to treatment provision (e.g.,
anti-retroviral therapy
A comparison of genital HIV-1 shedding and sexual risk behavior among

Kenyan women based on eligibility for initiation of HAART according
to WHO guidelines.
Author: McClelland, R. S.; Baeten, J. M.; Richardson, B. A.; Lavreys, L.; Emery, S.;
Mandaliya, K.; Ndinya-Achola, J. O., and Overbaugh, J.
Source: J Acquir Immune Defic Syndr. 2006 Apr 15; 41(5):611-5.
Guidelines for initiating antiretrovirals are based on markers of advanced
disease and are not directly linked to markers of HIV-1 transmission such as viral
shedding.
Methods:
We evaluated genital HIV-1 shedding and risk behavior among 650
antiretroviral-naive women stratified by WHO criteria for initiating
antiretrovirals based on CD4 count and symptoms.
Results:
Genital HIV-1 concentrations increased in stepwise fashion with declining CD4
counts and the presence of symptoms. Compared with the reference group
(asymptomatic with CD4 >350 cells/microL), those with advanced
immunosuppression (CD4 <200 cells/microL) had significantly higher cervical
HIV-1 RNA concentrations (2.4 log10 copies/swab vs. 3.8 log10 copies/swab, P <
0.001). However, women with CD4 counts <200 cells/microL were also less
likely than the reference group to report intercourse during the past week (58%
vs. 26%, P < 0.001).
Conclusions:
Antiretroviral guidelines focusing on individuals with the most advanced
immunosuppression will target those with the highest genital HIV-1
concentrations. However, individuals with less advanced immunosuppression
also have high levels of genital HIV-1 and may be more sexually active. The
effect of increased antiretroviral availability on the spread of HIV-1 might be
enhanced by extending treatment, in addition to other risk reduction services, to
those with less advanced disease.
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HIV-1 acquisition and disease progression are associated with decreased

high-risk sexual behaviour among Kenyan female sex workers.
Author: McClelland, R. S.; Hassan, W. M.; Lavreys, L.; Richardson, B. A.; Mandaliya, K.;
Ndinya-Achola, J.; Jaoko, W.; Kurth, A. E., and Baeten, J. M.
Source: AIDS. 2006 Oct 3; 20(15):1969-73.
Changes in sexual risk behaviour may occur following HIV-1 infection.
Objective:
To test the hypothesis that HIV-1 seroconversion and disease progression are
associated with changes in risk behaviours, using data from a cohort of Kenyan
female sex workers (FSWs).
Methods:
HIV-1-seronegative FSWs were enrolled in a prospective cohort study of risk
factors for HIV-1 acquisition. At monthly visits, standardized interviews were
conducted to assess sexual risk behaviour and HIV-1 serologic testing was
performed. Seroconverters were invited to continue with follow-up. Between
1993 and 2004 (when antiretroviral therapy was introduced in the cohort), 265
women seroconverted for HIV-1 (incidence 7.7/100 person-years) and were
included in this analysis.
Results:
Unprotected intercourse was reported at 546/2037 (27%) pre-seroconversion
visits versus 557/3732 (15%) post-seroconversion visits (P < 0.001). These
findings remained significant after adjustment for potential confounding factors
[adjusted odds ratio (AOR) 0.69; 95% confidence interval (CI), 0.55-0.86].
Compared with HIV-1-seronegative women, there was a progressive stepwise
decrease in unprotected intercourse among HIV-1-seropositive women with CD4
cell counts > or = 500 (AOR, 0.93; 95% CI, 0.62-1.39), 200-499 (AOR, 0.58; 95% CI,
0.41-0.82) and < 200 cells/microl (AOR, 0.45; 95% CI, 0.25-0.82). Decreases in
unprotected intercourse reflected increases in both abstinence and 100% condom
use. Women also reported fewer partners and fewer episodes of intercourse after
HIV-1 seroconversion.
Conclusions:
HIV-1 seroconversion and disease progression were associated with decreases in
sexual risk behaviour among Kenyan FSWs.
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Vaginal washing and increased risk of HIV-1 acquisition among African

women: a 10-year prospective study.
Author: McClelland, R. S.; Lavreys, L.; Hassan, W. M.; Mandaliya, K.; Ndinya-Achola, J.
O., and Baeten, J. M.
Source: AIDS. 2006 Jan 9; 20(2):269-73.
No prospective study has examined the risk of HIV-1 acquisition associated with
vaginal washing, although intravaginal practices have been identified as
potentially important contributors to HIV-1 susceptibility.
Objective:
To evaluate the contribution of vaginal washing to incident HIV-1 infection.
Design: Prospective cohort study.
Methods:
Data were derived from a 10-year study of risk factors for HIV-1 acquisition
among 1270 Kenyan female sex workers. Intravaginal practices were ascertained
at study enrollment. At monthly follow-up visits, women completed a
standardized interview and specimens were collected for diagnosis of HIV-1 and
genital tract infections.
Results:
Compared with women who did not perform vaginal washing, there was an
increased risk for acquiring HIV-1 among women who used water [adjusted
hazard ratio (HR), 2.64; 95% confidence interval (CI), 1.00-6.97] or soap (adjusted
HR 3.84; 95% CI, 1.51-9.77) to clean inside the vagina, after adjustment for
demographic factors, sexual behavior, and sexually transmitted infections.
Furthermore, women who performed vaginal washing with soap or other
substances were at higher risk for HIV-1 compared with those who used water
alone (adjusted HR, 1.47; 95% CI, 1.02-2.13).
Conclusions:
In populations where vaginal washing is common, this practice may be an
important factor promoting the spread of HIV-1. Intervention strategies aimed at
modifying intravaginal practices should be evaluated as a possible female-
controlled HIV-1 prevention strategy.
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Contribution of HIV-1 infection to acquisition of sexually transmitted

disease: a 10-year prospective study.
Author: McClelland, R. S.; Lavreys, L.; Katingima, C.; Overbaugh, J.; Chohan, V.;
Mandaliya, K.; Ndinya-Achola, J., and Baeten, J. M.
Source: J Infect Dis. 2005 Feb 1; 191(3):333-8.
Sexually transmitted diseases (STDs) enhance human immunodeficiency virus
(HIV)-1 susceptibility, but few studies have examined the reciprocal effect of
HIV-1 on STD acquisition.
Methods:
Data from a prospective cohort study conducted among female sex workers in
Mombasa, Kenya between 1993 and 2003 were used to determine the effect of
HIV-1 infection on STD susceptibility. The cohort included 1215 HIV-1-
seronegative women who underwent monthly HIV-1 and STD screening, of
whom 238 experienced seroconversion to HIV-1 during follow-up. Andersen-Gill
proportional-hazards models were used to compare the incidence rates for
genital-tract infections (syphilis, genital ulcer disease [GUD], Neisseria
gonorrhoeae infection, Chlamydia trachomatis infection, Trichomonas vaginalis
infection, vulvovaginal candidiasis, and bacterial vaginosis) in HIV-1-
seropositive versus HIV-1-seronegative women, after controlling for sexual
behavior and other potential confounding factors.
Results:
HIV-1 infection was associated with a significantly higher incidence of GUD
(hazard ratio [HR], 2.8; 95% confidence interval [CI], 2.0-3.9), gonorrhea (HR, 1.6;
95% CI, 1.1-2.2), and vulvovaginal candidiasis (HR, 1.5; 95% CI, 1.3-1.8). The risks
of GUD and vulvovaginal candidiasis increased with progressive levels of
immunosuppression.
Conclusions:
The increased incidence of genital-tract infections among HIV-1-seropositive
women could promote the spread of both HIV-1 and other STDs, particularly in
areas where these conditions are highly prevalent.

Author: McClelland, R. S.; Richardson, B. A.; Graham, S. M.; Masese, L. N.; Gitau, R.;
Lavreys, L.; Mandaliya, K.; Jaoko, W.; Baeten, J. M., and Ndinya-Achola, J. O.
Source: Sex Transm Dis. 2008 Jun; 35(6):617-23.

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Bacterial vaginosis (BV) is common and has been associated with increased HIV-
African women at high risk for acquiring HIV-1.
Methods:
We conducted a prospective study among 151 HIV-1-seronegative Kenyan
female sex workers. Nonpregnant women were eligible if they did not have
symptoms of abnormal vaginal itching or discharge at the time of enrollment. At
monthly follow-up, a vaginal examination and laboratory testing for genital tract
infections were performed. Multivariate Andersen-Gill proportional hazards
analysis was used to identify correlates of BV.
Results:
Participants completed a median of 378 (interquartile range 350-412) days of
follow-up. Compared with women reporting no vaginal washing, those who
reported vaginal washing 1 to 14 [adjusted hazard ratio (aHR) 1.29, 95%
confidence interval (CI) 0.88-1.89], 15 to 28 (aHR 1.60, 95% CI 0.98-2.61), and >28
times/wk (aHR 2.39, 95% CI 1.35-4.23) were at increased risk of BV. Higher BV
incidence was also associated with the use of cloth for intravaginal cleansing
(aHR 1.48, 95% CI 1.06-2.08) and with recent unprotected intercourse (aHR 1.75,
95% CI 1.47-2.08). Women using depot medroxyprogesterone acetate
contraception were at lower risk for BV (aHR 0.59, 95% CI 0.48-0.73).
Conclusions:
Vaginal washing and unprotected intercourse were associated with increased
risk of BV. These findings could help to inform the development of novel vaginal
health approaches for HIV-1 risk reduction in women.
Improvement of vaginal health for Kenyan women at risk for acquisition

of human immunodeficiency virus type 1: results of a randomized trial.
Author: McClelland, R. S.; Richardson, B. A.; Hassan, W. M.; Chohan, V.; Lavreys, L.;
Mandaliya, K.; Kiarie, J.; Jaoko, W.; Ndinya-Achola, J. O.; Baeten, J. M.; Kurth, A.
E., and Holmes, K. K.
Source: J Infect Dis. 2008 May 15; 197(10):1361-8.
Vaginal infections are common and have been associated with increased risk for
acquisition of human immunodeficiency virus type 1 (HIV-1).
Methods:
We conducted a randomized trial of directly observed oral treatment
administered monthly to reduce vaginal infections among Kenyan women at risk
for HIV-1 acquisition. A trial intervention of 2 g of metronidazole plus 150 mg of
fluconazole was compared with metronidazole placebo plus fluconazole placebo.
The primary end points were bacterial vaginosis (BV), vaginal candidiasis,
215
trichomoniasis vaginalis (hereafter, "trichomoniasis"), and colonization with

Lactobacillus organisms.
Results:
Of 310 HIV-1-seronegative female sex workers enrolled (155 per arm), 303 were
included in the primary end points analysis. A median of 12 follow-up visits per
subject were recorded in both study arms (P = .8). Compared with control
subjects, women receiving the intervention had fewer episodes of BV (hazard
ratio [HR], 0.55; 95% confidence interval [CI], 0.49-0.63) and more frequent
vaginal colonization with any Lactobacillus species (HR, 1.47; 95% CI, 1.19-1.80)
and H(2)O(2)-producing Lactobacillus species (HR, 1.63; 95% CI, 1.16-2.27). The
incidences of vaginal candidiasis (HR, 0.84; 95% CI, 0.67-1.04) and trichomoniasis
(HR, 0.55; 95% CI, 0.27-1.12) among treated women were less than those among
control subjects, but the differences were not statistically significant.
Conclusions:
Periodic presumptive treatment reduced the incidence of BV and promoted
colonization with normal vaginal flora. Vaginal health interventions have the
potential to provide simple, female-controlled approaches for reducing the risk
of HIV-1 acquisition.
Infection with Trichomonas vaginalis increases the risk of HIV-1

acquisition.
Author: McClelland, R. S.; Sangare, L.; Hassan, W. M.; Lavreys, L.; Mandaliya, K.; Kiarie,
J.; Ndinya-Achola, J.; Jaoko, W., and Baeten, J. M.
Source: J Infect Dis. 2007 Mar 1; 195(5):698-702.
Abstract: We conducted a prospective study among women in Mombasa, Kenya, to

determine whether Trichomonas vaginalis infection was associated with an
increased risk of human immunodeficiency virus type 1 (HIV-1) infection. At
monthly follow-up visits, laboratory screening for HIV-1 and genital tract
infections was conducted. Among 1335 HIV-1-seronegative women monitored
for a median of 566 days, there were 806 incident T. vaginalis infections (23.6/100
person-years), and 265 women seroconverted to HIV-1 (7.7/100 person-years).
Trichomoniasis was associated with a 1.52-fold (95% confidence interval, 1.04-
2.24-fold) increased risk of HIV-1 acquisition after adjustment for potential
confounding factors. Treatment and prevention of T. vaginalis infection could
reduce HIV-1 risk in women.
216
Implication of Ariaal sexual mixing on gonorrhea.

Author: McCluskey, C. C.; Roth, E., and van den Driessche, P.
Source: Am J Hum Biol. 2005 May-2005 Jun 30; 17(3):293-301.
Abstract: Recent research on sexual mixing in populations of sub-Saharan Africa raises the
question as to whether STDs can persist in these populations without the
presence of a core group. A mathematical model is constructed for the spread of
gonorrhea among the Ariaal population of Northern Kenya. A formula for the
basic reproduction number R(0) (the expected number of secondary infections
caused by a single new infective introduced into a susceptible population) is
determined for this population in the absence of a core group. Survey data taken
in 2003 on sexual behavior from the Ariaal population are used in the model
which is formulated for their age-set system including four subpopulations:
single and married, female and male. Parameters derived from the data, and
other information from sub-Saharan Africa are used to estimate R(0). Results
indicate that, even with the elevating effect of the age-set system, the disease
should die out since R(0) < 1. Thus, the persistence of gonorrhea in the
population must be due to factors not included in the model, for example, a core
group of commercial sex workers or concurrent partnerships.
Cross-clade CD8(+) T-cell responses with a preference for the

predominant circulating clade.
Author: McKinnon, L. R.; Ball, T. B.; Kimani, J.; Wachihi, C.; Matu, L.; Luo, M.; Embree, J.;
Fowke, K. R., and Plummer, F. A.
Source: J Acquir Immune Defic Syndr. 2005 Nov 1; 40(3):245-9.
Abstract: Human immunodeficiency virus (HIV) genetic diversity is a major impediment

to the design of a successful vaccine. Even if an HIV vaccine is proven effective, it
remains to be seen whether this protection will extend to inter-clade, intra-clade,
and recombinant strains. We used recombinant vaccinia-based interferon gamma
(IFN) Elispot assays to test the inter-clade crossreactivity of clades A, B, C, and D
HIV Env in two cohorts of HIV-infected Kenyans. Despite the tremendous
diversity in this HIV protein, a substantial proportion of multi-clade responses
were observed. Although these multi-clade responses correlated well with each
other in regression analyses, clade A responses were seen at a higher frequency
and at greater relative magnitudes in a proportion of these patients, when
compared to the other three clades. Epitope mapping indicates CD8(+) T cell
recognition of conserved regions of Env, accounting for the high degree of cross-
reactivity but not the clade A preference. A better understanding of cross-clade
CD8(+) T cell responses to HIV may help to predict whether a successful vaccine
could be used to stop geographically and genetically distinct HIV epidemics.
217
Epitope cross-reactivity frequently differs between central and effector

memory HIV-specific CD8+ T cells.
Author: McKinnon, L. R.; Ball, T. B.; Wachihi, C.; McLaren, P. J.; Waruk, J. L.; Mao, X.;
Ramdahin, S.; Anzala, A. O.; Kamene, J.; Luo, M.; Fowke, K. R., and Plummer, F.
A.
Source: J Immunol. 2007 Mar 15; 178(6):3750-6.
Abstract: HIV diversity may limit the breadth of vaccine coverage due to epitope sequence
differences between strains. Although amino acid substitutions within CD8(+) T
cell HIV epitopes can result in complete or partial abrogation of responses, this
has primarily been demonstrated in effector CD8(+) T cells. In an HIV-infected
Kenyan cohort, we demonstrate that the cross-reactivity of HIV epitope variants
differs dramatically between overnight IFN-gamma and longer-term
proliferation assays. For most epitopes, particular variants (not the index
peptide) were preferred in proliferation in the absence of corresponding
overnight IFN-gamma responses and in the absence of the variant in the HIV
quasispecies. Most proliferating CD8(+) T cells were polyfunctional via cytokine
analyses. A trend to positive correlation was observed between proliferation (but
not IFN-gamma) and CD4 counts. We present findings relevant to the
assessment of HIV vaccine candidates and toward a better understanding of how
viral diversity is tolerated by central and effector memory CD8(+) T cells.
Association of hygiene, socioeconomic status, and circumcision with

reduced risk of HIV infection among Kenyan men.
Author: Meier, A. S.; Bukusi, E. A.; Cohen, C. R., and Holmes, K. K.
Source: J Acquir Immune Defic Syndr. 2006 Sep; 43(1):117-8.
Abstract: Among Kenyan men recruited as sex partners of women with genital symptoms,
22 of 150 were HIV seropositive. Because male HIV infection and male hygiene
were unexpectedly found to be associated with each other, we examined the
relationship of 5 hygiene variables with HIV infection in the men in a principal
components analysis, controlling for socioeconomic status and other potential
confounders. By multivariate analyses, HIV infection in men was not only
independently associated with previous illness (odds ratio [OR], 5.1; 95%
confidence interval [CI], 1.4-19.1) and inversely associated with being
circumcised (OR, 0.12; 95% CI, 0.02-0.91), but also independently associated with
a combined measure of hygiene (OR, 0.41; 95% CI, 0.19-0.90).312
218

Author: Miller, A. N.; Fellows, K. L., and Kizito, M. N.
Source: Health Commun. 2007; 22(3):207-19.
Abstract: This study examined the impact of controllability of onset (i.e., means of
Motivations and methods for self-disclosure of HIV seropositivity in

Nairobi, Kenya.
Author: Miller, A. N. and Rubin, D. L.
Source: AIDS Behav. 2007 Sep; 11(5):687-97.
Abstract: This study employed structured interviews with 307 people living with HIV
(PLHIVs) in Nairobi, Kenya to investigate their serostatus disclosure with respect
to four types of relationships in their lives: partners, friends, family members,
and religious leaders/clergy. Regarding motivations for disclosure, it was found
that a sense of duty and seeking material support motivated disclosure to family
and partners, fear of loss of confidentiality inhibited disclosure to friends, and
the need for advice encouraged disclosure to religious leaders. The method of
disclosure most frequently mentioned was direct, with males less likely than
females to use direct methods when disclosing to spouses or partners.
Intermediated disclosure was common in partner/spouse relationships with
around one-third of partners preferring to disclose through a third party.
Methods used to disclose as well as reasons for doing so varied by relationship
type
219

Saharan Africa.
Author: Mishra, V.; Assche, S. B.; Greener, R.; Vaessen, M.; Hong, R.; Ghys, P. D.; Boerma,
J. T.; Van Assche, A.; Khan, S., and Rutstein, S.
Source: AIDS. 2007 Nov; 21 Suppl 7:S17-28.
Wealthier populations do better than poorer ones on most measures of health
status, including nutrition, morbidity and mortality, and healthcare utilization.
Objectives:
This study examines the association between household wealth status and HIV
serostatus to identify what characteristics and behaviours are associated with
HIV infection, and the role of confounding factors such as place of residence and
other risk factors.
Methods:
Results:
Conclusion:
In sub-Saharan Africa, HIV prevalence does not exhibit the same pattern of
association with poverty as most other diseases. HIV programmes should also
focus on the wealthier segments of the population.
220
Comparison of HIV prevalence estimates from antenatal care

surveillance and population-based surveys in sub-Saharan Africa.
Author: Montana, L. S.; Mishra, V., and Hong, R.
Source: Sex Transm Infect. 2008 Aug; 84 Suppl 1:i78-i84.
To compare HIV seroprevalence estimates obtained from antenatal care (ANC)
sentinel surveillance surveys in Ethiopia, Kenya, Malawi, Tanzania and Uganda
with those from population-based demographic and health surveys (DHS) and
AIDS indicator surveys (AIS).
Methods:
Geographical information system methods were used to map ANC surveillance
sites and DHS/AIS survey clusters within a 15-km radius of the ANC sites.
National DHS/AIS HIV prevalence estimates for women and men were
compared with national prevalence estimates from ANC surveillance. DHS/AIS
HIV prevalence estimates for women and men residing within 15 km of ANC
sites were compared with those from ANC surveillance. For women, these
comparisons were also stratified by current pregnancy status, experience of
recent childbirth and receiving ANC for the last birth.
Results:
In four of the five countries, national DHS/AIS estimates of HIV prevalence were
lower than the ANC surveillance estimates. Comparing women and men in the
catchment areas of the ANC sites, the DHS/AIS estimates were similar to ANC
surveillance estimates. DHS/AIS estimates for men residing in the catchment
areas of ANC sites were much lower than ANC surveillance estimates for
women in all cases. ANC estimates were higher for younger women than
DHS/AIS estimates for women in ANC catchment areas, but lower at older ages.
In all cases, urban prevalence was higher than rural prevalence but there were no
consistent patterns by education.
Conclusions:
ANC surveillance surveys tend to overestimate HIV prevalence compared to
prevalence among women in the general population in DHS/AIS surveys.
However, the ANC and DHS/AIS estimates are similar when restricted to
women and men, or to women only, residing in catchment areas of ANC sites.
Patterns by age and urban/rural residence suggest possible bias in the ANC
estimates.
221
Estimation of the sexual transmission of HIV in Kenya and Uganda on

the trans-Africa highway: the continuing role for prevention in high risk
groups.
Author: Morris, C. N. and Ferguson, A. G.
To explore the effect of transactional sex on the trans-Africa highway from
Mombasa-Kampala in contributing to the HIV epidemic and the impact that an
effective prevention intervention could have.
Methods:
Variables for input into a simple model of HIV prevention, AVERT, were derived
from a study of hot spots of transactional sex on the trans-Africa highway.
Diaries were completed by a sample of sex workers at selected sites of
transactional sex for a period of 28 consecutive days. Key information elicited
included numbers, types and occupations of clients, numbers of liaisons, sexual
acts in each liaison, and condom use. 857 diaries were distributed and 578
received and usable in 30 sites. A sexual patterning matrix was completed by 202
truckers at the Malaba border point as part of a health seeking behaviour survey.
Two methods were employed to estimate female sex worker (FSW) numbers on
the highway. FSW focus group discussions (FGDs) at 15 sites were carried out
and included questioning on the number of sex workers at the site. As most
transactional sex on the highway is centred on bars and lodgings, a patron
census and survey of 1007 bars and lodgings was carried out which included
questions on the presence and proportions of FSWs among the clientele.
Results:
There are an estimated 8000 FSWs on the trans-Africa highway from Mombasa to
Kampala. Annual numbers of different sexual partners per FSW were 129,
annual numbers of sexual acts per FSW were 634, percentage of sexual acts
protected by condom use was 77.7%. Using these input data an estimated 3200-
4148 new HIV infections occur on this portion of the trans-Africa highway in 1
year. Having a 90% condom use programme in place could prevent almost two
thirds of these infections and cumulative incidence would decline from 1.29% to
0.42%.
Conclusions:
In generalised epidemics there has been a debate as to the place of targeted
interventions. In the current east African epidemic we show that a targeted
intervention could have significant impact in averting HIV infections related to
the trans-Africa highway.
222
Sexual and treatment-seeking behaviour for sexually transmitted

infection in long-distance transport workers of East Africa.
Source: Sex Transm Infect. 2007 Jun; 83(3):242-5.
To investigate the sexual and treatment-seeking behaviour for sexually
transmitted infection (STI) in long-distance transport workers of East Africa.
Methods:
A health-seeking behaviour survey was carried out at four sites on the Mombasa-
Kampala trans-Africa highway (n = 381). The questionnaires probed details of
STI knowledge, symptoms and care-seeking behaviour. In one site at the Kenya-
Uganda border, a sexual patterning matrix was used (n = 202) to measure sexual
behaviour in truck drivers and their assistants over the 12-month period before
the interview.
Results:
Over half of the sexual acts of long-distance transport workers over 12 months
were with female sex workers, with an annual average of 2.8 sexual partners.
Condom use was reported at 70% for liaisons with casual partners. 15% of
truckers had had a self-reported STI and one-third exhibited high-risk sexual
behaviour in the previous year. Of those with an STI, 85% had symptoms when
on the road and 77.2% sought treatment within 1 week of onset of symptoms.
94% of drivers and 56% of assistants sought treatment for STI in a private health
facility or pharmacy. The cost of private facilities and pharmacies was not
significantly higher than in the public sector. Waiting times were three times
longer in the public sector. Only 28.9% of patients completed their medication
courses as prescribed.
Conclusions:
Truck drivers and their assistants in East Africa have high rates of reported STIs
and many continue to exhibit high-risk sexual behaviour. The transport workers
studied here favoured private health facilities because of convenience and
shorter waiting times.
Sexual Behavior of Female Sex Workers and Access to Condoms in

Kenya and Uganda on the trans-Africa Highway.
Author: Morris, C. N.; Morris, S. R., and Ferguson, A. G.
Abstract: Female sex workers and their clients remain a high risk core group for HIV in
Africa. We measured sexual behavior of a snowball sample of female sex
workers (FSW) along the Trans Africa highway from Mombasa, Kenya to
223
Kampala, Uganda and surveyed the availability of male condoms at 1,007 bars
and lodgings in Kenya along the highway trucking stops where transactional sex
occurs. There were 578 FSW one month sex diaries analyzed, 403 from Kenya
and 175 from Uganda. Kenyan FSW had a median of 45 sexual acts per 28 days
compared to 39 sex acts per 28 days by Ugandan FSW (P < 0.05). Condom use by
FSW for all sexual liaisons was 79% in Kenya compared to 74% in Uganda. In
multivariate analysis, adjusting for repeated measures, Kenyan FSW were more
likely to use a condom by an adjusted odds ratio of 2.54 (95% confidence interval
1.89-3.41) compared to Ugandan FSW. Condom use with regular clients was
50.8% in Uganda compared with 68.7% in Kenya (P < 0.01). The number of sex
workers reporting 100% condom use was 26.8% in Kenya and 18.9% in Uganda
(P < 0.01). Bars and lodges in Kenya compared to Uganda were more likely to:
have condom dispensers, 25% versus 1%, respectively (P < 0.01); distribute or sell
condoms, 73.9% versus 47.6% (P < 0.01); and have more weekly condom
distribution, 4.92 versus 1.27 condoms per seating capacity (P < 0.01). Our data
indicate that in both countries condom use for FSW is suboptimal, particularly
with regular partners, and greater condom use by Trans African highway FSW in
Kenya compared to Uganda may be related to availability. Targeted
interventions are warranted for FSW and truck drivers to prevent transmission in
this important core group.
Assessment of utilisation of PMTCT services at Nyanza Provincial

Hospital, Kenya.
Author: Moth, I. A.; Ayayo, A. B., and Kaseje, D. O.
Source: SAHARA J. 2005 Jul; 2(2):244-50.
Abstract: The main objective of the study was to assess the utilisation of prevention of
mother-to-child transmission (PMTCT) services among mothers registered for
services at Nyanza Provincial Hospital in Kenya. A crosssectional exploratory
study was conducted, using both quantitative and qualitative approaches to
collect primary and secondary data.The study population was 133 clients
registered for PMTCT services. The study revealed that 52.4% of clients received
PMTCT information at the health facility without prior knowledge about
intervention, 96% waited for more than 90 minutes, and 89% took less than 10
minutes for post-test counselling. Knowledge of MTCT and PMTCT was
inadequate even after counselling, as participants could not recall the
information divulged during counselling. In addition, 80% of clients did not
present for follow-up counselling irrespective of HIV status, and 95%, did not
disclose positive HIV status to spouses/relatives for fear of stigma,
discrimination and violence. Inadequate counselling services delivered to clients
affected service utilisation, in that significant dropout occurred at the stages of
HIV result (31.5%), enrollment (53.6%), and delivery (80.7%). Reasons for
dropout included fear of positive HIV result, chronic illness, stigma and
discrimination, unsupportive spouse and inability to pay for the services
224
Promoting female condoms in HIV voluntary counselling and testing

centres in Kenya.
Author: Mung'ala, L.; Kilonzo, N.; Angala, P.; Theobald, S., and Taegtmeyer, M.
Source: Reprod Health Matters. 2006 Nov; 14(28):99-103.
Abstract: Promotion of male condoms and voluntary counselling and testing for HIV
(VCT) have been cornerstones of Kenya's fight against the HIV epidemic. This
paper argues that there is an urgent need to promote the female condom in
Kenya through VCT centres, which are rapidly being scaled-up across the
country and are reaching increasingly large numbers of people. Training of
counsellors using a vaginal demonstration model is needed, as well an adequate
supply of free female condoms. In a study in five VCT centres, however,
counsellors reported that most people they counselled believed female condoms
were "not as good" as male condoms. In fact, many clients had little or no
knowledge or experience of female condoms. Counsellors' knowledge too was
largely based on hearsay; most felt constrained by lack of experience and had
many doubts about female condoms, which need addressing. Additional areas
that require attention in training include how to re-use female condoms and the
value of female condoms for contraception. VCT counsellors in Kenya already
promote male condoms as a routine part of risk reduction counselling alongside
HIV testing. This cadre, trained in client-centred approaches, has the potential to
champion female condoms as well, to better support the right to a healthy and
safe sex life.

considerations.
Author: Muturi, N.
Source: J Health Commun. 2005 Jan-2005 Feb 28; 10(1):77-98.
Africa in spite of the various efforts and resources put in place to prevent it. In
Kenya, reproductive health programs have used the mass media and other
contributing to the lack of change in behavior and sexual practices. I draw on the
theoretical framework of Grunig's model of excellence in communication, the
225
symmetrical communication contributes toward this understanding and the
maintenance of the newly adopted behaviors and practices.
Validation of a new clinical scoring system for acute bronchitis.

Author: Mwachari, C.; Nduba, V.; Nguti, R.; Park, D. R.; Sanguli, L., and Cohen, C. R.
Source: Int J Tuberc Lung Dis. 2007 Nov; 11(11):1253-9.
Abstract: Introduction:
Although several clinical prediction rules exist for lower respiratory tract
infection (LRTI), few are for acute bronchitis (acute bronchitis) and most have
not been validated in high human immunodeficiency virus (HIV) prevalence
settings.
Methods:
An Acute Bronchitis Severity Score (ABSS) was developed and validated during
a randomized trial of antibiotic treatment for acute bronchitis. Ambulatory
adults with productive cough of < or =2 weeks at out-patient respiratory disease
clinics in Nairobi, Kenya, were recruited and assessed for clinical response to
therapy. The ABSS quantitative ratings of LRTI-associated symptoms, physical
signs and sputum Gram stain purulence were assessed using standard
psychometric tests.
Results:
The ABSS was evaluated among 649 cases of acute bronchitis; 129 (20%) were
HIV-seropositive. The ABSS had small floor and ceiling effects (1.8/0.2) and
demonstrated high internal consistency (alpha-coefficient of 0.66) and internal
validity, with a mean inter item total correlation of > or =0.25. Effect sizes from
baseline to subsequent follow-up visits were large (>0.5). Wheezing and chest
pain were associated with higher ABSS values, whereas irrelevant clinical
variables were not.
Conclusion:
226
The ABSS demonstrated good responsiveness, high internal consistency, good

correlation with common respiratory signs and symptoms and high
discriminatory validity among patients with acute bronchitis in a high HIV-
seroprevalence setting.
Modelling the public health impact of male circumcision for HIV

prevention in high prevalence areas in Africa.
Author: Nagelkerke, N. J.; Moses, S.; de Vlas, S. J., and Bailey, R. C.
Recent clinical trials in Africa, in combination with several observational
epidemiological studies, have provided evidence that male circumcision can
reduce HIV female-to-male transmission risk by 60% or more. However, the
public health impact of large-scale male circumcision programs for HIV
prevention is unclear.
Methods:
Two mathematical models were examined to explore this issue: a random mixing
model and a compartmental model that distinguishes risk groups associated
with sex work. In the compartmental model, two scenarios were developed, one
calculating HIV transmission and prevalence in a context similar to the country
of Botswana, and one similar to Nyanza Province, in western Kenya.
Results:
In both models, male circumcision programs resulted in large and sustained
declines in HIV prevalence over time among both men and women. Men
benefited somewhat more than women, but prevalence among women was also
reduced substantially. With 80% male circumcision uptake, the reductions in
prevalence ranged from 45% to 67% in the two "countries", and with 50% uptake,
from 25% to 41%. It would take over a decade for the intervention to reach its full
effect.
Conclusion:
Large-scale uptake of male circumcision services in African countries with high
HIV prevalence, and where male circumcision is not now routinely practised,
could lead to substantial reductions in HIV transmission and prevalence over
time among both men and women.
Factors leading to self-disclosure of a positive HIV diagnosis in Nairobi,

Kenya: people living with HIV/AIDS in the Sub-Sahara.
Author: Neville Miller, A. and Rubin, D. L.
227
Source: Qual Health Res. 2007 May; 17(5):586-98.
Abstract: Understanding why, how, and to whom people living with HIV/AIDS disclose
their diagnosis to others is a critical issue for HIV prevention and care efforts, but
previous investigations of those issues in sub-Saharan Africa have been limited
to one or two questions included in quantitative studies of social support or
stigma. Instruments and findings on serostatus disclosure based on U.S.
populations are likely to be at best only partially relevant because of Africa's
primarily heterosexual transmission vectors and highly communalistic social
structures. This qualitative analysis of two male and two female focus groups
comprised of persons living with HIV/AIDS (PLWHAs) in Nairobi, Kenya,
revealed several HIVstatus disclosure patterns that appear distinctive to Africa.
These include (a) intermediaries as vehicles for disclosure to family, (b)
indirectness as a communication strategy, and (c) church pastors as common
targets for disclosure.
Sustained changes in sexual behavior by female sex workers after

completion of a randomized HIV prevention trial.
Author: Ngugi, E. N.; Chakkalackal, M.; Sharma, A.; Bukusi, E.; Njoroge, B.; Kimani, J.;
MacDonald, K. S.; Bwayo, J. J.; Cohen, C. R.; Moses, S., and Kaul, R.
Behavioral interventions in female sex workers (FSWs) are associated with
changes in sexual behavior and reduced rates of sexually transmitted infections
(STIs) and HIV We examined the sustainability of such interventions.
Methods:
HIV-uninfected Kenyan FSWs were enrolled in a clinical trial that provided free
male condoms, community and clinic-based counseling, and STI management.
After trial completion, scaled-back community-based resources remained in
place. More than a year later, women were invited to complete a follow-up
behavioral questionnaire and to undergo STI/HIV counseling and testing.
Individual changes in sexual behavior were assessed by paired analysis.
Results:
One hundred seventy-two women participated in the resurvey 1.2 years after
trial termination. Client numbers had risen (paired t test, P < 0.001), but condom
use had also increased (P < 0.001); both remained substantially lower than at
enrollment. Regular partners accounted for a greater proportion of unprotected
FSW sexual encounters (35% vs. 10%; P < 0.001). Only 9 (5.2%) of 172 women had
a conventional STI, and the follow-up HIV incidence of 1.6 per 100 person-years
(PYs) was similar to that during the trial period (3.7 per 100 PYs). Incident STIs
and HIV were associated with the frequency of unprotected sex and younger
age.
228
Conclusions:
Less intensive community-based risk reduction services after clinical trial
termination may support ongoing reductions in STIs and HIV among high-risk
FSWs.
Ethical dilemmas of social science research on AIDS and orphanhood in

Western Kenya.
Author: Nyambedha, E. O.
Source: Soc Sci Med. 2008 Sep; 67(5):771-9.
Abstract: This paper is based on the experiences drawn from a long-term social science
research programme on the impact of the AIDS pandemic on orphanhood in
western Kenya. It discusses the ethical dilemma of maintaining a delicate balance
between research ethics, the expectations of the study population and
negotiating the community's vested interests in a health related research project
in a low-income society. I argue that informed consent and the intended benefits
of the study to the participants continue to be major challenges facing the
justification of social research with people affected by or living with AIDS in low-
income societies. The paper underscores the importance of community feedback
sessions as a way of enhancing chances of acceptability of research efforts and
obtaining informed consent. It further shows how community feedback sessions
contribute to local knowledge of the problem being studied, creating
opportunities for advocacy. This discussion adds to the existing ethical debate on
the wider contexts within which research on vulnerable people affected by AIDS
is conducted by arguing that research practice is inseparable from
epistemological concerns of knowledge production. I suggest that ethnographers
should enhance efforts to innovatively design action research projects to serve
the twin purposes of data collection and deal with ethical challenges that are
experienced when doing long-term research on vulnerable groups.
229
Sexual and demographic determinants for herpes simplex virus type 2

among fishermen along Lake Victoria, Kenya.
Author: O Ng'ayo, M.; Bukusi, E.; A Morrow, R.; Rowhani-Rahbar, A.; A Obare, B.;
Friedrich, D., and Holmes, K. K.
Source: Sex Transm Infect. 2008 Apr; 84(2):140-2.
To determine the prevalence and correlates of herpes simplex virus type 2 (HSV-
2) seropositivity among fishermen along the shores of Lake Victoria in Kisumu
district, Kenya.
Methods:
Sera from a random sample of 250 fishermen from 18 beaches were collected
after a detailed sociodemographic interview. HSV-2 infection was tested by
Kalon HSV-2 ELISA.
Results:
The HSV-2 seroprevalence was 63.9%. In multivariate analysis, fishermen were
more likely to be infected with HSV-2 if they were HIV positive (prevalence ratio
(PR) 1.27; 95% CI 1.06 to 1.52) compared with those testing HIV negative, were
aged 18-20 (PR 0.49; 95% CI 0.24 to 0.99) and older than 40 (PR 1.66; 95% CI 1.30
to 2.14) years compared with those aged 21-25 years, perceived their last two
sexual partners to have a sexually transmitted infection (STI; PR 1.27; 95% CI 1.06
to 1.52) compared with those who did not and were more likely to be
circumcised (PR 1.49; 95% CI 1.19 to 1.86).
Conclusions:
HSV-2 seroprevalence is high among this population and is associated with HIV
serostatus, age, perception about partner's STI status and circumcision.
Viral load, CD4+ T-lymphocyte counts and antibody titres in HIV-1

infected untreated children in Kenya; implication for immunodeficiency
and AIDS progression.
Author: Ochieng, W.; Ogoyi, D.; Mulaa, F. J.; Ogola, S.; Musoke, R., and Otsyula, M. G.
Source: Afr Health Sci. 2006 Mar; 6(1):3-13.
There are limited reports on HIV-1 RNA load, CD4+ T-lymphocytes and
antibody responses in relation to disease progression in HIV-1 infected untreated
children in Africa.
230
Methods:
To describe the relationships between these parameters, we conducted a
longitudinal cohort study involving 51 perinatally HIV-1 infected children aged
between 1 and 13 years. HIV status was determined by ELISA and confirmed by
western blot and PCR. Antibodies were quantified by limiting dilution ELISA,
plasma HIV-1 RNA load by RT-PCR and CD4+ T-lymphocytes by FACSCount.
Results:
Asymptomatic and symptomatic disease had, respectively, a rise in median
HIV-1 RNA load from 1,195 to 132,543 and from 42,962 to 1,109,281 copies/ml in
children below 6 years. The increase in viral load was 10-fold higher for
asymptomatic compared to other categories and 2-fold faster for children less
than 6 years than those above. Similarly, symptomatic children below 6 years
had initial median CD4+ T-lymphocyte counts of 647 (22%) cells/muL, declining
to 378 (20%) while those above 6 years had initial values of below 335 (15%) but
which increased to 428 (17%). Median viral load correlated significantly with
median CD4+ T-lymphocyte percentage in children above 6 years (p=0.026) but
not below.
Conclusions:
Viral load is lower in older than younger children and correlates significantly
with percentage CD4+ T-lymphocytes. Survival by HIV-1 infected children
requires a competent immune response early in infection to counter the rapidly
replicating virus. Interventions aimed at boosting the naive immune system may
prolong survival in these children.
Tuberculosis and oral Candida species surveillance in HIV infected

individuals in Northern Kenya, and the implications on tuberculin skin
test screening for DOPT-P.
Author: Ochieng, W.; Wanzala, P.; Bii, C.; Oishi, I.; Ichimura, H.; Lihana, R.; Mpoke, S.;
Mwaniki, D., and Okoth, F. A.
Source: East Afr Med J. 2005 Dec; 82(12):609-13.
To determine the pattern of opportunistic infections such as TB and Candida
species in HIV infected patients in Northern Kenya.
Design:
Cross-sectional study. SETTING: Five health facilities in Moyale (n=224),
Mandera (n=121) and Turkana Kakuma; (n=83), Lopiding; (n=94) districts during
different periods in 2003. SUBJECTS: Five hundred and fifty two patients.
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Results:
In total 94 (18%) patients were found to be HIV positive (Moyale=42,
Mandera=13, Turkana; Kakuma=8, Lopiding=31). Only 65 of 94 HIV positive
patients provided saliva samples. Of these, 11 (17%) were TB smear positive and
19 (29.2%) were colonized by oral Candida species. The Candida isolates were as
follows; Co-infection of Candida species and TB (n=4), C. albicans only (n=12), C.
tropicalis only (n=1), C. albicans and C. glabarata (n=1) and C. albicans, C.
glabarata and C. tropicalis. co-infection (n=1).
Conclusion:
The findings provides an important insight into the differences in mucosal
susceptibility to bacteria (TB) infection and fungal (Candida species) colonization
during HIV immunosuppression, based on collected blood, sputum and saliva
specimens. Further studies are needed to elucidate the comparative transmission
dynamics and pathogenetic mechanisms of these opportunistic infections-in
different regions of Kenya. Such studies would improve the efficiency of directly
observed preventive therapy programme (DOPT-P) whose implementation
involves screening by tuberculin skin testing.
Provider-initiated HIV testing and counselling for TB patients and

suspects in Nairobi, Kenya.
Author: Odhiambo, J.; Kizito, W.; Njoroge, A.; Wambua, N.; Nganga, L.; Mburu, M.;
Mansoer, J.; Marum, L.; Phillips, E.; Chakaya, J., and De Cock, K. M.
Source: Int J Tuberc Lung Dis. 2008 Mar; 12(3 Suppl 1):63-8.
Abstract: Setting:
Integrated tuberculosis (TB) and human immunodeficiency virus (HIV) services
in a resource-constrained setting.
Objective:
Pilot provider-initiated HIV testing and counselling (PITC) for TB patients and
suspects. DESIGN: Through partnerships, resources were mobilised to establish
and support services. After community sensitisation and staff training, PITC was
introduced to TB patients and then to TB suspects from December 2003 to
December 2005.
Results:
Of 5457 TB suspects who received PITC, 89% underwent HIV testing. Although
not statistically significant, TB suspects with TB disease had an HIV prevalence
of 61% compared to 63% for those without. Of the 614 suspects who declined
HIV testing, 402 (65%) had TB disease. Of 2283 patients referred for
cotrimoxazole prophylaxis, 1951 (86%) were enrolled, and of 1727 patients
assessed for antiretroviral treatment (ART), 1618 (94%) were eligible and 1441
(83%) started treatment.
232
Conclusions:
PITC represents a paradigm shift and is feasible and acceptable to TB patients
and TB suspects. Clear directives are nevertheless required to change practice.
When offered to TB suspects, PITC identifies large numbers of persons requiring
HIV care. Community sensitisation, staff training, multitasking and access to
HIV care contributed to a high acceptance of HIV testing. Kenya is using this
experience to inform national response and advocate wide PITC implementation
in settings faced with the TB-HIV epidemic.
Role of governmental and non-governmental organizations in mitigation

of stigma and discrimination among HIV/AIDS persons in Kibera,
Kenya.
Author: Odindo, M. A. and Mwanthi, M. A.
Source: East Afr J Public Health. 2008 Apr; 5(1):1-5.
This study assessed the role of governmental and non-governmental
organizations in mitigation of stigma and discrimination among people infected
and affected by HIV/AIDS in informal settlements of Kibera.
Methods:
This was a descriptive cross-sectional study and used a multi stage stratified
sampling method. The study was conducted in Kibera, an informal settlement
with a population of over one million people which makes it the largest slum not
only in Kenya but in sub-Saharan Africa. The study targeted infected
individuals, non-infected community members, managers of the organizations
implementing HIV/AIDS programmes and service providers. In the process
1331 households were interviewed using qualitative and quantitative data
collection instruments. Statistical Package for Social Sciences (SPSS) and Nudist 4
packages were used to analyze the quantitative and qualitative data respectively.
Results:
More than 61% of the respondents had patients in their households. Fifty five
percent (55%) of the households received assistance from governmental and non-
governmental organizations in taking care of the sick. Services provided
included awareness, outreach, counseling, testing, treatment, advocacy, home
based care, assistance to the orphans and legal issues. About 90% of the
respondents perceived health education, counseling services and formation of
post counseling support groups to combat stigma and discrimination to be
helpful.
233
Conclusion:
Stigma and discrimination affects the rights of People Living with HIV/AIDS
(PLWHAs). Such stigmatization and discrimination goes beyond and affects
those who care for the PLWHAs, and remains the biggest impediment in the
fight against HIV/AIDS in Kibera. Governmental and non-governmental
organizations continue to provide key services in the mitigation of stigma and
discrimination in Kibera. However, personal testimonies by PLWHAs showed
that HIV positive persons still suffer from stigma and discrimination.
Approximately 43% of the study population experienced stigma and
discrimination.
Secrecy, disclosure and accidental discovery: perspectives of diaphragm

users in Mombasa, Kenya.
Author: Okal, J.; Stadler, J.; Ombidi, W.; Jao, I.; Luchters, S.; Temmerman, M., and
Chersich, M. F.
Source: Cult Health Sex. 2008 Jan; 10(1):13-26.
Abstract: The diaphragm is receiving renewed attention as a promising female-controlled

method of preventing HIV and other sexually-transmitted infections. It is
anticipated that female-controlled technologies will reduce women's biological
susceptibility and assist in counteracting their sociocultural vulnerability to HIV.
Understanding the subjective experiences of diaphragm users in different
settings has the potential to inform the development and promotion of such
methods. This paper explores the perspectives of female sex workers and women
attending sexual and reproductive health services in Mombasa, Kenya. Data are
reported from focus group discussions and in-depth interviews with women and
men, following a prospective study investigating diaphragm continuation rates
over six months. Discussions highlighted covert use of the diaphragm, during
sex work or with casual partners, and coital independence as favourable
attributes. These features were especially pronounced compared with male
condoms. Few difficulties with diaphragm use were reported, although its
insertion and removal occasionally presented problems. Many women--
especially those in long term partnerships--wished to disclose its use but found
the disclosure process highly problematic. Accidental discovery often resulted in
partner conflict. Although future uptake of the diaphragm may be high in this
setting, its use may be limited to certain types of relationships and relationship
context
234

Hospital, Kenya.
Author: Omwega, A. M.; Oguta, T. J., and Sehmi, J. K.
Source: East Afr Med J. 2006 Nov; 83(11):610-8.
Mother- to- Child Transmission (MTCT) of HIV is a relatively new concept in
methods for infants born to mothers infected with the virus.
Objectives:
To determine maternal knowledge on MTCT of HIV in the rural setting and to
Design:
A cross- sectional study, supported by an observational study.
Setting:
A rural district community and Homa-Bay District Hospital in South Western
Kenya.
Subjects:
One hundred and twelve non-tested mothers having infants aged 0-12 months in
the community and a sub-group (10%) of HIV positive mothers from the District
Hospital.
Results:
Maternal knowledge on MTCT of HIV was as low as 8.9% in the study area. The
MTCT knowledge was found to influence the alternative feeding choice as
mentioned by the non-tested mothers (p = 0.001; OR = 1.41; 95%CI, 1.04-3.86).
feeding alternatives other than cowmilk like expressed breastmilk (p = 0.1 5),
0.015; OR = 1.34; 95%CI, 1.13-5.50) than their counterparts with low MTCT
nutritional constraints.
Conclusion:
Maternal MTCT knowledge influences the choice of alternative infant feeding
option but not breastfeeding practices. Cowmilk is the most common, socio-
culturally acceptable and accessible breastmilk alternative in this community. It
is recommended that in order to improve MTCT knowledge, health education
235
and nutrition counselling be intensified in PMTCT programmes, VCT centers

and ANC clinics. Concurrently, effort should be made to increase the supply of
cowmilk within the community so as to make it more readily available and
affordable.
HIV/AIDS and home-based health care.

Author: Opiyo, P. A.; Yamano, T., and Jayne, T. s.
Source: Int J Equity Health. 2008; 7:8.
Abstract: This paper highlights the socio-economic impacts of HIV/AIDS on women. It

argues that the socio-cultural beliefs that value the male and female lives
differently lead to differential access to health care services. The position of
women is exacerbated by their low financial base especially in the rural
community where their main source of livelihood, agricultural production does
not pay much. But even their active involvement in agricultural production or
any other income ventures is hindered when they have to give care to the sick
and bedridden friends and relatives. This in itself is a threat to household food
security. The paper proposes that gender sensitive policies and programming of
intervention at community level would lessen the burden on women who bear
the brunt of AIDS as caregivers and livelihood generators at household level.
Improvement of medical facilities and quality of services at local dispensaries is
seen as feasible since they are in the rural areas. Other interventions should
target freeing women's and girls' time for education and involvement in income
generating ventures. Two separate data sets from Western Kenya, one being
quantitative and another qualitative data have been used.

Study.
Author: Orroth, K. K.; Freeman, E. E.; Bakker, R.; Buve, A.; Glynn, J. R.; Boily, M. C.;
White, R. G.; Habbema, J. D., and Hayes, R. J.
Source: Sex Transm Infect. 2007 Aug; 83 Suppl 1:i5-16.
To determine if the differences in risk behaviours, the proportions of males
circumcised and prevalences of sexually transmitted infections (STIs) observed in
two African cities with low prevalence of HIV (Cotonou, Benin, and Yaounde,
Cameroon) and two cities with high prevalence (Kisumu, Kenya, and Ndola,
Zambia) could explain the contrasting HIV epidemics in the four cities.
Methods:
236

were held constant across the four populations. The probabilities of HIV,
syphilis and chancroid acquisition were assumed to be doubled among
uncircumcised males. A priori plausible ranges for model inputs and outputs
were defined and sexual behaviour characteristics, including those pertaining to
commercial sex workers (CSWs) and their clients, which were allowed to vary
across the sites, were identified based on comparisons of the empirical data from
the four sites. The proportions of males circumcised in the model, 100% in
Cotonou and Yaounde, 25% in Kisumu and 10% in Ndola, were similar to those
observed. A sensitivity analysis was conducted to assess how changes in critical
parameters may affect the model fit.
Results:
Population characteristics observed from the study that were replicated in the
model included younger ages at sexual debut and marriage in east Africa
compared with west Africa and higher numbers of casual partners in the past 12
months in Yaounde than in the other three sites. The patterns in prevalence of
STIs in females in the general population and CSWs were well fitted. HIV
prevalence by age and sex and time trends in prevalence in the model were
consistent with study data with the highest simulated prevalences in Kisumu
and Ndola, intermediate in Yaounde and lowest in Cotonou. The sensitivity
analysis suggested that the effect of circumcision on the development of the HIV
epidemics may have been mediated indirectly by its effect on ulcerative STI.
Conclusions:
The contrasting HIV epidemics in east and west Africa could be replicated in our
model by assuming that male circumcision reduced susceptibility to HIV,
syphilis and chancroid. Varying rates of male circumcision may have played an
important role in explaining the strikingly different HIV epidemics observed in
different parts of sub-Saharan Africa.
Vasculitis in HIV: report of eight cases.

Author: Otedo, A. E.; Oyoo, G. O.; Obondi, J. O., and Otieno, C. F.
237
To describe vasculitis in HIV patients, their CD4 levels, anatomical sites affected
and clinical patterns. DESIGN: Prospective, descriptive study.
Setting:
Kisumu District Hospital and Nairobi Rheumatology Clinic between January
2002 and May 2005.
Subjects:
Eight patients with HIV and vasculitis. RESULTS: Eight patients (four males and
four females) were recruited with an age range of 24-61 years, mean 33.13 years.
Five had central nervous system vasculitis and three had peripheral vasculitis.
The CD4 counts were low, range 2-200 cells/mm3 (mean of 79.25 cells/mm3),
normal levels of CD4 are 355-1298 cells/mm3, indicating severe
immunosuppression. Two patients tested positive for HBV (hepatitis B virus).
Conclusion:
HIV associated vasculitis is recognised and may be complicated by coinfection
with hepatitis viruses. It occurs at low CD4 counts. Central nervous system
involvement is a common site. Management is multidisciplinary.
HIV-1 disease progression in breast-feeding and formula-feeding

mothers: a prospective 2-year comparison of T cell subsets, HIV-1 RNA
levels, and mortality.
Author: Otieno, P. A.; Brown, E. R.; Mbori-Ngacha, D. A.; Nduati, R. W.; Farquhar, C.;
Obimbo, E. M.; Bosire, R. K.; Emery, S.; Overbaugh, J.; Richardson, B. A., and
John-Stewart, G. C.
There is conflicting evidence regarding the effects of breast-feeding on maternal
mortality from human immunodeficiency virus type 1 (HIV-1) infection, and
little is known about the effects of breast-feeding on markers of HIV-1 disease
progression.
Methods:
HIV-1-seropositive women were enrolled during pregnancy and received short-
course zidovudine. HIV-1 RNA levels and CD4 cell counts were determined at
baseline and at months 1, 3, 6, 12, 18, and 24 postpartum and were compared
between breast-feeding and formula-feeding mothers.
238
Results:
Of 296 women, 98 formula fed and 198 breast-fed. At baseline, formula-feeding
women had a higher education level and prevalence of HIV-1-related illness than
did breast-feeding women; however, the groups did not differ with respect to
CD4 cell counts and HIV-1 RNA levels. Between months 1 and 24 postpartum,
CD4 cell counts decreased 3.9 cells/ microL/month (P<.001), HIV-1 RNA levels
increased 0.005 log(10) copies/mL/month (P=.03), and body mass index (BMI)
decreased 0.03 kg/m(2)/month (P<.001). The rate of CD4 cell count decline was
higher in breast-feeding mothers (7.2 cells/ microL/month) than in mothers who
never breast-fed (4.0 cells/ microL/month) (P=.01). BMI decreased more rapidly
in breast-feeding women (P=.04), whereas HIV-1 RNA levels and mortality did
not differ significantly between breast-feeding and formula-feeding women.
Conclusions:
Breast-feeding was associated with significant decreases in CD4 cell counts and
BMI. HIV-1 RNA levels and mortality were not increased, suggesting a limited
adverse impact of breast-feeding in mothers receiving extended care for HIV-1
infection.
Using VCT statistics from Kenya in understanding the association

between gender and HIV.
Author: Otwombe, K. N.; Ndindi, P.; Ajema, C., and Wanyungu, J.
Source: SAHARA J. 2007 Nov; 4(3):707-10.
Abstract: This paper demonstrates the importance of utilising official statistics from the
voluntary counselling and testing centres (VCT) to determine the association
between gender and HIV infection rates in Kenya.The study design adopted was
a record based survey of data collected from VCT sites in Kenya between the
second quarter of 2001 and the second quarter of 2004. Of those who were
tested, significantly more females tested positive (P<0.0001) and had twice as
high a chance of being infected by HIV (Odds ratio 2.27 with CI 2.23 to 2.31) than
males.We conclude that VCT statistics may lead to better planning of services
and gender sensitive interventions if utilised well.
Improving national data collection systems from voluntary counselling

and testing centres in Kenya.
Author: Otwombe, K. N.; Wanyungu, J.; Nduku, K., and Taegtmeyer, M.
Source: Bull World Health Organ. 2007 Apr; 85(4):315-8.
239
Abstract: Problem:
Voluntary counselling and testing (VCT) data from the registered sites in Kenya
have been fraught with challenges, leading to insufficient statistics in the national
office for planning purposes. An exercise was carried out to determine the
barriers to the flow of data in VCT sites in Kenya.
Approach:
A record-based survey was conducted at 332 VCT sites in Kenya. Data from on-
site records were compared with those in the national office. The exercise was
conducted in 2004 between 5 September and 15 October.
Local setting:
All registered VCT sites in Kenya. RELEVANT CHANGES: After the exercise,
various measures to enhance VCT data collection and reporting were
implemented. They include the provision of a uniform data collection and
reporting tool to all the districts in the country, the strengthening of a feedback
mechanism to update provinces and districts on their reporting status and
increased support to the data component of the national quality assurance for
VCT.
Lessons learned:
Periodical field visits by the national officials to offer on-the-job training about
data management to data collectors and to address data quality issues can
dramatically improve the quality and completeness of VCT reports. The
perceived relevance of the data and the data collection process to those working
at the sites is the critical factor for data quality and timeliness of reporting.
An integrative bioinformatic approach for studying escape mutations in

human immunodeficiency virus type 1 gag in the Pumwani Sex Worker
Cohort.
Author: Peters, H. O.; Mendoza, M. G.; Capina, R. E.; Luo, M.; Mao, X.; Gubbins, M.;
Nagelkerke, N. J.; Macarthur, I.; Sheardown, B. B.; Kimani, J.; Wachihi, C.;
Thavaneswaran, S., and Plummer, F. A.
Source: J Virol. 2008 Feb; 82(4):1980-92.
Abstract: Human immunodeficiency virus type 1 (HIV-1) is able to evade the host
cytotoxic T-lymphocyte (CTL) response through a variety of escape avenues.
Epitopes that are presented to CTLs are first processed in the presenting cell in
several steps, including proteasomal cleavage, transport to the endoplasmic
reticulum, binding by the HLA molecule, and finally presentation to the T-cell
receptor. An understanding of the potential of the virus to escape CTL responses
can aid in designing an effective vaccine. To investigate such a potential, we
analyzed HIV-1 gag from 468 HIV-1-positive Kenyan women by using several
bioinformatic approaches that allowed the identification of positively selected
amino acids in the HIV-1 gag region and study of the effects that these
240
mutations could have on the various stages of antigen processing. Correlations

between positively selected residues and mean CD4 counts also allowed study of
the effect of mutation on HIV disease progression. A number of mutations that
could create or destroy proteasomal cleavage sites or reduce binding affinity of
the transport antigen processing protein, effectively hindering epitope
presentation, were identified. Many mutations correlated with the presence of
specific HLA alleles and with lower or higher CD4 counts. For instance, the
mutation V190I in subtype A1-infected individuals is associated with HLA-
B*5802 (P = 4.73 x 10(-4)), a rapid-progression allele according to other studies,
and also to a decreased mean CD4 count (P = 0.019). Thus, V190I is a possible
HLA escape mutant. This method classifies many positively selected mutations
across the entire gag region according to their potential for immune escape and
their effect on disease progression.
Examination of a second region of the HIV type 1 genome reveals

additional cases of superinfection.
Author: Piantadosi, A.; Ngayo, M. O.; Chohan, B., and Overbaugh, J.
Source: AIDS Res Hum Retroviruses. 2008 Sep; 24(9):1221.
Abstract: HIV-1 superinfection may occur at a rate similar to that of initial infection, aising
concerns for HIV-1 vaccine strategies predicated on eliciting immune responses
similar to those in natural infection. Because of the high rate of recombination
during HIV-1 replication, studies examining only one region of the HIV-1
genome are likely to miss cases of HIV-1 superinfection. We examined HIV-1
gag sequences from 14 high-risk Kenyan women in whom superinfection was
not detected in a previous study of env sequences. We detected two additional
cases of HIV-1 superinfection: one intersubtype superinfection that occurred
between 1046 and 1487 days postinfection (DPI) and one intrasubtype
superinfection that occurred between 341 and 440 DPI. Our results suggest that
studies that examine only small genome regions may lead to underestimates of
the risk of superinfection, highlighting the need for more extensive studies
examining multiple regions of the HIV-1 genome
Circumcision and HIV transmission.

Author: Quinn, T. C.
Source: Curr Opin Infect Dis. 2007 Feb; 20(1):33-8.
241
Abstract: Purpose Of Review:

To review the recent literature on male circumcision and its effect on HIV
acquisition.
Recent findings:
The report from the randomized clinical trial of male circumcision in South
Africa demonstrating a 60% protective effect in preventing HIV acquisition
provided the first clinical trial evidence of efficacy of male circumcision in
protecting men against HIV infection. This protective effect was consistent with
both ecological and epidemiologic studies which also show a protective effect of
50-70% in men at high risk for HIV infection. Biological studies also demonstrate
an increased number of HIV receptor cells in the mucosa of foreskin providing
additional evidence of HIV susceptibility in the uncircumcised male. Male
circumcision may also have a beneficial effect in preventing HIV acquisition in
women and lowering selected sexually transmitted infections in both sexes.
Summary:
The results of two ongoing randomized clinical trials of male circumcision in
Kenya and Uganda are awaited with interest, however male circumcision should
be carefully considered as a potential public health tool in preventing HIV
acquisition. If other trials confirm the results of the South African trial,
implementation of this surgical procedure will need to be carefully scaled up and
integrated into other prevention programs with emphasis on surgical training,
aseptic techniques, acceptability, availability and cultural considerations.
No evidence for rapid subtype C spread within an epidemic in which

multiple subtypes and intersubtype recombinants circulate.
Author: Rainwater, S.; DeVange, S.; Sagar, M.; Ndinya-Achola, J.; Mandaliya, K.; Kreiss, J.
K., and Overbaugh, J.
Source: AIDS Res Hum Retroviruses. 2005 Dec; 21(12):1060-5.
Abstract: There are multiple subtypes of HIV-1 circulating worldwide, but recently,
subtype C has become highly prevalent, particularly in certain geographic
regions. It is unclear whether the dominance of subtype C or other subtypes is
due to increased fitness of certain subtypes for transmission, or a founder effect
in new, rapidly growing epidemics. To examine whether the prevalence of one
subtype increases over the course of an expanding epidemic that includes several
circulating subtypes, we examined the distribution of HIV-1 subtypes in Kenya
from 1986 to 2000. We found no evidence for an increase in the prevalence of
subtype C, which remained low throughout this approximately 15-year period.
Interestingly, the percentage of subtype D present in the population decreased
significantly over that period, with a slight increase in subtype A. Throughout
that period, intersubtype recombinant viruses were detected, including at the
early stages of the epidemic. This latter finding suggests that reinfection may
242
have occurred in high-risk groups early in the epidemic, leading to intersubtype

recombinant viruses that underwent secondary spread.
Does the private sector care about AIDS? Evidence from firm surveys in
East Africa.
Author: Ramachandran, V.; Shah, M. K., and Turner, G. L.
Source: AIDS. 2007 Jul; 21 Suppl 3:S61-72.
Our objective was to identify the determinants of HIV/AIDS prevention activity
and pre-employment health checks by private firms in Kenya, Uganda and
Tanzania.
Design:
We used data from the World Bank Enterprise Surveys for Uganda, Kenya and
Tanzania, encompassing 860 formally registered firms in the manufacturing
sector.
Methods:
Econometric analysis of firm survey data was used to identify the determinants
of HIV/AIDS prevention including condom distribution and voluntary
counselling and testing (VCT). Multivariate regression analysis was the main tool
used to determine statistical significance.
Results:
Approximately a third of enterprises invest in HIV/AIDS prevention.
Prevention activity increases with size, most likely because larger firms and firms
with higher skilled workers have greater replacement costs. Even in the category
of larger firms, less than 50% provide VCT. We found that the propensity of
firms to carry out pre-employment health checks of workers also varies by the
size of firm and skill level of the workforce. Finally, data from worker surveys
showed a high degree of willingness on the part of workers to be tested for HIV
in the three East African countries.
Psychological distress symptoms of individuals seeking HIV-related

psychosocial support in western Kenya.
Author: Reece, M.; Shacham, E.; Monahan, P.; Yebei, V.; Ong'or, W. O.; Omollo, O., and
Ojwang, C.
Source: AIDS Care. 2007 Nov; 19(10):1194-200.
243
Abstract: While researchers in many western countries have documented the nature of
psychological distress that is commonly present among individuals living with
HIV, there has been virtually no research on the same topic among other high
prevalence areas of the world, particularly in countries like Kenya. This study
sought to document the nature of psychological distress among 397 individuals
living with HIV in western Kenya and who were participating in psychosocial
support groups in conjunction with their enrollment in HIV-related treatment.
Psychological distress was assessed using the Brief Symptom Inventory (BSI), a
53-item self-report psychological inventory that asks individuals to recall
symptoms experienced in the prior seven days. The levels of psychological
distress in this sample were moderate with a substantial proportion of
participants meeting the criteria that suggested a need for further psychiatric
evaluation. Findings support the need for further assessments of the range and
nature of psychological distress among the diverse communities of countries like
Kenya and the need for greater attention to the inclusion of mental health
services in the rapidly developing treatment and prevention programs in this
region of the world.
HIV/AIDS: the first 25 years--a view from Nairobi.

Author: Rees, P. H.
Source: East Afr Med J. 2008 Jun; 85(6):292-300.
Abstract: HIV infections are zoonoses occurring in communities that hunt chimpanzees
(HIV 1) and sooty mangabeys (HIV 2) in the forests of equatorial and West Africa
respectively. Most cross species transmission to man probably fizzles out, but the
transmission of HIV 1 type M around 1930 eventually resulted in a pandemic
that has spread around the world. HIV 2 types A and B have caused epidemics in
West Africa. HIV infections are characterised by three phases (i) an initial,
primary infective phase with rising viraemia, asymptomatic and silent, lasting
for some 10 weeks, (ii) a long quiescent phase with the viraemia and illness
mostly held in check by the immune response and lasting some 10 years in HIV 1
and 20 years or so in HIV 2 and (iii) a terminal third phase lasting some 10
months with rising viraemia, falling CD4 levels and multiple opportunistic
infections recognised in a community by the onset of a florid AIDS epidemic. The
silent primary epidemic reached Nairobi around 1980, with the florid secondary
AIDS epidemic peaking here around 1992 and overwhelming the hospitals and
other health services. The introduction of highly active antiretroviral therapy
(HAART) has dramatically improved the prognosis for individual patients with
AIDS, but it has been education and a changing attitude to condoms that has led
to a progressive fall in incidence, so that the worst of the epidemic may now be
over. Modifying the immunological response during the quiescent phase with
the hope of prolonging this phase indefinitely may be the way forward for those
who are already infected. Steroids have been shown to have a possible role here
rather than anti-retroviral drugs (ARVs) which are not curative and prone to the
development of drug resistance. Limited personal experience suggests that
244
steroids may also have a role in salvaging critically ill AIDS patients, who need
to be treated as emergencies. With an educated public and attention to
alternative routes of infection such as blood transfusion, the epidemic should be
increasingly contained during the next 25 years, and may even fizzle out.
The private sector and HIV/AIDS in Africa: taking stock of 6 years of

applied research.
Author: Rosen, S.; Feeley, F.; Connelly, P., and Simon, J.
Until recently, little was known about the costs of the HIV/AIDS epidemic to
businesses in Africa or about business responses to the epidemic. This paper
synthesizes the results of a set of studies conducted between 1999 and 2006.
Methods:
Data for the studies included were drawn from human resource, financial, and
medical records of 16 large companies and from 7 surveys of small, medium-
sized, and large companies in South Africa, Uganda, Kenya, Zambia, Ethiopia,
and Rwanda.
Results:
Estimated workforce HIV prevalence ranged from 5 to 37%. The average cost per
employee lost to AIDS varied from 0.5 to 5.6 times the average annual
compensation of the employee affected. Labor cost increases were estimated at
0.6-10.8% but exceeded 3% at only two of 14 companies. Antiretroviral treatment
at a cost of US$360/patient per year was found to have positive financial returns
for most but not all companies. Managers of small and medium-sized
enterprises (SME) reported low AIDS-related employee attrition, little concern
about the impacts of AIDS, and relatively little interest in taking action. AIDS
was estimated to increase the average operating costs of SME by less than 1%.
Conclusion:
For most companies, AIDS is causing a moderate increase in labor costs, with
costs determined mainly by HIV prevalence, employee skill level, and
employment policies. Treatment of HIV-positive employees is a good investment
for many large companies. Small companies have less capacity to respond to
workforce illness and little concern about it. Research on the effectiveness of
workplace interventions is needed.
Field experiences integrating family planning into programs to prevent

mother-to-child transmission of HIV.
245
Author: Rutenberg, N. and Baek, C.
Source: Stud Fam Plann. 2005 Sep; 36(3):235-45.
Abstract: This article reviews field experiences with provision of family planning services
in prevention of mother-to-child transmission (PMTCT) programs in ten
countries in Africa, Asia, and Latin America. Family planning is a standard
component of most antenatal care and maternal-child health programs within
which PMTCT programs are offered. Yet PMTCT sites often miss opportunities
to provide HIV-positive clients with family planning counseling. Demand for
family planning among HIV-positive women varies depending on the extent of
communities' openness about HIV/AIDS, fertility norms, and knowledge of
PMTCT programs. In Kenya and Zambia, no differences were observed in use of
contraceptives between HIV-positive and HIV-negative women in the study
communities, but HIV-positive women have more affirmative attitudes about
condoms and use them significantly more frequently than do their HIV-negative
counterparts. In the Dominican Republic, India, and Thailand, where HIV
prevalence is low and sterilization rates are high, HIV-positive women are
offered sterilization, which most women accept. This article draws out the policy
implications of these findings and recommends that policies be based on respect
for women's right to informed reproductive choice in the context of HIV/AIDS.
The future of HIV prevention: control of sexually transmitted infections

and circumcision interventions.
Author: Sahasrabuddhe, V. V. and Vermund, S. H.
Source: Infect Dis Clin North Am. 2007 Mar; 21(1):241-57, xi.
Abstract: Prevention and control of sexually transmitted infections (STIs) has proven
effective in reducing HIV infection when treatment is available promptly for
symptomatic persons in conditions of an emerging epidemic. Biologically, it is
assumed that reduced genital tract inflammation reduces infectiousness for HIV
as well as reducing susceptibility in HIV-uninfected persons. Male circumcision
has been demonstrated effective in reducing risk for HIV infection in three
separate trials from South Africa, Kenya, and Uganda. Global expansion of STI
treatment and male circumcision programs are vital tools for control of HIV
infection; current evidence is reviewed and research priorities are presented.
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Impact of HIV on novel therapies for tuberculosis control.

Author: Sanchez, M. S.; Lloyd-Smith, J. O.; Porco, T. C.; Williams, B. G.; Borgdorff, M. W.;
Mansoer, J.; Salomon, J. A., and Getz, W. M.
Source: AIDS. 2008 May 11; 22(8):963-72.
Abstract: Objective And Design:

The increased risk for tuberculosis in HIV-infected people has fueled a
worldwide resurgence of tuberculosis. A major hindrance to controlling
tuberculosis is the long treatment duration, leading to default, jeopardizing cure,
and generating drug resistance. We investigated how tuberculosis is impacted by
reducing treatment duration alone or combined with enhanced case detection
and/or cure under different HIV prevalence levels.
Methods:
Our model includes HIV stages I-IV and was calibrated to long-term tuberculosis
and HIV data from Kenya. Benefits were assessed in terms of absolute and
relative reductions in new tuberculosis cases and deaths.
Results:
Compared with present-day strategies, at 3-20% HIV prevalence we attain a 6-
20% decrease in incidence and mortality in 25 years when reducing treatment
duration alone; benefits exceed 300% when combined with increased detection
and cure. Benefits vary substantially according to HIV status and prevalence.
Challenges arise because in absolute terms the number of infected people and
deaths increases dramatically with increasing HIV prevalence, and because the
relative efficacy of tuberculosis control policies displays a nonlinear pattern
whereby they become less effective on a per capita basis at HIV prevalence levels
greater than 15%. Benefits of reducing treatment duration may even be reversed
at extreme HIV prevalence levels. Benefits of increasing cure versus detection
increase as HIV prevalence increases.
Conclusion:
Reducing tuberculosis treatment duration, alone or in combination with other
control strategies, can provide enormous benefits at high HIV prevalence.
Tuberculosis control policies need to account for HIV levels because the efficacy
of different interventions varies substantially with HIV prevalence.
HIV-1 infection in high risk men who have sex with men in Mombasa,
Kenya.
Author: Sanders, E. J.; Graham, S. M.; Okuku, H. S.; van der Elst, E. M.; Muhaari, A.;
Davies, A.; Peshu, N.; Price, M.; McClelland, R. S., and Smith, A. D.
Source: AIDS. 2007 Nov 30; 21(18):2513-20.
247
The role of homosexuality and anal sex practices in the African HIV -1 epidemic
is not well described. We aimed to assess the risk factors for prevalent HIV-1
infection among men who have sex with men (MSM) to guide HIV-1 prevention
efforts.
Methods:
Socio-behavioural characteristics, signs and symptoms of sexually transmitted
diseases (STD), and serological evidence of HIV-1 were determined for 285 MSM
at enrolment into a vaccine preparedness cohort study. We used multivariate
logistic regression to assess risk factors for prevalent HIV-1 infection. RESULTS:
HIV-1 prevalence was 43.0% [49/114, 95% confidence interval (CI), 34-52%] for
men who reported sex with men exclusively (MSME), and 12.3% (21/171, 95%
CI, 7-17%) for men who reported sex with both men and women (MSMW).
Eighty-six (75%) MSME and 69 (40%) MSMW reported recent receptive anal sex.
Among 174 MSM sexually active in the last week, 44% reported no use of
condoms with casual partners. In the previous 3 months, 210 MSM (74%)
reported payment for sex, and most clients (93%) were local residents. Prevalent
HIV-1 infection was associated with recent receptive anal sex [odds ratio (OR),
6.1; 95% CI, 2.4-16], exclusive sex with men (OR, 6.3; 95% CI, 2.3-17), and
increasing age (OR, 1.1 per year; 95% CI, 1.04-1.12). Only four MSM reported
injecting drug use.
Conclusions:
The high prevalence of HIV-1 in Kenyan MSM is probably attributable to
unprotected receptive anal sex. There is an urgent need for HIV-1 prevention
programmes to deliver targeted risk-reduction interventions and STD services to
MSM in Kenya.
Short- and long-term efficacy of modified directly observed

antiretroviral treatment in Mombasa, Kenya: a randomized trial.
Author: Sarna, A.; Luchters, S.; Geibel, S.; Chersich, M. F.; Munyao, P.; Kaai, S.;
Mandaliya, K. N.; Shikely, K. S.; Temmerman, M., and Rutenberg, N.
To determine short- and long-term efficacy of modified directly observed
therapy (m-DOT) on antiretroviral adherence.
Design: Randomized controlled trial.
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Setting and analytic approach:

From September 2003 to November 2004, 234 HIV-infected adults were assigned
m-DOT (24 weeks of twice weekly health center visits for nurse-observed pill
ingestion, adherence support, and medication collection) or standard care.
Follow-up continued until week 72. Self-reported and pill-count adherence and,
secondarily, viral suppression and body mass index measures are reported.
Generalized estimating equations adjusted for intraclient clustering and
covariates were used.
Results:
During weeks 1-24, 9.1% (9/99) of m-DOT participants reported missing doses
compared with 19.1% (20/105) of controls (P = 0.04) and 96.5% (517/571) of m-
DOT pill-count measures were >or=95% compared with 86.1% (445/517) in
controls [adjusted odds ratio = 4.4; 95% confidence interval (CI) = 2.6 to 7.5; P <
0.001. Adherence with m-DOT was 4.8 times greater (95% CI = 2.7 to 8.6; P <
0.001) with adjustment for depression and HIV-related hospitalization. In weeks
25-48, adherence with m-DOT (488/589) was similar to controls (507/630). Viral
suppression at 48 weeks was 2.0 times (95% CI = 0.8 to 5.2; P = 0.13) as likely in
m-DOT participants as controls. M-DOT patients had larger body mass index
increases at 24 weeks (2.2 vs 1.4 kg/m3; P = 0.014). Viral suppression was more
likely at week 48 (21/25 vs 13/22; P = 0.057) and week 72 (27/30 vs 15/23; P =
0.027) among depressed participants receiving m-DOT.
Conclusions:
M-DOT increased adherence, most notably among depressed participants.
Sexual risk behaviour and HAART: a comparative study of HIV-infected

persons on HAART and on preventive therapy in Kenya.
Author: Sarna, A.; Luchters, S. M.; Geibel, S.; Kaai, S.; Munyao, P.; Shikely, K. S.;
Mandaliya, K.; van Dam, J., and Temmerman, M.
Source: Int J STD AIDS. 2008 Feb; 19(2):85-9.
the last six months. Participants receiving PT were more likely to report > or =2
partners (13% vs.1%; P = 0.006). Participants receiving PT reported more UPS
with regular partners (odds ratio [OR]: 3.9; 95% confidence interval [CI]: 1.8-8.4)
and also more sexually transmitted infections (STI) symptoms (OR: 1.7; 95% CI:
1.0-2.8; P = 0.059). More than 40% of all participants did not know the HIV-
status of regular partners. Therefore, HAART was not associated with increased
249
sexual risk behaviours though considerable risk of HIV-transmission remains.

HIV-care services need to emphasize partner testing and consistent condom use
with all partners.
Epidemiology of HIV-1 infection in agricultural plantation residents in

Kericho, Kenya: preparation for vaccine feasibility studies.
Author: Sateren, W. B.; Foglia, G.; Renzullo, P. O.; Elson, L.; Wasunna, M.; Bautista, C. T.,
and Birx, D. L.
Abstract: A cross-sectional study was performed to determine the prevalence and risk
factors for HIV-1 infection among agricultural plantation residents in Kericho,
Kenya. Volunteers were recruited, interviewed, and phlebotomized for HIV-1
serologic testing. Sex-specific adjusted odds ratios were estimated using logistic
regression. The overall HIV-1 prevalence was 9.9% (81/820), with prevalence in
women more than twice that in men (17.4% vs 8.0%, P=0.001). Among men,
elevated HIV-1 prevalence was seen with increasing age, peaking in those older
than 30 years (10.3%), marriage (10.4%), Luo tribe affiliation (23.5%),
employment (8.9%), travel (11.0%), and being uncircumcised (29.2%). Among
women, elevated HIV-1 prevalence was seen in those with no formal education
(36.8%) and those who received goods in exchange for sex (36.0%). More than
97% of volunteers expressed a willingness to participate in future HIV-1 studies
requiring semiannual visits. HIV prevention efforts have been implemented,
along with further research to characterize this population for future cohort
feasibility studies and HIV-1 vaccine efficacy trials.
Characterization of intersubtype recombinant HIV type 1 genomes using

a nonradioactive heteroduplex tracking assay.
Author: Schroeder, T. L.; Burger, H.; Weiser, B.; Bengualid, V.; Kimani, J.; Anzala, A. O.;
Parker, M. M.; Lamson, D., and Philpott, S. M.
Source: AIDS Res Hum Retroviruses. 2005 Apr; 21(4):314-8.
Abstract: The HIV-1 epidemic is characterized by the dominance of distinct viral subtypes
in different regions of the world, and intersubtype recombinants are common.
Traditional subtyping methods analyze only a small fragment of the HIV-1
genome, so the true extent of diversity and recombination has been difficult to
examine. We developed a heteroduplex tracking assay (HTA) to identify viral
subtypes and rapidly detect recombinant HIV-1 genomes. By using probes that
target seven regions across the HIV-1 genome, HTAs can identify intersubtype
recombinants on the basis of the heteroduplex mobility pattern. We used this
method to analyze HIV-1 strains from 12 patients from the United States and
250
Kenya, comparing the results with those obtained by sequencing. HTA analysis
correctly identified the subtype of each region of the genome, revealing that
several isolates were recombinants. This method is suitable for studies of HIV-1
diversity and recombination in areas of the world where multiple subtypes are
found.
Anal and dry sex in commercial sex work, and relation to risk for
sexually transmitted infections and HIV in Meru, Kenya.
Author: Schwandt, M.; Morris, C.; Ferguson, A.; Ngugi, E., and Moses, S.
To examine the practices of anal intercourse and dry sex within a cohort of
female sex workers (FSWs) in Kenya, focusing on the prevalence and perceived
risk of the practices, demographic and behavioural correlates, and association
with sexually transmitted infections (STI).
Methods:
A survey was conducted among FSWs in Meru, Kenya, with 147 participants
randomly sampled from an existing cohort of self identified FSWs.
Results:
40.8% of participants reported ever practising anal intercourse and 36.1%
reported ever practising dry sex. Although the majority of women surveyed
believed anal intercourse and dry sex to be high risk practices for HIV infection
compared with vaginal sex, about one third of women reported never or rarely
using condoms during anal intercourse, and about 20% never or rarely using
condoms during dry sex. Reported consistent condom use was lower with both
of these practices than with penile-vaginal intercourse. Anal intercourse was
associated with experience of recent forced sexual intercourse, while dry sex was
not. Anal intercourse was almost always initiated by clients, whereas dry sex was
likely to be initiated by the women themselves. Sex workers reported charging
higher fees for both practices than for vaginal intercourse. Both practices were
associated with reported symptoms and diagnoses of STI.
Conclusions:
Both anal intercourse and dry sex were common in this sample, and although
perceived as high risk practices, were not adequately protected with condom use.
Education and other interventions regarding these high risk sexual behaviours
need to be translated into safer practices, particularly consistent condom use,
even in the face of financial vulnerability.
251
Can data from programs for the prevention of mother-to-child

transmission of HIV be used for HIV surveillance in Kenya?
Author: Seguy, N.; Hladik, W.; Munyisia, E.; Bolu, O.; Marum, L. H., and Diaz, T.
Source: Public Health Rep. 2006 Nov-2006 Dec 31; 121(6):695-702.
In Africa, HIV surveillance is conducted among antenatal clinic (ANC) attendees
using unlinked-anonymous testing (UAT). In Kenya, the utility of prevention of
mother-to-child transmission (PMTCT) program data for HIV surveillance was
evaluated.
Methods:
UAT and PMTCT data were compared at the same clinics and for the same time
(2003 UAT survey) period. The HIV testing uptake for PMTCT was defined as
the number of ANC attendees tested for HIV out of those who had their first
ANC visit during the ANC surveillance period. Odds ratios and 95% confidence
intervals were calculated to determine associations between demographic
characteristics and HIV testing acceptance.
Results:
Of 39 ANC-UAT sites, six had PMTCT data. PMTCT data were recorded across
several logbooks with varying quality. For PMTCT, 2,239 women were offered
HIV testing and 1,258 (56%) accepted; for UAT, 1,852 women were sampled.
Median UAT-based HIV prevalence was 12.8% (range, 8.1%-26.3%) compared
with 14.4% (range, 7.0%-27.2%) in PMTCT. HIV testing acceptance for PMTCT
ranged from 48% to 69% across clinics, and was more likely among
primigravidae than multigravidae.
Conclusion:
Because of varying PMTCT data quality and varying HIV testing acceptance for
PMTCT, PMTCT-based HIV prevalence estimates cannot currently replace UAT-
based estimates in Kenya.
Report and policy brief from the 4th Africa Conference on Social Aspects
of HIV/AIDS Research: innovations in access to prevention, treatment
and care in HIV/AIDS, Kisumu, Kenya.
Author: Setswe, G.; Peltzer, K.; Banyini, M.; Skinner, D.; Seager, J.; Maile, S.; Sedumedi, S.;
Gomis, D., and van der Linde, I.
Abstract: About 520 delegates from all over Africa and 21 countries attended the
conference.This report and policy brief summarises the key findings and
252
suggested policy options that emerged from rapporteur reports of conference

proceedings including the following themes: (1) Orphans and vulnerable
children, (2) Treatment, (3) Prevention, (4) Gender and male involvement, (5)
Male circumcision, (6) People living with HIV/AIDS, (7) Food and nutrition, (8)
Socioeconomics, and (9) Politics/policy. Two (11.8%) of the 17 OVC projects from
the three countries were classified as best practice interventions. Of the 83
abstracts that were accepted at the conference, only 7 (8.4%) were dealing with
antiretroviral therapy (ART). There has been tremendous effort by various
organisations to provide information about prevention of HIV/AIDS.
Information received by adolescents has been effective in increasing their
knowledge, but without positive sexual behaviour change. The conference noted
the contribution of gender discrimination and violence to the HIV epidemic and
the different risks that men and women face in relation to the epidemic. Social
scientists need to study the deep cultural meanings attached to male
circumcision among different ethnic groups to be able to guide the debate on the
latest biomedical findings on the protective effect of circumcision against HIV.
Palliative care and support is crucial for coping among people living with
HIV/AIDS (PLWHA) in order to deal with medical and psychological issues.
Results from several countries have helped researchers to explore alternative
ways of examining poverty in the context of HIV and AIDS. Policy frameworks
which are likely to succeed in combating HIV/AIDS need to be updated to cover
issues of access, testing, disclosure and stigma. In general, the conference was
successful in identifying innovations in access to prevention, treatment and care
in HIV/AIDS.

Author: Shacham, E.; Reece, M.; Ong'or, W. O.; Omollo, O.; Monahan, P. O., and Ojwang,
C.
253
friends. Symptoms of psychological distress were more prevalent among
women on multiple measures, including depression, anxiety, paranoid ideation,

Auhtor: Shaffer, D. N.; Bautista, C. T.; Sateren, W. B.; Sawe, F. K.; Kiplangat, S. C.;
Miruka, A. O.; Renzullo, P. O.; Scott, P. T.; Robb, M. L.; Michael, N. L., and Birx,
D. L.
Data from prospective cohort studies are helpful in considering generalizability
of RCT results to populations with unique epidemiologic/cultural
characteristics.
Methods:
rate ratios (HRs).
Results:
254

0.55; 95% CI: 0.20 to 1.49).
Conclusions:
Circumcision by traditional circumcisers offers protection from HIV infection in
adult men in rural Kenya. Data from well-designed prospective cohort studies in
populations with unique cultural characteristics can supplement RCT data in
recommending public health policy.
Equitable treatment for HIV/AIDS clinical trial participants: a focus

group study of patients, clinician researchers, and administrators in
Western Kenya.
Author: Shaffer, D. N.; Yebei, V. N.; Ballidawa, J. B.; Sidle, J. E.; Greene, J. Y.; Meslin, E.
M.; Kimaiyo, S. J., and Tierney, W. M.
Source: J Med Ethics. 2006 Jan; 32(1):55-60.
To describe the concerns and priorities of key stakeholders in a developing
country regarding ethical obligations held by researchers and perceptions of
equity or "what is fair" for study participants in an HIV/AIDS clinical drug trial.
Design: Qualitative study with focus groups.
Setting:
Teaching and referral hospital and rural health centre in Western Kenya.
Participants:
Potential HIV/AIDS clinical trial participants, clinician researchers, and
administrators. RESULTS: Eighty nine individuals participated in a total of 11
focus groups over a four month period. The desire for continued drug therapy,
most often life long, following an HIV/AIDS clinical trial was the most common
priority expressed in all focus groups. Patients with and without HIV/AIDS also
thought subsidizing of drug therapies and education were critical forms of
compensation for clinical trial participation. Financial incentives were considered
important primarily for purchasing drug therapy as well as obtaining food.
Patients noted a concern for the potential mismanagement of any money offered.
Clinician researchers and administrators felt strongly that researchers have a
moral obligation to participants following a trial to provide continued drug
therapy, adverse event monitoring, and primary care. Finally, clinician
researchers and administrators stressed the need for thorough informed consent
to avoid coercion of study participants.
Conclusions:
255
Kenyan patients, clinician researchers, and administrators believe that it would

be unfair to stop antiretroviral therapy following an HIV/AIDS clinical trial and
that researchers have a long term obligation to participants.
HIV immunosuppression and antimalarial efficacy: sulfadoxine-

pyrimethamine for the treatment of uncomplicated malaria in HIV-
infected adults in Siaya, Kenya.
Author: Shah, S. N.; Smith, E. E.; Obonyo, C. O.; Kain, K. C.; Bloland, P. B.; Slutsker, L.,
and Hamel, M. J.
The altered immune response of persons with human immunodeficiency virus
(HIV) infection could result in increased rates of antimalarial treatment failure.
We investigated the influence of HIV infection on the response to sulfadoxine-
pyrimethamine treatment.
Methods:
Febrile adults with Plasmodium falciparum parasitemia were treated with
sulfadoxine-pyrimethamine and were monitored for 28 days. HIV status and
CD4 cell count were determined at study enrollment.
Results:
Of the adults enrolled in the study, 508 attended all follow-up visits, including
130 HIV-uninfected adults, 256 HIV-infected adults with a high CD4 cell count (>
or =200 cells/ micro L), and 122 HIV-infected adults with a low CD4 cell count
(<200 cells/ micro L). The hazard of treatment failure at day 28 of follow-up was
significantly higher for HIV-infected adults with a low CD4 cell count (20.5%)
than for HIV-uninfected adults (7.7%). Anemia (hemoglobin level, <110 g/L)
modified the effect of HIV status on treatment failure. When we controlled for
fever and parasite density, the hazard of treatment failure for HIV-infected
adults with a low CD4 cell count and anemia was 3.4 times higher than that for
HIV-uninfected adults (adjusted hazard ratio, 3.38; 95% confidence interval,
1.56-7.34).
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Conclusions:
HIV-infected persons with a low CD4 cell count and anemia have an increased
risk of antimalarial treatment failure. The response to malaria treatment in HIV-
infected persons must be carefully monitored. Proven measures for the control
and prevention of malaria must be incorporated into the basic package of
services provided by HIV/acquired immunodeficiency syndrome care and
treatment programs in malarious areas
Mucosal Neisseria gonorrhoeae coinfection during HIV acquisition is

associated with enhanced systemic HIV-specific CD8 T-cell responses.
Author: Sheung, A.; Rebbapragada, A.; Shin, L. Y.; Dobson-Belaire, W.; Kimani, J.; Ngugi,
E.; MacDonald, K. S.; Bwayo, J. J.; Moses, S.; Gray-Owen, S., and Kaul, R.
Source: AIDS. 2008 Sep 12; 22(14):1729-37.
The host immune response against mucosally acquired pathogens may be
influenced by the mucosal immune milieu during acquisition. As Neisseria
gonorrhoeae can impair dendritic cell and T-cell immune function, we
hypothesized that coinfection during HIV acquisition would impair subsequent
systemic T-cell responses.
Methods:
Monthly screening for sexually transmitted infections was performed in high
risk, HIV seronegative Kenyan female sex workers as part of an HIV prevention
trial. Early HIV-specific CD8 T-cell responses and subsequent HIV viral load set
point were assayed in participants acquiring HIV, and were correlated with the
presence of prior genital infections during HIV acquisition.
Results:
Thirty-five participants acquired HIV during follow-up, and 16 out of 35 (46%)
had a classical sexually transmitted infection at the time of acquisition. N.
gonorrhoeae coinfection was present during HIV acquisition in 6 out of 35 (17%),
and was associated with an increased breadth and magnitude of systemic HIV-
specific CD8 T-cell responses, using both interferon-gamma gamma and MIP-1
beta as an output. No other genital infections were associated with differences in
HIV-specific CD8 T-cell response, and neither N. gonorrhoeae nor other genital
infections were associated with differences in HIV plasma viral load at set point.
Conclusion:
Unexpectedly, genital N. gonorrhoeae infection during heterosexual HIV
acquisition was associated with substantially enhanced HIV-specific CD8 T-cell
responses, although not with differences in HIV viral load set point. This may
have implications for the development of mucosal HIV vaccines and adjuvants.
257
Bronchoscopic study on aetiology of chronic cough in HIV-infected

adults with negative sputum smears for Mycobacterium tuberculosis.
Author: Siika, A. M.; Chakaya, J. M.; Revathi, G.; Mohamed, S. S., and Bhatt, K. M.
Source: Kenyatta National Hospital, Nairobi. East Afr Med J. 2006 Jun; 83(6):295-305.
Abstract: objective:
To establish the aetiology of chronic cough in HIV-infected patients with
negative sputum smears for Acid Fast Bacilli (AFB).
Design: A cross-sectional descriptive study.
Setting: Kenyatta National Hospital, a tertiary referral centre in Kenya
Subjects:
Sixty five HIV-infected adults presenting with chronic cough and negative
sputum smears for AFBs.
Results:
Sixty-two patients were included in the final analysis. Aetiology of chronic cough
was established in 42 (68%) patients. Pneumocystis jiroveci, bacterial pneumonia
and Mycobacterium tuberculosis were diagnosed in 22 (35.5%), 17 (27.4%) and 14
(22.5%) patients respectively. Majority (98%) of patients with a diagnosis had
multiple causes established in them. Ciprofloxacin had activity against 91% of
the isolated organisms while Penicillin was active against 35% only.
Conclusion:
This study documents Pneumocystis jiroveci pneumonia as a common cause of
morbidity in a subset of HIV infected patients with chronic cough and negative
sputum smears for AFB in Kenya.
An electronic medical record system for ambulatory care of HIV-infected

patients in Kenya.
Author: Siika, A. M.; Rotich, J. K.; Simiyu, C. J.; Kigotho, E. M.; Smith, F. E.; Sidle, J. E.;
Wools-Kaloustian, K.; Kimaiyo, S. N.; Nyandiko, W. M.; Hannan, T. J., and
Tierney, W. M.
Source: Int J Med Inform. 2005 Jun; 74(5):345-55.
Abstract: Administering and monitoring therapy is crucial to the battle against HIV/AIDS
in sub-Saharan Africa. Electronic medical records (EMRs) can aid in
documenting care, monitoring drug adherence and response to therapy, and
providing data for quality improvement and research. Faculty at Moi University
in Kenya and Indiana and University in the USA opened adult and pediatric
258
HIV clinics in a national referral hospital, a district hospital, and six rural health
centers in western Kenya using a newly developed EMR to support
comprehensive outpatient HIV/AIDS care. Demographic, clinical, and HIV risk
data, diagnostic test results, and treatment information are recorded on paper
encounter forms and hand-entered into a central database that prints summary
flowsheets and reminders for appropriate testing and treatment. There are
separate modules for monitoring the Antenatal Clinic and Pharmacy. The EMR
was designed with input from clinicians who understand the local community
and constraints of providing care in resource poor settings. To date, the EMR
contains more than 30,000 visit records for more than 4000 patients, almost half
taking antiretroviral drugs. We describe the development and structure of this
EMR and plans for future development that include wireless connections, tablet
computers, and migration to a Web-based platform.
Building Upendo Village: a global effort.

Author: Sister Beatrice Hernandez; Sister Sheila Kinsey, and Rocole, T.
Source: Health Prog. 2006 Jul-2006 Aug 31; 87(4):33-6.
Abstract: What began as a conversation in 2000 between two women religious on how to
help Kenyans affected by HIV/AIDS has evolved into a far-reaching ministry
supported by the Wheaton Franciscan sisters. Inspired by the parable of the
Good Samaritan, Sr. Florence Muia, ASN, a native of Kenya, explored with Sr.
Marge Zulaski, OSF, a Wheaton Franciscan sister, how to offer assistance and
support to Kenyans with HIV/AIDS. The two began by establishing a
partnership involving the Wheaton, IL, congregation; the Assumption Sisters of
Nairobi; and community members in Kenya. These partners have worked
together closely to secure local community members' buy-in for a care program,
study models for success, build a program infrastructure, secure funds, staff up,
and interact with government agencies. The result? Upendo Village, a program
that helps ensure the physical, economic, and emotional safety of people
suffering from HIV/AIDS. This partnership has enabled the Wheaton
Franciscans, the Assumption Sisters, and the Kenyan community to live out a
simple principle: We are called to help each other.
A reverse transcriptase assay for early diagnosis of infant HIV infection

in resource-limited settings.
Author: Sivapalasingam, S.; Patel, U.; Itri, V.; Laverty, M.; Mandaliya, K.; Valentine, F.,
and Essajee, S.
Source: J Trop Pediatr. 2007 Oct; 53(5):355-8.
Abstract: Early diagnosis of pediatric HIV infection is confounded by persistence of

maternal antibodies until 18 months, necessitating the use of expensive assays
259
such as HIV-1 DNA PCR, an untenable option in resource-limited settings. This

is the first report of a low-cost, commercial, reverse transcriptase (RT) assay for
the diagnosis of HIV-1 infection in infants. RT assays were performed on 42
samples from 30 HIV-exposed Kenyan infants under 15 months of age. When
correlated with serologic testing conducted after 18 months, the sensitivity,
specificity, positive and negative predictive values of the RT assay were 92%,
93%, 87% and 96%. A low-cost assay for infant HIV diagnosis is urgently needed,
and these results merit further evaluation.
Modified vaccinia Ankara expressing HIVA antigen stimulates HIV-1-

specific CD8 T cells in ELISpot assays of HIV-1 exposed infants.
Author: Slyker, J. A.; Lohman, B. L.; Mbori-Ngacha, D. A.; Reilly, M.; Wee, E. G.; Dong,
T.; McMichael, A. J.; Rowland-Jones, S. L.; Hanke, T., and John-Stewart, G.
Source: Vaccine. 2005 Sep 7; 23(38):4711-9.
Abstract: Recombinant modified vaccinia virus Ankara expressing HIV-1 antigens

(MVA.HIVA) was used in ELISpot assays to monitor HIV-1-specific T cell
responses in infants. Responses to MVA.HIVA and HIV-1 peptides were
examined in 13 infected and 81 exposed uninfected infants in Nairobi, Kenya.
Responses to MVA.HIVA (38%) and peptide stimulation (38%) were similar in
frequency (p=1.0) and magnitude (mean 176 versus 385 HIVSFU/10(6), p=0.96)
in HIV-1 infected infants. In exposed uninfected infants, MVA.HIVA detected
more positive responses and higher magnitude responses as compared to
peptide. MVA.HIVA ELISpot is a sensitive method for quantification of HIV-1-
specific CD8+ T cell responses in HIV-1 exposed infants. These results
demonstrate the relevance of HIV-1 clade A consensus-derived immunogen
HIVA for the viruses currently circulating in Nairobi.
Should rapid tests for HIV infection now be mandatory during

pregnancy? Global differences in scarcity and a dilemma of
technological advance.
Author: Smith, C. B.; Battin, M. P.; Francis, L. P., and Jacobson, J. A.
Source: Dev World Bioeth. 2007 Aug; 7(2):86-103.
Abstract: Since testing for HIV infection became possible in 1985, testing of pregnant
women has been conducted primarily on a voluntary, 'opt-in' basis. Faden, Geller
and Powers, Bayer, Wilfert, and McKenna, among others, have suggested that
with the development of more reliable testing and more effective therapy to
reduce maternal-fetal transmission, testing should become either routine with
'opt-out' provisions or mandatory. We ask, in the light of the new rapid tests for
HIV, such as OraQuick, and the development of antiretroviral treatment that can
260
reduce maternal-fetal transmission rates to <2%, whether that time is now.

Illustrating our argument with cases from the United States (US), Kenya, Peru,
and an undocumented Mexican worker in the US, we show that when testing is
accompanied by assured multi-drug therapy for the mother, the argument for
opt-out or mandatory testing for HIV in pregnancy is strong, but that it is
problematic where testing is accompanied by adverse events such as spousal
abuse or by inadequate intrapartum or follow-up treatment. The difference is not
a 'double standard', but reflects the presence of conflicts between the health
interests of the mother and the fetus--conflicts that would be abrogated by the
assurance of adequate, continuing multi-drug therapy. In light of these conflicts,
where they still occur, careful processes of informed consent are appropriate,
rather than opt-out or mandatory testing.
An evaluation of intravaginal rings as a potential HIV prevention device

in urban Kenya: behaviors and attitudes that might influence uptake
within a high-risk population.
Author: Smith, D. J.; Wakasiaka, S.; Hoang, T. D.; Bwayo, J. J.; Del Rio, C., and Priddy, F.
H.
Source: J Womens Health (Larchmt). 2008 Jul-2008 Aug 31; 17(6):1025-34.
Abstract: Purpose:
We sought to assess the potential acceptability of intravaginal rings (IVRs) as an
HIV prevention method among at-risk women and men.
Methods:
We conducted a qualitative assessment of initial attitudes toward IVRs, current
HIV prevention methods, and common behavioral practices among female sex
workers (FSWs) and men who frequent FSWs in Mukuru, an urban slum
community in Nairobi, Kenya. Nineteen women and 21 men took part in six
focus group discussions.
Results:
Most participants, both male and female, responded positively to the concept of
an IVR as a device for delivering microbicides. Women particularly liked the
convenience offered by its slow-release capacity. Some female respondents raised
concerns about whether male customers would discover the ring and respond
negatively, whereas others thought it unlikely that their clients would feel the
ring. Focus groups conducted with male clients of FSWs suggested that many
would be enthusiastic about women, and particularly sex workers, using a
microbicide ring, but that women's fears about negative responses to covert use
were well founded. Overall, this high-risk population of FSWs and male clients
in Nairobi was very open to the IVR as a potential HIV prevention device.
Conclusion:
261
Themes that emerged from the focus groups highlight the importance of
understanding attitudes toward IVRs as well as cultural practices that may
impact IVR use in high-risk populations when pursuing clinical development of
this potential HIV prevention device.
Plasma and mucosal fluid from HIV type 1-infected patients but not
from HIV type 1-exposed uninfected subjects prevent HIV type 1-
exposed DC from infecting other target cells.
Author: Soderlund, J.; Hirbod, T.; Smed-Sorensen, A.; Johansson, U.; Kimani, J.; Plummer,
F.; Spetz, A. L.; Andersson, J.; Kaul, R., and Broliden, K.
Source: AIDS Res Hum Retroviruses. 2007 Jan; 23(1):101-6.
Abstract: Highly exposed persistently seronegative (HEPS) individuals have previously

been shown to mount HIV-1-specific humoral and cellular immune responses in
the mucosa, despite their uninfected status. It is thus possible that HEPS
individuals are protected from HIV-1 infection at the mucosal level. Recent work
supports the hypothesis that dendritic cells are involved in the establishment of a
mucosal HIV-1 infection as well as the dissemination to other target cells.
However, no previous study has investigated if samples collected from HEPS
individuals have the capacity to prevent HIV-1 infection in the presence of
dendritic cells in vitro. We therefore established an assay that measures HIV-1
neutralization in cocultures of HIV-1-exposed dendritic cells (DC) and PBMC.
Plasma and cervicovaginal lavage (CVL) samples from HIV-1-infected patients
and HEPS individuals, enrolled in a well-characterized sex worker cohort in
Kenya, were evaluated. Most plasma and CVL samples of HIV-1-infected
patients neutralized HIV-1 in the DC/PBMC cocultures. Neither plasma nor CVL
samples of most HEPS individuals had this capacity. However, they readily
neutralized HIV-1 infection of PBMC alone. This may suggest that protection
against HIV-1 infection in HEPS individuals occurs prior to interaction between
HIV-1-exposed DC and other target cells.
262
Efficacy of highly active antiretroviral therapy in HIV-1 infected children

in Kenya.
Author: Song, R.; Jelagat, J.; Dzombo, D.; Mwalimu, M.; Mandaliya, K.; Shikely, K., and
Essajee, S.
Source: Pediatrics. 2007 Oct; 120(4):e856-61.
Few studies have investigated the efficacy of antiretroviral therapy among HIV-
infected children in resource-poor settings. This observational, retrospective
analysis describes the clinical, immunologic, and virologic effects of highly active
antiretroviral therapy in treatment-naive, HIV-infected children in Mombasa,
Kenya. In keeping with a public health approach, all children were treated by
using a simplified, nationally approved, triple-drug regimen.
Methods:
Clinical data and stored plasma samples from 29 children who were followed
prospectively between April 2003 and October 2004 were analyzed. All children
received generic formulations of nevirapine, zidovudine, and lamivudine and
were evaluated at baseline and at 3, 6, 9, 12, and 15 months. At each visit, weight
and CD4 lymphocyte counts were measured and plasma samples were stored for
analysis. HIV RNA load was determined retrospectively at baseline and 9
months after initiation of therapy.
Results:
The mean age of the children was 8.5 years (range: 2-16 years). At baseline, the
mean CD4 count (+/-SD) was 182.3 x 10(6) cells per microL (+/-145.6). On
treatment, CD4 counts increased step-wise by a mean of 187 x 10(6) cells per
microL at 3 months, 293 cells per microL at 6 months, 308 cells per microL at 9
months, 334 cells per microL at 12 months, and 363 cells per microL at 15
months. The mean plasma viral load decreased from a baseline level of 622,712 to
35,369 copies per mL, and at 9 months was undetectable in 55% of the patients.
Mean z scores for weight for age increased from a baseline of -1.61 to -1.12 at 12
months into therapy.
Conclusions:
A public health approach using 1 treatment regimen in generic form showed
excellent efficacy among treatment-naive, HIV-infected children in a resource-
limited country. Clinical and immunologic improvement occurred in all patients,
but 9 months after the start of therapy, only 55% of the children had an
undetectable viral load.
Implementation of an antiretroviral access program for HIV-1-infected

individuals in resource-limited settings: clinical results from 4 African
countries.
263
Author: Sow, P. S.; Otieno, L. F.; Bissagnene, E.; Kityo, C.; Bennink, R.; Clevenbergh, P.;
Wit, F. W.; Waalberg, E.; Rinke de Wit, T. F., and Lange, J. M.
Source: J Acquir Immune Defic Syndr. 2007 Mar 1; 44(3):262-7.
We assessed the effectiveness and safety of highly active antiretroviral therapy
(HAART) in HIV-1-infected patients in resource-limited African countries. HIV-1
screening, therapy, counseling, monitoring, training, and education were
provided free of charge.
Methods:
In an open-label cohort program, 206 antiretroviral-naive HIV-1-infected patients
who could not afford HAART were recruited in 4 urban clinics in Senegal, Cote
d'Ivoire, Uganda, and Kenya and were treated with saquinavir boosted with
ritonavir (1600/100 mg once daily), lamivudine (150 mg twice daily), and
zidovudine (300 mg twice daily). The primary outcome was a plasma viral load
(pVL) of <400 copies/mL after 96 weeks of treatment. Secondary analyses
included CD4 cell count changes and the occurrence of treatment-emergent
adverse events.
Results:
The median age of the patient group was 36 years, 38% were male, 35% of the
patients had AIDS, the median CD4 count was 119 cells/microL, and the median
pVL was 304,210 copies/mL. Overall, 65%/52% (on treatment [OT]/intent to
treat [ITT]) of the patients had a pVL <400 copies/mL after 96 weeks of follow-
up. This proportion varied significantly between sites, however; although in
Nairobi and Dakar, 51%/40% and 56%/46% (OT/ITT) were found, respectively,
Abidjan and Kampala showed proportions of 69%/54% and 83%/69% (OT/ITT),
respectively. The median increase in the CD4 count was 198 cells/microL
(interquartile range: 86-319 cells/microL), ranging from 191 to 292 cells/microL
between the sites. Fourteen patients (6.8%) died between 8 and 96 weeks of
follow-up, whereas 18 (9%) developed an AIDS-defining event between 8 and 96
weeks of follow-up. Non-HIV-related serious adverse events occurred in 55
patients (26.7%), of whom 13 were diagnosed with severe anemia. Thirty-five
patients (17%) changed treatment for toxicity reasons.
Conclusions:
Although a statistically significant difference was observed between sites with
respect to virologic success, overall virologic and immunologic responses to
HAART in resource-limited African settings can be as good as in Western
settings. There were some difficulties (eg, laboratory, logistics, proper training)
during the early phase of the program. Therefore, provision of adequate medical
care, counseling, proper instruction, and education of patients and medical staff
during the entire study is warranted in such programs, with special care in the
early phase.
264
Piloting post-exposure prophylaxis in Kenya raises specific concerns for

the management of childhood rape.
Author: Speight, C. G.; Klufio, A.; Kilonzo, S. N.; Mbugua, C.; Kuria, E.; Bunn, J. E., and
Taegtmeyer, M.
Source: Trans R Soc Trop Med Hyg. 2006 Jan; 100(1):14-8.
Abstract: Thika District, Kenya, is the site of an operational research study on the
provision of comprehensive post-rape care, including the free provision of HIV
post-exposure prophylaxis (PEP). It is a typical rural Kenyan district in terms of
resources and patient throughput. The high rate of children attending for post-
rape services was unexpected and had significant programming implications. An
age-disaggregated analysis of existing quantitative data from the first 8 months
of service provision was conducted. Ninety-four case records were reviewed, of
whom 48 (51%) were in the age range 1.5-17 years inclusive. All three cases of
male rape were in children. Children were more likely to know their assailant
than adults and were more likely to be HIV-negative at baseline. The majority
(86%) of children presented in time for PEP, with adherence and completion
rates similar to adults but lower rates of 6-week follow-up. The use of weight
bands to determine drug dosages greatly simplified the appropriate and early
administration of paediatric PEP. The high rates of childhood rape and demand
for post-rape services were an enormous challenge for service providers and
policy-makers.
Analysis of HIV-1 sequences vertically transmitted to infants in Kisumu,

Kenya.
Author: Steain, M. C.; Wang, B., and Saksena, N. K.
Source: J Clin Virol. 2006 Aug; 36(4):298-302.
HIV-1 prevalence in Kenya among women aged between 15-19 years is
approximately 23%. These women are prospective mothers and therefore can
play an important role in mother-to-child transmission of HIV. The risk of a
seropositve mother transmitting the virus to her infant is 25-35% in developing
countries, such as Kenya, where antiretroviral drugs are not readily available.
Objectives:
This study was undertaken to evaluate the molecular nature of HIV-1 strains,
assess recombination and it's relevance in mother-to-child transmission in Kenya.
Study design:
265
HIV-1 gag and gp120 sequences were derived from peripheral blood
mononuclear cells (PBMC) of 16 infected mothers and infants, from Kisumu,
Kenya. PCR, cloning, and phylogenetic analyses were conducted to examine any
sequence differences between HIV-1 strains derived from mother-infant pairs.
Results:
The cohort consisted of seven pairs harboring possible subtype A/D
recombinants, eight pairs with apparent pure A or D strains and one possible
dual infection. This dual infection comprised of a pure subtype A region and an
A/D recombinant, and was detected in one of the mother's sample.
Interestingly, only the recombinant virus was detected in the paired baby
sample.
Conclusions:
This study shows that HIV-1 inter-subtype recombinants can be effectively
transmitted vertically to infants, and could possibly be favored in this setting
where multiple subtypes infect women. Together, dual infections and the co-
existence of multiple HIV-1 subtypes is encouraging the emergence of
recombinant HIV strains and their rapid dispersal.
HIV type 1 sequence diversity and dual infections in Kenya. AIDS Res
Hum Retroviruses.
Author: Steain, M. C.; Wang, B.; Yang, C.; Shi, Y. P.; Nahlen, B.; Lal, R. B., and Saksena, N.
K.
Abstract: As vertical transmission of HIV-1 is an ongoing problem in East Africa, we

analyzed HIV-1 strains of infected mothers, from Kisumu, Kenya. We sequenced
the gag and gp120 regions from peripheral blood mononuclear cells (PBMC) of
15 HIV-infected mothers attending an antenatal clinic. PCR, cloning,
bootscanning, using the program Simplot, and phylogenetic analyses were
conducted to assign subtypes and identify recombinants. Our analyses showed
two dual infections from patients who had infections with pure subtypes and
recombinants subtype D. In addition, we also noted the presence of subsubtype
A1 and A2, as well as unique recombinants in this area. These results imply that
the HIV epidemic in western Kenya is a dynamic one and is continually
evolving. Therefore, continued monitoring of the epidemic in this region is
necessary if a vaccine for the area is to be developed.
266
Evaluation of two commercially available alternatives for HIV-1 viral

load testing in resource-limited settings.
Author: Steegen, K.; Luchters, S.; De Cabooter, N.; Reynaerts, J.; Mandaliya, K.; Plum, J.;
Jaoko, W.; Verhofstede, C., and Temmerman, M.
Source: Virol Methods. 2007 Dec; 146(1-2):178-87.
Abstract: There is an urgent need for low-cost assays for HIV-1 quantitation to ensure
adequate follow-up of HIV-infected patients on antiretroviral therapy (ART) in
resource-limited countries. Two low-cost viral load assays are evaluated, a
reverse transcriptase activity assay (ExavirLoad v2, Cavidi) and a real-time
reverse transcriptase PCR assay (Generic HIV viral load, Biocentric). Both tests
were compared with the ultrasensitive HIV Amplicor Monitor assay. Samples
were collected in Mombasa, Kenya, from 20 HIV-1 seronegative and 150 HIV-1
seropositive individuals of whom 50 received antiretroviral treatment (ART). The
ExavirLoad and the Generic HIV viral load assay were performed in a local
laboratory in Mombasa, the Amplicor Monitor assay (version 1.5, Roche
Diagnostics) was performed in Ghent, Belgium. ExavirLoad and Generic HIV
viral load reached a sensitivity of 98.3% and 100% and a specificity of 80.0% and
90.0%, respectively. Linear regression analyses revealed good correlations
between the Amplicor Monitor and the Generic HIV viral load (r=0.935, p<0.001)
with high accuracy (100.1%), good precision (5.5%) and a low percent similarity
coefficient of variation (5.4%). Bland-Altman analysis found 95% of the samples
within clinically acceptable limits of agreement (-1.19 to 0.87logcopies/ml).
Although, the ExavirLoad also showed a good linear correlation with the
Amplicor Monitor (r=0.901, p<0.001), a problem with false positive results was
more significant. The cost per test remains relatively high (US$ 30 for ExavirLoad
and US$ 20 for the Generic HIV viral load). Hence, false positive results and the
need for an expensive PCR instrument for the Generic HIV viral load assays still
limit the implementation of these tests in less equipped, less experienced
laboratories.
The ABCs of HIV prevention in men: associations with HIV risk and
protective behaviors.
Author: Steele, M. S.; Bukusi, E.; Cohen, C. R.; Shell-Duncan, B. A., and Holmes, K. K.
Source: J Acquir Immune Defic Syndr. 2006 Dec 15; 43(5):571-6.
To elucidate associations between beliefs in abstinence, fidelity, and condom use
(the "ABCs" of preventing HIV and other sexually transmitted infections) and
associated self-reported risk behaviors among Kenyan men.
Methods:
267
We assessed associations of beliefs in the ABCs with sociodemographic

characteristics and sexual risk behaviors in a respondent-driven sample of 500
men in Nairobi.
Results:
Younger age, single marital status, and higher education were associated with
beliefs in abstinence and condom use as "best" prevention methods; and older
age and marriage were associated with belief in fidelity. Many of these and other
associations persisted in multivariate models. Men citing abstinence or fidelity
belief less often reported sex with a female sex worker (FSW) ever or recent
concurrent partnerships less often. Belief in fidelity was negatively associated
with reported use of condoms ever. Belief in condom use to prevent HIV was
most common among those having recent concurrent partnerships.
Conclusions:
Beliefs in abstinence, fidelity ("being faithful"), or condom use were associated, in
plausible directions, with life stages and other demographic factors and with
corresponding risk and preventive behaviors. Context-specific and selective
educational promotion of individual ABC components rather than
comprehensive education from an early age in a wide repertoire of prevention
strategies ignores the evolution of sexual behaviors and the relative utility of
different approaches throughout the life course.
A peer-led HIV counselling and testing programme for the deaf in

Kenya.
Author: Taegtmeyer, M.; Hightower, A.; Opiyo, W.; Mwachiro, L.; Henderson, K.;
Angala, P.; Ngare, C., and Marum, E.
Source: Disabil Rehabil. 2008 May 28; 1-7.
Abstract: Purpose. To describe and evaluate the establishment of the first VCT services for
the Deaf in Africa. Method. Operational research methods were used to
document programme establishment. The demographics of deaf VCT clients
were compared with hearing clients at the same sites as well as where clients
had learned of the service, HIV risks, and HIV test results. Univariate and
multivariate analyses were used. Results. During the two year period (January
2004 to December 2005) 1709 Deaf and 1649 hearing clients were seen at three
Deaf VCT sites. The majority of Deaf clients in this sample learned of the services
through the peer education programme. Data indicate that Deaf VCT clients are
as much at risk of HIV from sexual transmission as their hearing counterparts
and that Deaf persons seeking VCT services have an HIV prevalence of 7%,
similar to the national rate of 6.7%. Conclusions. The Deaf in Kenya are at risk of
HIV and there is an urgent need for Deaf-friendly HIV services, supplemented
by peer education programmes. This is the first published report describing HIV
services run by the Deaf for the Deaf in the developing world.
268
Using gender analysis to build voluntary counselling and testing

responses in Kenya.
Author: Taegtmeyer, M.; Kilonzo, N.; Mung'ala, L.; Morgan, G., and Theobald, S.
Source: Trans R Soc Trop Med Hyg. 2006 Apr; 100(4):305-11.
Abstract: The rapid expansion of voluntary counselling and testing (VCT) for HIV in sub-
Saharan Africa has led to concerns over the quality and equity of the services.
Kenya has seen an unprecedented scale-up of VCT, and valuable lessons have
been learnt at national as well as at district and community levels. We combined
quantitative and qualitative research methodology and showed how the results
of gender analysis can be used to develop equity in VCT scale-up. A gender-
disaggregated analysis of VCT client data was conducted for the first 8 months of
2003. These quantitative data revealed that despite an increased vulnerability to
HIV, women are underrepresented in VCT sites in all settings in Kenya. Our
data also showed that women were also less likely to use condoms or to take
home condoms after a VCT visit than their male counterparts. Further
exploration through in-depth qualitative work with women and men allowed a
better understanding of the reasons behind gender differences in Kenyan VCT
sites and helped to develop strategies to address gender inequity. We conclude
that there is an ongoing need to mainstream gender in monitoring and
evaluation strategies to ensure services meet the needs and priorities of all
groups.
Working with risk: occupational safety issues among healthcare workers

in Kenya.
Author: Taegtmeyer, M.; Suckling, R. M.; Nguku, P. M.; Meredith, C.; Kibaru, J.; Chakaya,
J. M.; Muchela, H., and Gilks, C. F.
Source: AIDS Care. 2008 Mar; 20(3):304-10.
Abstract: The objective of this study was to explore knowledge of, attitudes towards and
practice of post-exposure prophylaxis (PEP) among healthcare workers (HCWs)
in the Thika district, Kenya. We used site and population-based surveys,
qualitative interviews and operational research with 650 staff at risk of
needlestick injuries (NSIs). Research was conducted over a 5-year period in five
phases: (1) a bio-safety assessment; (2) a staff survey: serum drawn for
anonymous HIV testing; (3) interventions: biosafety measures, antiretrovirals for
PEP and hepatitis B vaccine; (4) a repeat survey to assess uptake and
acceptability of interventions; in-depth group and individual interviews were
conducted; and (5) health system monitoring outside a research setting. The main
outcome measures were bio-safety standards in clinical areas, knowledge,
attitudes and practice as regards to PEP, HIV-sero-prevalence in healthcare
269
workers, uptake of interventions, reasons for poor uptake elucidated and

sustainability indicators. Results showed that HCWs had the same HIV sero-
prevalence as the general population but were at risk from poor bio-safety. The
incidence of NSIs was 0.97 per healthcare worker per year. Twenty-one percent
had had an HIV test in the last year. After one year there was a significant drop
in the number of NSIs (OR: 0.4; CI: 0.3-0.6; p<0.001) and a significant increase in
the number of HCWs accessing HIV testing (OR: 1.55; CI: 1.2-2.1; p=0.003). In
comparison to uptake of hepatitis B vaccination (88% of those requiring vaccine)
the uptake of PEP was low (4% of those who had NSIs). In-depth interviews
revealed this was due to HCWs fear of HIV testing and their perception of NSIs
as low risk. We concluded that Bio-safety remains the most significant
intervention through reducing the number of NSIs. Post-exposure prophylaxis
can be made readily available in a Kenyan district. However, where HIV testing
remains stigmatised uptake will be limited - particularly in the initial phases of a
programme.
A prospective study assessing the effects of introducing the female

condom in a sex worker population in Mombasa, Kenya.
Author: Thomsen, S. C.; Ombidi, W.; Toroitich-Ruto, C.; Wong, E. L.; Tucker, H. O.;
Homan, R.; Kingola, N., and Luchters, S.
To assess the impact and costs of adding female condoms to a male condom
promotion and distribution peer education programme for sex workers in
Mombasa, Kenya.
Design: A 12 month, prospective study of 210 female sex workers.
Methods:
We interviewed participants about their sexual behaviour every 2 months for a
total of seven times and introduced female condoms after the third interview. We
also collected cost data and calculated the cost and cost effectiveness of adding
the female condom component to the existing programme.
Results:
Introduction of the female condom in an HIV/AIDS prevention project targeting
sex workers led to small, but significant, increases in consistent condom use with
all sexual partners. However, there was a high degree of substitution of the
female condom for male condoms. The cost per additional consistent condom
user at a programme level is estimated to be 2160 dollars (1169 pounds sterling,
1711 euros) (95% CI: 1338 to 11 179).
Conclusions:
270
The female condom has some potential for reducing unprotected sex among sex
workers. However, given its high cost, and the marginal improvements seen
here, governments should limit promotion of the female condom in populations
that are already successfully using the male condom. More research is needed to
identify effective methods of encouraging sex workers to practise safer sex with
their boyfriends.
The AMPATH medical record system: creating, implementing, and

sustaining an electronic medical record system to support HIV/AIDS care
in western Kenya.
Author: Tierney, W. M.; Rotich, J. K.; Hannan, T. J.; Siika, A. M.; Biondich, P. G.; Mamlin,
B. W.; Nyandiko, W. M.; Kimaiyo, S.; Wools-Kaloustian, K.; Sidle, J. E.; Simiyu,
C.; Kigotho, E.; Musick, B.; Mamlin, J. J., and Einterz, R. M.
Source: Stud Health Technol Inform. 2007; 129(Pt 1):372-6.
Abstract: Providing high-quality HIV/AIDS care requires high-quality, accessible data on

individual patients and visits. These data can also drive strategic decision-
making by health systems, national programs, and funding agencies. One major
obstacle to HIV/AIDS care in developing countries is lack of electronic medical
record systems (EMRs) to collect, manage, and report clinical data. In 2001, we
implemented a simple primary care EMR at a rural health centre in western
Kenya. This EMR evolved into a comprehensive, scalable system serving 19
urban and rural health centres. To date, the AMPATH Medical Record System
contains 10 million observations from 400,000 visit records on 45,000 patients.
Critical components include paper encounter forms for adults and children,
technicians entering/managing data, and modules for patient registration,
scheduling, encounters, clinical observations, setting user privileges, and a
concept dictionary. Key outputs include patient summaries, care reminders, and
reports for program management, operating ancillary services (e.g., tracing
patients who fail to return for appointments), strategic planning (e.g., hiring
health care providers and staff), reports to national AIDS programs and funding
agencies, and research.
271
Anti-viral activity of the extracts of a Kenyan medicinal plant Carissa

edulis against herpes simplex virus.
Author: Tolo, F. M.; Rukunga, G. M.; Muli, F. W.; Njagi, E. N.; Njue, W.; Kumon, K.;
Mungai, G. M.; Muthaura, C. N.; Muli, J. M.; Keter, L. K.; Oishi, E., and Kofi-
Tsekpo, M. W.
Source: J Ethnopharmacol. 2006 Mar 8; 104(1-2):92-9.
Abstract: Herpes simplex virus (HSV) infection is a major opportunistic infection in

immunosuppressed persons. It is therefore a serious disease in high HIV/AIDS
prevalence areas as in sub-Saharan Africa where infections due to HSV have
risen significantly. The development of resistant strains of HSV to the available
drugs for infection management, as is evident in the first drug of choice
acyclovir, has further compounded this situation. There is therefore an urgent
need to identify and develop new alternative agents for management of HSV
infections, more so, for those due to resistant strains. We report here on an
aqueous total extract preparation from the roots of Carissa edulis (Forssk.) Vahl
(Apocynaceae), a medicinal plant locally growing in Kenya that has exhibited
remarkable anti-HSV activity in vitro and in vivo for both wild type and resistant
strains of HSV. The extract significantly inhibited formation of plaques in Vero
E6 cells infected with 100PFU of wild type strains of HSV (7401H HSV-1 and Ito-
1262 HSV-2) or resistant strains of HSV (TK(-) 7401H HSV-1 and AP(r) 7401H
HSV-1) by 100% at 50 microg/ml in vitro with minimal cell cytotoxicity
(CC(50)=480 microg/ml). When the extract was examined for in vivo efficacy in a
murine model using Balb/C mice cutaneously infected with wild type or
resistant strains of HSV, the extract at an oral dose of 250 mg/kg significantly
delayed the onset of HSV infections by over 50%. It also increased the mean
survival time of treated infected mice by between 28 and 35% relative to the
infected untreated mice (p<0.05 versus control by Student's t-test). The mortality
rate for mice treated with extract was also significantly reduced by between 70
and 90% as compared with the infected untreated mice that exhibited 100%
mortality. No acute toxicity was observed in mice at the oral therapeutic dose of
250 mg/kg. These results suggest that this herbal extract has potent anti-viral
agents against herpes simplex viruses that can be exploited for development of
an alternative remedy for HSV infections.
Effects of HIV/AIDS on maternity care providers in Kenya.

Author: Turan, J. M.; Bukusi, E. A.; Cohen, C. R.; Sande, J., and Miller, S.
Source: J Obstet Gynecol Neonatal Nurs. 2008 Sep-2008 Oct 31; 37(5):588-95.
272
To explore the impact of HIV/AIDS on maternity care providers in labor and
delivery in a high HIV-prevalence setting in sub-Saharan Africa.
Design:
Qualitative one-on-one in-depth interviews with maternity care providers.
Setting:
Four health facilities providing labor and delivery services (2 public hospitals, a
public health center, and a small private maternity hospital) in Kisumu, Nyanza
Province, Kenya.
Participants:
Eighteen maternity care providers, including 14 nurse/midwives, 2 physician
assistants, and 2 physicians (ob/gyn specialists).
Results:
The HIV/AIDS epidemic has had numerous adverse effects and a few positive
effects on maternity care providers in this setting. Adverse effects include
reductions in the number of health care providers, increased workload, burnout,
reduced availability of services in small health facilities when workers are absent
due to attending HIV/AIDS training programs, difficulties with confidentiality
and unwanted disclosure, and maternity care providers' fears of becoming HIV
infected and the resulting stigma and discrimination. Positive effects include
improved infection control procedures on maternity wards and enhanced
maternity care provider knowledge and skills.
Conclusion:
A multifaceted package including policy, infrastructure, and training
interventions is needed to support maternity care providers in these settings and
ensure that they are able to perform their critical roles in maternal healthcare
and prevention of HIV/AIDS transmission.
HIV/AIDS and maternity care in Kenya: how fears of stigma and

discrimination affect uptake and provision of labor and delivery
services.
Author: Turan, J. M.; Miller, S.; Bukusi, E. A.; Sande, J., and Cohen, C. R.
Source: AIDS Care. 2008 Sep; 20(8):938-45.
Abstract: Although policies and programs exist to promote safe motherhood in sub-
Saharan Africa, maternal health has not improved and may be deteriorating in
some countries. Part of the explanation may be the adverse effects of HIV/AIDS
on maternity care. We conducted a study in Kisumu, Kenya to explore how fears
related to HIV/AIDS affect women's uptake and health workers' provision of
labor and delivery services. In-depth qualitative interviews with 17 maternity
273
workers, 14 pregnant or postpartum women, four male partners and two

traditional birth attendants; as well as structured observations of 22 births; were
conducted at four health facilities. Participants reported that fears of HIV testing;
fears of involuntary disclosure of HIV status to others, including spouses; and
HIV/AIDS stigma are among the reasons that women avoid delivering in health
facilities. Maternity workers now have to take into account the HIV status of the
women they serve (as well as their own fears of becoming infected and
stigmatized) but do not seem to be adequately prepared to handle issues related
to consent, confidentiality and disclosure. Importantly, it appeared that women
of unknown HIV status during labor and delivery were likely to be targets of
stigma and discriminatory practices and that these women were not receiving
needed counseling services. The findings suggest that increasing infection
control precautions will not be enough to address the challenges faced by
maternity care providers in caring for women in high-HIV-prevalence settings.
Maternity workers need enhanced culturally sensitive training regarding
consent, confidentiality and disclosure. Furthermore, this study points to the
necessity of paying more attention to the care of women of unknown HIV-
serostatus during labor and delivery. Such interventions may improve the
quality of maternity care, increase utilization and contribute to overall
improvements in maternal health, while also enhancing prevention of mother-to-
child-transmission and HIV care.
Reasons for unsatisfactory acceptance of antiretroviral treatment in the

urban Kibera slum, Kenya.
Author: Unge, C.; Johansson, A.; Zachariah, R.; Some, D.; Van Engelgem, I., and Ekstrom,
A. M.
Abstract: The aim of this study was to explore why patients in the urban Kibera slum,
Nairobi, Kenya, offered free antiretroviral treatment (ART) at the Medecins Sans
Frontiers (MSF) clinic, choose not to be treated despite signs of AIDS. Qualitative
semi-structured interviews were conducted with 26 patients, 9 men and 17
women. Six main reasons emerged for not accepting ART: a) fear of taking
medication on an empty stomach due to lack of food; b) fear that side-effects
associated with ART would make one more ill; c) fear of disclosure and its
possible negative repercussions; d) concern for continuity of treatment and care;
e) conflicting information from religious leaders and community, and seeking
alternative care (e.g. traditional medicine); f) illiteracy making patients unable to
understand the information given by health workers
Evaluation of TB and HIV services prior to introducing TB-HIV activities

in two rural districts in western Kenya.
274
Author: Van't Hoog, A. H.; Onyango, J.; Agaya, J.; Akeche, G.; Odero, G.; Lodenyo, W.,
and Marston, B. J.
Abstract: Setting:
Health facilities providing tuberculosis (TB) treatment in two districts in rural
western Kenya with a high TB and human immunodeficiency virus (HIV)
burden.
Objective:
To evaluate TB and HIV/acquired immune-deficiency syndrome (AIDS) services
at the facilities and identify barriers to providing quality diagnostic HIV testing
and counseling (DTC) and HIV treatment for TB patients in anticipation of the
introduction of TB-HIV collaborative services.
Methods:
We performed a standard interview with health workers responsible for TB care,
inspected the facilities and collected service delivery data. A self-administered
questionnaire on training attended was given to all health workers. Results were
shared with stakeholders and plans for implementation were developed.
Results:
Of the 59 facilities, 58 (98%) provided TB treatment, 19 (32%) offered sputum
microscopy and 24 (41%) HIV testing. Most facilities (72%) advised HIV testing
only if TB patients were suspected of having AIDS. Barriers identified included
unaccommodating TB clinic schedules and lack of space, which was an obstacle
to holding confidential discussions. The need to refer for HIV testing and/or HIV
care was a perceived barrier to recommending these services. Activities
implemented following the assessment aimed 1) to provide HIV testing and
cotrimoxazole prophylaxis at all TB treatment clinics, 2) to increase availability of
HIV treatment services, and 3) to address structural needs at each facility.
Conclusion:
This evaluation identified barriers to the implementation of HIV testing and care
services within facilities providing TB treatment.
275
The impact of pre-exposure prophylaxis (PrEP) on HIV epidemics in

Africa and India: a simulation study.
Author: Vissers, D. C.; Voeten, H. A.; Nagelkerke, N. J.; Habbema, J. D., and de Vlas, S. J.
Pre-exposure prophylaxis (PrEP) is a promising new HIV prevention method,
especially for women. An urgent demand for implementation of PrEP is expected
at the moment efficacy has been demonstrated in clinical trials. We explored the
long-term impact of PrEP on HIV transmission in different HIV epidemics.
Methodology/principal findings:
We used a mathematical model that distinguishes the general population, sex
workers and their clients. PrEP scenarios varying in effectiveness, coverage and
target group were modeled in the epidemiological settings of Botswana, Nyanza
Province in Kenya, and Southern India. We also studied the effect of condom
addition or condom substitution during PrEP use. Main outcome was number of
HIV infections averted over ten years of PrEP use. PrEP strategies with high
effectiveness and high coverage can have a substantial impact in African settings.
In Southern India, by contrast, the number of averted HIV infections in different
PrEP scenarios would be much lower. The impact of PrEP may be strongly
diminished or even reversed by behavioral disinhibition, especially in scenarios
with low coverage and low effectiveness. However, additional condom use
during low coverage and low effective PrEP doubled the amount of averted HIV
infections.
Conclusions/significance:
The public health impact of PrEP can be substantial. However, this impact may
be diminished, or even reversed, by changes in risk behavior. Implementation of
PrEP strategies should therefore come on top of current condom campaigns, not
as a substitution.
Female sex workers and unsafe sex in urban and rural Nyanza, Kenya:
regular partners may contribute more to HIV transmission than clients.
Author: Voeten, H. A.; Egesah, O. B.; Varkevisser, C. M., and Habbema, J. D.
Source: Trop Med Int Health. 2007 Feb; 12(2):174-82.
To compare the sexual behaviour of female sex workers in urban and rural areas
in Nyanza province in Kenya, and to compare their unsafe sex with clients and
with regular partners.
276
Methods:
In a cross-sectional study among 64 sex workers (32/32 in urban/rural areas),
sex workers kept a sexual diary for 14 days after being interviewed face-to-face.
Results:
Most sex workers were separated/divorced and had one or two regular partners,
who were mostly married to someone else. Sex workers in Kisumu town were
younger, had started sex work at an earlier age, and had more clients in the past
14 days than rural women (6.6 vs. 2.4). Both groups had an equal number of sex
contacts with regular partners (4.7). With clients, condom use was fairly frequent
(75%) but with regular partners, it was rather infrequent (<40%). For both urban
and rural areas, the mean number of sex acts in which no condom was used was
greater for regular partners (3.2 and 2.8 respectively) than for clients (1.9 and 1.0
respectively).
Conclusions:
Sex workers in urban and rural areas of Nyanza province practise more unsafe
sex with regular partners than with clients. Interventions for sex workers should
also focus on condom use in regular partnerships.
Association of antiretroviral and clinic adherence with orphan status

among HIV-infected children in Western Kenya.
Author: Vreeman, R. C.; Wiehe, S. E.; Ayaya, S. O.; Musick, B. S., and Nyandiko, W. M.
Source: J Acquir Immune Defic Syndr. 2008 Oct 1; 49(2):163-70.
Pediatric adherence to antiretroviral therapy (ART) is not well studied in
resource-limited settings. Reported ART adherence may be influenced by
contextual factors, such as orphan status.
Objectives:
The objectives of this study were to describe self- and proxy-reported pediatric
ART adherence in a resource-limited population and to investigate associated
contextual factors.
Patients and methods:

This was a retrospective study involving pediatric, HIV-infected patients in
Western Kenya. We included patients aged 0-14 years, who were on ART and
had at least 1 adherence measurement (N = 1516). We performed logistic
regression to assess the association between orphan status and odds of imperfect
adherence, adjusting for sex, age, clinic site, number of adherence measures, and
ART duration, stratified by age and ART duration.
Results:
277
Of the 1516 children, only 33% had both parents living when they started ART.
Twenty-one percent had only father dead, 28% had only mother dead, and 18%
had both parents dead. Twenty-nine percent reported imperfect ART adherence.
The odds of ART nonadherence increase for children with both parents dead.
Fifty-seven percent of children had imperfect clinic adherence. There was no
significant association between orphan status and imperfect clinic adherence.
Conclusions:
The majority of pediatric patients in this resource-limited setting maintained
perfect ART adherence, though only half kept all scheduled clinic appointments.
Understanding contextual factors, such as orphan status, will strengthen
adherence interventions.
Morbidity among HIV-1-infected mothers in Kenya: prevalence and

correlates of illness during 2-year postpartum follow-up.
Author: Walson, J. L.; Brown, E. R.; Otieno, P. A.; Mbori-Ngacha, D. A.; Wariua, G.;
Obimbo, E. M.; Bosire, R. K.; Farquhar, C.; Wamalwa, D., and John-Stewart, G. C.
Much of the burden of morbidity affecting women of childbearing age in sub-
Saharan Africa occurs in the context of HIV-1 infection. Understanding patterns
of illness and determinants of disease in HIV-1-infected mothers may guide
effective interventions to improve maternal health in this setting.
Methods:
We describe the incidence and cofactors of comorbidities affecting peripartum
and postpartum HIV-1-infected women in Kenya. Women were evaluated by
clinical examination and standardized questionnaires during pregnancy and for
up to 2 years after delivery.
Results:
Five hundred thirty-five women were enrolled in the cohort (median CD4 count
of 433 cells/mm) and accrued 7736 person-months of follow-up. During 1-year
follow-up, the incidence of upper respiratory tract infections was 161 per 100
person-years, incidence of pneumonia was 33 per 100 person-years, incidence of
tuberculosis (TB) was 11 per 100 person-years, and incidence of diarrhea was 63
per 100 person-years. Immunosuppression and HIV-1 RNA levels were
predictive for pneumonia, oral thrush, and TB but not for diarrhea; CD4 counts
<200 cells/mm(3) were associated with pneumonia (relative risk [RR] = 2.87, 95%
confidence interval [CI]: 1.71 to 4.83), TB (RR = 7.14, 95% CI: 2.93 to 17.40) and
thrush. The risk of diarrhea was significantly associated with crowding (RR =
1.86, 95% CI: 1.19 to 2.92) and breast-feeding (RR = 1.71, 95% CI: 1.19 to 2.44).
Less than 10% of women reported hospitalization during 2-year follow-up;
mortality risk in the cohort was 1.9% and 4.8% for 1 and 2 years, respectively.
278
Conclusions:
Mothers with HIV-1, although generally healthy, have substantial morbidity as a
result of common infections, some of which are predicted by immune status or
by socioeconomic factors. Enhanced attention to maternal health is increasingly
important as HIV-1-infected mothers transition from programs targeting the
prevention of mother-to-child transmission to HIV care clinics.
Albendazole treatment of HIV-1 and helminth co-infection: a

randomized, double-blind, placebo-controlled trial.
Author: Walson, J. L.; Otieno, P. A.; Mbuchi, M.; Richardson, B. A.; Lohman-Payne, B.;
Macharia, S. W.; Overbaugh, J.; Berkley, J.; Sanders, E. J.; Chung, M. H., and
John-Stewart, G. C.
Source: AIDS. 2008 Aug 20; 22(13):1601-9.
Several co-infections have been shown to impact the progression of HIV-1
infection. We sought to determine if treatment of helminth co-infection in HIV-1-
infected adults impacted markers of HIV-1 disease progression.
Design:
To date, there have been no randomized trials to examine the effects of soil-
transmitted helminth eradication on markers of HIV-1 progression.
Methods:
A randomized, double-blind, placebo-controlled trial of albendazole (400 mg
daily for 3 days) in antiretroviral-naive HIV-1-infected adults (CD4 cell count
>200 cells/microl) with soil-transmitted helminth infection was conducted at 10
sites in Kenya (Clinical Trials.gov NCT00130910). CD4 and plasma HIV-1 RNA
levels at 12 weeks following randomization were compared in the trial arms
using linear regression, adjusting for baseline values.
Results:
Of 1551 HIV-1-infected individuals screened for helminth infection, 299 were
helminth infected. Two hundred and thirty-four adults were enrolled and
underwent randomization and 208 individuals were included in intent-to-treat
analyses. Mean CD4 cell count was 557 cells/microl and mean plasma viral load
was 4.75 log10 copies/ml at enrollment. Albendazole therapy resulted in
significantly higher CD4 cell counts among individuals with Ascaris
lumbricoides infection after 12 weeks of follow-up (+109 cells/microl; 95%
confidence interval +38.9 to +179.0, P = 0.003) and a trend for 0.54 log10 lower
HIV-1 RNA levels (P = 0.09). These effects were not seen with treatment of other
species of soil-transmitted helminths.
Conclusion:
279
Treatment of A. lumbricoides with albendazole in HIV-1-coinfected adults

resulted in significantly increased CD4 cell counts during 3-month follow-up.
Given the high prevalence of A. lumbricoides infection worldwide, deworming
may be an important potential strategy to delay HIV-1 progression.
Early response to highly active antiretroviral therapy in HIV-1-infected

Kenyan children.
Author: Wamalwa, D. C.; Farquhar, C.; Obimbo, E. M.; Selig, S.; Mbori-Ngacha, D. A.;
Richardson, B. A.; Overbaugh, J.; Emery, S.; Wariua, G.; Gichuhi, C.; Bosire, R.,
and John-Stewart, G.
To describe the early response to World Health Organization (WHO)-
recommended nonnucleoside reverse transcriptase inhibitor (NNRTI)-based
first-line highly active antiretroviral therapy (HAART) in HIV-1-infected Kenyan
children unexposed to nevirapine. DESIGN: Observational prospective cohort.
Methods:
HIV-1 RNA level, CD4 lymphocyte count, weight for age z score, and height for
age z score were measured before the initiation of HAART and every 3 to 6
months thereafter. Children received no nutritional supplements.
Results:
Sixty-seven HIV-1-infected children were followed for a median of 9 months
between August 2004 and November 2005. Forty-seven (70%) used zidovudine,
lamivudine (3TC), and an NNRTI (nevirapine or efavirenz), whereas 25% used
stavudine (d4T), 3TC, and an NNRTI. Nevirapine was used as the NNRTI by 46
(69%) children, and individual antiretroviral drug formulations were used by 63
(94%), with only 4 (6%) using a fixed-dose combination of d4T, 3TC, and
nevirapine (Triomune; Cipla, Mumbai, India). In 52 children, the median height
for age z score and weight for age z score rose from -2.54 to -2.17 (P<0.001) and
from -2.30 to -1.67 (P=0.001), respectively, after 6 months of HAART.
Hospitalization rates were significantly reduced after 6 months of HAART (17%
vs. 58%; P<0.001). The median absolute CD4 count increased from 326 to 536
cells/microL (P<0.001), the median CD4 lymphocyte percentage rose from 5.8%
before treatment to 15.4% (P<0.001), and the median viral load fell from 5.9 to 2.2
log10 copies/mL after 6 months of HAART (P<0.001). Among 43 infants, 47%
and 67% achieved viral suppression to less than 100 copies/mL and 400
copies/mL, respectively, after 6 months of HAART.
Conclusion:
Good early clinical and virologic response to NNRTI-based HAART was
observed in HIV-1-infected Kenyan children with advanced HIV-1 disease.
280

Author: Waruru, A. K.; Nduati, R., and Tylleskar, T.
Source: BMC Med Inform Decis Mak. 2005; 5:24.
interviewing and explored its feasibility, usability, and acceptability in a PMTCT
program in Kenya.
Methods:
compare ability to use ACASI by education level.
Results:
Mean ages for intended time for breastfeeding as reported by ACASI were 11
months by ACASI and 19 months by FTF interviewing (p < 0.001). Introduction
of complementary foods at <or=3 months was reported more frequently by
respondents in ACASI compared to FTF interviews for 7 of 13 complementary
food items commonly utilized in the study area (p < 0.05). More respondents
reported use of unsuitable utensils for infant feeding in ACASI than in FTF
interviewing (p = 0.001). In other sensitive questions, 7% more respondents
reported unstable relationships with ACASI than when interviewed FTF (p =
0.039). Regardless of education level, respondents used ACASI similarly and
majority (65%) preferred it to FTF interviewing mainly due to enhanced usability
and privacy. Most respondents (79%) preferred ACASI to FTF for future
interviewing.
Conclusion:
281
education is low.
Power brokering, empowering, and educating: the role of home-based

care professionals in the reduction of HIV-related stigma in Kenya.
Author: Waterman, H.; Griffiths, J.; Gellard, L.; O'Keefe, C.; Olang, G.; Ayuyo, J.;
Obwanda, E.; Ogwethe, V., and Ondiege, J.
Source: Qual Health Res. 2007 Oct; 17(8):1028-39.
Abstract: In this article the authors report on how home-based care (HBC) professionals
reduce stigmatizing behavior in Kenya. This study was part of an action research
project that evaluated the introduction of HBC. HBC professionals coordinate the
delivery of HIV/AIDS services at a district level and educate community-based
health workers in HBC. Understanding how HBC professionals reduce stigma is
crucial to reduce, prevent, and treat HIV/AIDS. Fifty HBC professionals
participated in 27 focus group interviews over 18 months. Stigma featured
strongly when they discussed barriers to the introduction of HBC. Using
sociological theory, the authors organized the data into five themes: Power
broking and mobilization, Stigma as a social construction, Community and
structural interventions, Educating and training people, and Historical context.
The HBC professionals appear to operate at mostly individual and community
levels in their efforts to challenge stigma, and in spite of the difficulties they
appear to be having some impact.
Initial outcomes of an emergency department rapid HIV testing program

in western Kenya.
Author: Waxman, M. J.; Kimaiyo, S.; Ongaro, N.; Wools-Kaloustian, K. K.; Flanigan, T. P.,
and Carter, E. J.
Source: AIDS Patient Care STDS. 2007 Dec; 21(12):981-6.
Abstract: This paper reports the initial operational outcomes of an emergency department-
based HIV testing program in a high-prevalence and resource-limited setting by
describing (1) the number and percentage of patients approached, tested, and
found to be HIV positive and (2) the linkage of care to the HIV clinic. A
retrospective log and chart review of the initial 5 months (January 2006 to April
2006) of the HIV testing program was performed. Patients were selected for HIV
testing by routine screening and by provider initiated referrals. Out of the 1371
patients who were approached for HIV testing, 1339 (97.7%) patients were tested
for HIV. Three hundred twelve (22.7%) of the patients tested were HIV positive.
Within a sample group of patients newly diagnosed with HIV in the department,
82% were compliant with their initial HIV clinic visit and 65% were compliant
282
with a 1-month follow-up visit. The implementation of an emergency

department-based HIV testing program in a high HIV prevalence and resource
poor country is feasible with a high percentage of patients accepting HIV testing
and a high percentage of positive patients presenting to follow-up care.
Establishment of rapid HIV testing in emergency departments can identify
significant numbers of HIV-positive patients who would otherwise remain
undiagnosed and provides an education opportunity for those patients who are
HIV negative.
Determinants of Consistent Condom Use Vary by Partner Type among

Young Men in Kisumu, Kenya: A Multi-level Data Analysis.
Author: Westercamp, N.; Mattson, C. L.; Madonia, M.; Moses, S.; Agot, K.; Ndinya-
Achola, J. O.; Otieno, E.; Ouma, N., and Bailey, R. C.
Source: AIDS Behav. 2008 Sep 13.
Abstract: To evaluate whether determinants of consistent condom use vary by partner type
among young sexually active Kenyan men, we conducted a cross-sectional
assessment of lifetime sexual histories from a sub-sample of men enrolled in a
clinical trial of male circumcision. 7913 partnerships of 1370 men were analyzed.
262 men (19%) reported never, 1018 (74%) sometimes and 92 (7%) always using
a condom with their partners. Condoms were always used in 2672 (34%) of the
total relationships-212 (70%) of the relationships with sex workers, 1643 (40%) of
the casual and 817 (23%) of the regular/marital relationships. Factors
influencing condom use varied significantly by partner type, suggesting that HIV
prevention messages promoting condom use with higher-risk partners have
achieved a moderate level of acceptance. However, in populations of young,
single men in generalized epidemic settings, interventions should promote
consistent condom use in all sexual encounters, independently of partner type
and characteristics.
283
Renal disease in an antiretroviral-naive HIV-infected outpatient

population in Western Kenya.
Author: Wools-Kaloustian, K.; Gupta, S. K.; Muloma, E.; Owino-Ong'or, W.; Sidle, J.;
Aubrey, R. W.; Shen, J.; Kipruto, K.; Zwickl, B. E., and Goldman, M.
Source: Nephrol Dial Transplant. 2007 Aug; 22(8):2208-12.
Several commonly used antiretrovirals (ARVs) require dose adjustments to
prevent toxicities in the presence of renal insufficiency. Because no prospective
studies of the prevalence or risk factors for kidney disease in stable outpatient
human immunodeficiency virus (HIV)-infected indigenous African populations
have been published to date, it is not known if already scarce resources should be
allocated to detect renal dysfunction, in those without risk factors for kidney
disease, prior to initiation of increasingly available antiretrovirals in developing
countries.
Methods:
A cross-sectional study to determine the prevalence of and risk factors for renal
disease in a cohort of medically stable, HIV-infected, antiretroviral-naive adults,
without diabetes or hypertension, presenting to an HIV clinic in western Kenya.
Results:
Of 373 patients with complete data, renal insufficiency (CrCl <60 ml/min) was
identified in 43 (11.5%) [18 (4.8%) had a CrCl <50 ml/min]. Despite high
correlation coefficients between the three renal function estimating equations
used, when compared to creatinine clearance as calculated by Cockcroft-Gault,
lower rates of moderate to severe renal insufficiency were identified by the
Modification of Diet in Renal Disease equations. Proteinuria, defined as a urine
dipstick protein of equal to or greater than 1+, was detected in only 23 subjects
(6.2%).
Conclusions:
Renal insufficiency is not uncommon, even in stable patients without diabetes or
hypertension. Conversely, proteinuria was unexpectedly infrequent in this
population. Utilizing resources to assess renal function prior to initiation of
antiretrovirals in order to identify those likely to benefit from dosage adjustment
is justified.
284
Viability and effectiveness of large-scale HIV treatment initiatives in

sub-Saharan Africa: experience from western Kenya.
Author: Wools-Kaloustian, K.; Kimaiyo, S.; Diero, L.; Siika, A.; Sidle, J.; Yiannoutsos, C.
T.; Musick, B.; Einterz, R.; Fife, K. H., and Tierney, W. M.
Source: AIDS. 2006 Jan 2; 20(1):41-8.
To determine the clinical and immunological outcomes of a cohort of HIV-
infected patients receiving antiretroviral therapy.
Design:
Retrospective study of prospectively collected data from consecutively enrolled
adult HIV-infected patients in eight HIV clinics in western Kenya.
Methods:
CD4 cell counts, weight, mortality, loss to follow-up and adherence to
antiretroviral therapy were collected for the 2059 HIV-positive non-pregnant
adult patients treated with antiretroviral drugs between November 2001 and
February 2005.
Results:
Median duration of follow-up after initiation of antiretroviral therapy was 40
weeks (95% confidence interval, 38-43); 111 patients (5.4%) were documented as
deceased and 505 (24.5%) were lost to follow-up. Among 1766 (86%) evaluated
for adherence to their antiretroviral regimen, 78% reported perfect adherence at
every visit. Although patients with and without perfect adherence gained
weight, patients with less than perfect adherence gained 1.04 kg less weight than
those reporting perfect adherence (P = 0.059). CD4 cell counts increased by a
mean of 109 cells/microl during the first 6 weeks of therapy and increased more
slowly thereafter, resulting in overall CD4 cell count increases of 160, 225 and 297
cells/microl at 12, 24, and 36 months respectively. At 1 year, a mean increase of
170 cells/microl was seen among patients reporting perfect adherence compared
with 123 cells/microl among those reporting some missed doses (P < 0.001).
Conclusions:
Antiretroviral treatment of adult Kenyans in this cohort resulted in significant
and persistent clinical and immunological benefit. These findings document the
viability and effectiveness of large-scale HIV treatment initiatives in resource-
limited settings.
285
Payment for antiretroviral drugs is associated with a higher rate of

patients lost to follow-up than those offered free-of-charge therapy in
Nairobi, Kenya.
Author: Zachariah, R.; Van Engelgem, I.; Massaquoi, M.; Kocholla, L.; Manzi, M.; Suleh,
A.; Phillips, M., and Borgdorff, M.
Source: Trans R Soc Trop Med Hyg. 2008 Mar; 102(3):288-93.
Abstract: This retrospective analysis of routine programme data from Mbagathi District
Hospital, Nairobi, Kenya shows the difference in rates of loss to follow-up
between a cohort that paid 500 shillings/month (approximately US$7) for
antiretroviral drugs (ART) and one that received medication free of charge. A
total of 435 individuals (mean age 31.5 years, 65% female) was followed-up for
146 person-years: 265 were in the 'payment' cohort and 170 in the 'free' cohort.
The incidence rate for loss to follow-up per 100 person-years was 47.2 and 20.5,
respectively (adjusted hazard ratio 2.27, 95% CI 1.21-4.24, P=0.01). Overall risk
reduction attributed to offering ART free of charge was 56.6% (95% CI 20.0-76.5).
Five patients diluted their ART regimen to one tablet (instead of two tablets)
twice daily in order to reduce the monthly cost of medication by half. All these
patients were from the payment cohort. Payment for ART is associated with a
significantly higher rate of loss to follow-up, as some patients might be unable to
sustain payment over time. In resource-limited settings, ART should be offered
free of charge in order to promote treatment compliance and prevent the
emergence of drug resistance.
AIDS in Kenya: trends, interventions and impact. 7th edition.

Abstract: Over two decades since the first AIDS case was described in Kenya, HIV/AIDS
still remains a huge problem for the country in its efforts for social and economic
development. Responses to the pandemic have evolved over time as people
became aware of this new disease, as they experienced illness and death among
family members, and as services have developed to confront this epidemic.
Initially many segments of society expressed denial of the disease. Early in the
epidemic in Kenya political commitment was limited. While awareness of AIDS
has been nearly universal for more than a decade, misconceptions still abound
and many still have not dealt with this disease at a personal or community level.
This 7th edition of AIDS in Kenya comes at a crossroads in response to the
epidemic. In the last 5 years HIV-related health services have expanded
dramatically; they include the widespread availability of testing and counselling,
and treatment with antiretroviral drugs, both to prevent mother-to-child
transmission and to improve health and prolong life for people with advanced
HIV infection and AIDS. While HIV remains an incurable infection, Kenya has
now entered an era in which there is new hope in treating and caring for people
with AIDS. This hope also offers new, effective opportunities for preventing HIV
286
infection, as people with HIV infection learn they are infected and learn how to
better protect their loved ones. (ex
Community-Based HIV / AIDS Prevention Care and Support Project

(COPHIA).
Source: Project No. 623-A-00-99-000045-00. Final report: July 1999 - June 2005.
Abstract: Prior to COPHIA's commencement, when discharged from a hospital most

Kenyans with AIDS were cared for by family, friends or volunteers with limited
nursing knowledge and skills, no professional backup, and very little
understanding of the virus and its consequences. Fear of the disease and stigma
aimed at those infected by household and community members and even
healthcare workers, meant that many HIV-infected people received little or no
care and were simply left to die. To address the overwhelming need for home-
based care, USAID/Kenya awarded Pathfinder International a cooperative
agreement to launch the Community-Based HIV/AIDS Care, Support, and
Prevention (COPHIA) project in June 1999. COPHIA was designed to meet the
entire spectrum of needs experienced by People Living With HIV/AIDS
(PLWHA) and their families-physical, social, psychological, emotional, and
spiritual-by providing comprehensive home-based care. And in doing so,
COPHIA responded to the devastating toll the HIV/AIDS pandemic has taken
on Kenyan families and communities, both in terms of human and development
losses. Initially envisioned as a three-year, $2 million initiative, the program
evolved into a $7.5 million, 6-year program, which continued beyond this project
period with funding from other sources. (excerpt)
Corporate partners support vocational programs for orphans and

vulnerable children in Kenya.
Source: Pathways. 2005 Jun; 5.
Abstract: The story of Laban Liboyi, a 20-year-old Kenyan youth, is like many others in his
homeland, AIDS-ravaged Western Province of Kenya. Having lost first his father,
then his mother, to AIDS by the age of 17, he became the sole support for his
three little brothers and two sisters. Relatives and neighbors already burdened
with the epidemic and too many dependents withdrew their support, and the
chances of survival for Laban and his siblings grew slim. However, Laban’s
experience diverges from the 650,000 orphans and vulnerable children (OVC) in
Kenya whose support networks have been decimated by the AIDS epidemic.
One day in July 2003, Laban met a community health worker at the market, who
urged him to register with the Kabras Jua Kali Association (KJKA). Under an
initiative led by Pathfinder International and Barclay’s Bank of Kenya, Ltd.,
KJKA runs a program for orphans and vulnerable children ages 15-21 years. The
program trains them in vocational skills such as carpentry and tailoring, and
287
links them to jobs and resources, such as micro credit groups. Laban soon
enrolled. (excerpt)
Early infant diagnosis of HIV through dried blood spot testing:

Pathfinder International / Kenya's Prevention of Mother to Child
Transmission project.
Abstract: Without treatment, an infant infected with HIV in Africa has a 35 percent chance
of dying by his first birthday and a 53 percent chance of dying before the age of
two. But if the baby receives prophylactic antibiotics, such as cotrimoxazole, soon
after birth and Antiretroviral Therapy (ART) as soon as is medically indicated, he
has a good chance of surviving childhood and living a long, healthy life. The
challenge in resource-limited settings is identifying HIV-infected infants and
providing early access to this lifesaving medicine. Access to Antiretroviral (ARV)
drugs has improved in Kenya in the last few years, spurred in large part by the
introduction of the President's Emergency Plan for AIDS Relief. But until very
recently, little could be done to diagnose infants' HIV status in their first year of
life. (excerpt)
Evaluations of five programs for orphans and vulnerable children in

Kenya and Tanzania.
Abstract: In sub-Saharan Africa, an estimated 12 million children 17 years of age or
younger have lost one or both parents to AIDS. Many more children live with
one or more chronically ill parent. Despite the recognition of the magnitude and
negative consequences of this problem, there is little empirical evidence on "what
works" to improve the well-being of children affected by HIV and AIDS.
Governments, program managers, and service providers need strategic
information on how to reach more orphans and vulnerable children (OVC) with
services that improve their well-being. Information on effectiveness and costs of
interventions for OVC can help donors, policymakers, and program managers
make better informed decisions on the allocation of scarce resources. In an
attempt to fill these knowledge gaps, MEASURE Evaluation with U.S. President's
Emergency Plan for AIDS Relief funds from the U.S. Agency for International
Development (USAID) will conduct evaluations of four programs for OVC in
Kenya and Tanzania. There will also be a costing component of the study that
will inform resource allocation and help estimate the costs of scaling up
programs. (excerpt)
288
Financing framework: resource requirement for the Kenya National

AIDS Strategic Plan (KNASP), 2005-2010.
Abstract: The following report provides a summary analysis of the resources required to
achieve the broad objectives outlined in Kenya's National AIDS Strategic Plan
(KNASP). The report specifically provides summary information on the key
interventions as laid out in the KNASP (2005-2010) and the financial resources
required for a credible response to the epidemic. The report also includes the best
estimates on the current coverage of those interventions; the current assumptions
about HIV/AIDS capacity required to scale up coverage; the best current
estimates; and the current and projected HIV/AIDS resources. The data specific
to Kenya were obtained using a combination of: 1) key informant interviews with
representatives from government, US government agencies, UN institutions, and
local universities; 2) a review of six existing HIV/AIDS budgets in Kenya; 3)
review of international literature; and 4) various demographic and economic
surveys conducted on HIV/AIDS interventions in Kenya. (excerpt)
HIV / AIDS and sexually transmitted infection in Kenya. Behavioural

surveillance survey 2002. Summary report.
Abstract: The government of Kenya through the National AIDS/STI Control Program
(NASCOP) of the Ministry of Health in collaboration with Family Health
International (FHI), the Centers for Disease Control and Prevention (CDC), and
the Central Bureau of Statistics (CBS) conducted a national behavioural
surveillance survey of HIV/AIDS and sexually transmitted infection in Kenya in
late 2002 in order to understand the behaviour dynamics driving the HIV
epidemic. The behavioural surveillance survey is a monitoring and evaluation
tool to track trends in HIV/AIDS knowledge, attitudes and behaviour in
populations at particular risk of HIV infection, such as youth, female sex workers
and migrant men. It is envisaged that this survey will be repeated every two or
three years to monitor trends and changes in HIV and sexually transmitted
infection risky behaviour in the country. The populations selected to participate
in the first round of the national behavioural surveillance survey were out-of-
school youth, youth in school, female sex workers, women in low-income
settings, matatu or mini-van drivers and their touts or helpers, bodaboda or
bicycle taxi cyclists, policemen, and men in large worksites. Questionnaires were
developed in both English and Kiswahili. They were administered to
respondents in the selected groups by trained interviewers under close
supervision of a team of supervisors. High standards of conducting the survey
were adhered to in terms of a well-planned data collection strategy and a
commitment to establish high-quality data systems. EpiData software was used
for data entry and processing, and a statistical software package for social
sciences was used for data analysis. (excerpt)
HIV and AIDS Planning Workshop report.
289
Abstract: This is a report of the first workshop ever held in Kenya for HIV-positive
teachers, between 13th and 18th December 2004. It was organised by the Kenya
Network of Positive Teachers (KENEPOTE) and the POLICY Project with
support from USAID. The 60 HIV-positive teachers attending came from all
Kenyan provinces. The top leadership of the Ministry of Education, Science and
Technology (MOEST) and Kenya National Union of Teachers (KNUT)
participated in the opening and closing ceremonies of the Workshop while the
Director of the Teachers Service Commission/ AIDS Control Unit (TSC/ACU)
attended throughout. USAID officer responsible for its HIV and AIDS programs
in Kenya attended the closing ceremony. (excerpt
HIV notes from MEASURE DHS.

Abstract: The Kenya HIV Service Provision Assessment (SPA) survey, the first SPA to look
at national HIV/AIDS health care delivery services, has just been published in
Kenya. The 2004 KSPA includes a nationally representative sample of 440 health
care facilities ranging from stand alone VCT sites to provincial and national
referral hospitals. Survey results show a complex picture of uneven availability
and quality but also provide clear evidence of PEPFAR funds at work. Almost 10
percent of Kenya health care facilities and just over 50 percent of its hospitals
now provide antiretroviral treatment (ART). NGO and private for-profit facilities
are more likely to offer ART than government-managed facilities. 24 percent of
facilities offer some element of PMTCT. Only 13 percent offer the full PMTCT
package with HIV counseling and testing, counseling on infant feeding and
family planning, and ARV prophylaxis for the infant. Just 4 percent of facilities
nationwide offer PMTCT+. (excerpt)
Hormonal Contraception and HIV: Science and Policy.

Source: Africa Regional Meeting, Nairobi 19-21 September 2005. Statement (final).
Abstract: The World Health Organization Headquarters Office and Regional Office for
Africa, in partnership with the Reproductive Health and HIV Research Unit of
the University of Witwatersrand in South Africa (a WHO Collaborating Centre),
International Planned Parenthood Federation Africa Region and Family Health
International (FHI), convened a meeting of 72 representatives from 17
francophone, lusophone and Anglophone sub-Saharan African countries on
“Hormonal Contraception and HIV: Science and Policy”. The participants
included policymakers and programme managers involved with family
planning, sexual and reproductive health, and HIV/AIDS, women’s health
advocates, people living with HIV and scientists and clinicians involved with
family planning and HIV research. They were joined by 13 representatives from
international donor and non-governmental organizations and agencies. The goal
of the meeting was to promote evidence-based discussion and decision-making
290
in response to new information on any potential association between hormonal

contraceptive use and the acquisition of HIV. (excerpt)
USAID's Implementing AIDS Prevention and Care (IMPACT) project.

Source: Kenya final report, September 1999 - September 2007.
Abstract: The project design included activities to support the HIV/AIDS program at the
national level. It involved mobilizing private and parastatal businesses to initiate
HIV interventions; supporting nongovernmental organizations (NGOs) and
other networks to expand coverage; improving blood safety; strengthening sero-
surveillance and behavioral surveillance; and supporting prevention and care
initiatives. In 2000, with USAID's Leadership and Investing in Fighting an
Epidemic (LIFE) Initiative, FHI expanded IMPACT/Kenya's geographic
coverage from five to ten community sites in the three provinces and broadened
its focus to include activities linking prevention, care, and psychosocial support.
In 2003, IMPACT/Kenya adapted to address priorities put forth by the U.S.
President's Emergency Plan for AIDS Relief (PEPFAR). As a result, IMPACT
increased its focus on care and treatment and linked it to the prevention, care,
and support program. Likewise, the communication response evolved from
purely a preventionprogram to include treatment and support messages and
prevention in the care setting. Nairobi was also added as a priority region.
(excerpt)
Estimating expenditures on general health and HIV / AIDS care.

Source: Kenya National Health Accounts 2002:
Abstract: The government of Kenya (GoK) faces the dilemma of combating a growing
burden of disease, regulating quality, and improving equity in health care
distribution within the context of declining public financing that is forcing
rationalization of health service delivery. To help resolve the dilemma, Kenyan
policymakers need a comprehensive understanding of the organization and
financing of the country’s health care system, including the expenditures on
health care made by donors, public sector entities, and the private sector,
particularly households. One tool that the government is using to understand
health care expenditures is National Health Accounts (NHA), an internationally
accepted framework for tracking the expenditures from their sources to their end
uses. (excerpt
291
Kenya Network of HIV-Positive Teachers (KENEPOTE).

Abstract: Teachers interact with many people as they perform their many and varied roles,
in classrooms and at school, as teachers, counsellors, role models and parents.
They are also leaders in the church and the community, holding responsible
positions, and are held in high esteem. Their countrywide distribution enables
them to effectively advocate behaviour change since HIV and AIDS is a
behavioural disease. "A teacher can save more lives than a doctor". KENEPOTE
is a network of HIV-positive teachers founded in September 2003 by two HIV-
positive teachers (Elsa Ouko, now retired, and living in Kitale, and Margaret
Wambete, a teacher at Sosiani Primary School in Eldoret Municipality) after
attending the International Conference on Sexually Transmitted Diseases and
AIDS in Sub-Saharan Africa (ICASA) in Nairobi. The idea of the network had
been muted earlier by a number of teachers both in the work place and others
who had retired or forced to retire because of their HIV status. Some of these
teachers have dedicated their time to running Community Based Organizations
(CBOs) for people living with HIV and AIDS (PLWHAs); and providing support
for orphans and vulnerable children (OVCs). (excerpt)
Kenyan national guidelines on nutrition and HIV / AIDS.

Abstract: People infected with HIV are at greater risk of malnutrition than those who are
not infected. HIV and opportunistic infections interfere with the desire and
ability to eat thus reducing dietary intake; causing mal-absorption of nutrients;
increasing energy demand thus increasing nutrient requirements; and causing
abnormal use of protein. Limited food security and inadequate knowledge of
good nutrition in regions of Kenya where HIV is prevalent, makes the situation
worse. The fundamental nutritional concerns for HIV-infected people include:
the availability of a balanced diet on a continuous basis; factors that negatively
impact food intake and utilization; drug/nutrient interactions; and interventions
to help cope with nutrition-related, chronic conditions such as diabetes mellitus.
HIV infection and associated malnutrition progressively weaken the immune
system, lowering quality of life and odds for survival, thus infected persons and
caregivers need clear, concise information on nutritional careand support.
Nutritional care, as an adjunctive intervention to ART viral treatment, will
enhance rehabilitation, optimize antiretroviral therapy, and enhance adherence
to ART. The purpose of these Guidelines is to: Provide simple and practical ways
to assess the nutritional status of HIV-infected clients and assess the risk of
malnutrition; Assist service providers to identify locally-appropriate, sustainable
ways of increasing dietary intake by those who are infected with HIV; and
Mainstream nutrition interventions into the national HIV/AIDS response.
(excerpt)
292
Lessening the burden of HIV / AIDS.

Source: Ray of Hope: A Newsletter of the Hope for African Children Initiative. 2006 Mar;
10.
Abstract: Every Friday, Members of Tupendane Support Group gather at the Fish Group
Office in Manyatta Sub-location in Kisumu to make aloe vera soap. Tupendane is
a Swahili word for "let's love one another" and the members try to live up to the
name by assisting one another in difficult times. Brought to together by a
common goal -- to prevent early death from HIV/AIDS and support their
families -- the group has learnt to work as a solid unit. "When we meet, we share
our experiences and give one another a shoulder to lean on. This has helped
strengthen our group and lessen the burden of HIV/AIDS on individual
members,'' says Rachel Nyagweth, a member of the group. The Group, founded
by the Fish Group and benefiting from HACI support, brings together forty
people living with HIV/AIDS. According to Rachel, a resident of Kano Kasule
Village in Kisumu's Winam Division, the group provides invaluable support to
people infected with the HIV virus. "When I tested positive for HIV in 2004, I
thought my world would crumble. I lost hope and started worrying about how
my neighbors and friends would react to the news. However, the support group
gave me the hope to live and the resolve to defy early death. Now I am alive and
I want to see my children complete their studies,'' says Rachel, a mother of five
who lost her husband to the virus in 2003. (excerpt
Letting them fail: government neglect and the right to education for
children affected by AIDS.
Abstract: This report is based on detailed interviews with dozens of children affected by
HIV/AIDS and their caregivers in three sub-Saharan African countries--Kenya,
South Africa, and Uganda. Their testimonies revolve around a common theme:
neglect and abuse within families, in communities, and by schools and
governments have hindered AIDS-affected children's ability to enroll, remain, or
advance in school. Children whose parents were terminally ill dropped out of
school to act as caregivers to their parents and younger siblings. The successive
death of multiple family members to HIV/AIDS led to the gradual erosion of
children's extended-family safety net, resulting in inadequate financial support
for schooling. Parental illness or exploitation by subsequent caregivers led
children to work long hours to offset lost family income or provide basic
sustenance. The stigma associated with HIV led to taunting by peers, and made it
difficult for children to communicate with their teachers about illness or death in
the family. Children who were themselves HIV-positive experienced prolonged
absences from school due to ill-health, poor access to essential medicines, and
AIDS-related stigma and discrimination. (excerpt)
293
Male circumcision for HIV prevention: Research implications for policy

and programming WHO / UNAIDS technical consultation 6 -- 8 March
2007 conclusions and recommendations (excerpts).
Source: Reproductive Health Matters. 2007 May; 15(29):11-14.
Abstract: A number of observational studies indicate that circumcised men have lower
levels of HIV infection than uncircumcised men. On 13 December 2006, the US
National Institutes of Health announced that two trials assessing the impact of
male circumcision on HIV risk would be stopped on the recommendation of the
Data Safety and Monitoring Board. The trials being carried out in Kisumu,
Kenya, and Rakai District, Uganda revealed at least a 53% and 51% reduction in
risk of acquiring HIV infection, respectively. These results support findings
published in 2005 from the South Africa Orange Farm Intervention Trial,
sponsored by the French National Agency for Research on AIDS, which
demonstrated at least a 60% reduction in HIV infection among men who were
circumcised. WHO and UNAIDS convened an international consultation to
review the results of the three randomised controlled trials and other evidence
on male circumcision and HIV prevention, to discuss the policy and programme
implications, and to make recommendations regarding public health issues. This
document summarizes the principal conclusions and recommendations of the
meeting. The international consultation was attended by experts representing a
wide range of stakeholders, including government representatives, researchers,
civil society representatives, gender experts, human rights and women's health
advocates, young people, funding agencies and implementing partners. (excerpt)
Missing the target. Off target for 2010: how to avoid breaking the
promise of universal access. Update to ITPC's AIDS treatment report
from the frontlines.
Abstract: Actions by governments and multilateral institutions over the last year helped
lay the foundation for gradual expansion of AIDS treatment access. Yet the world
is on a trajectory that will fall significantly short of the internationally endorsed
universal access goal for 2010, leaving millions without lifesaving care and
hundreds of thousands of people with HIV/AIDS facing the prospect of
imminent death. In December 2005, the "3 by 5" initiative came to an end, having
helped spur treatment expansion but falling 1.7 million people below its goal. In
the wake of this failure the international community has made new promises,
developed new plans, and is experimenting with new systems of operating.
Despite these positive developments, no one should be fooled that the current
pace or magnitude of the response will come close to achieving the universal
access pledge that will be solemnly reaffirmed at the UNGASS Review meeting
in May 2006. According to the World Health Organization (WHO), about 600,000
more people gained treatment access in 2005. At that rate fewer than half of those
who need AIDS treatment will have access in 2010. An international alliance of
civil society advocates has called for setting a new global AIDS treatment target
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of "10 by 10" - 10 million people accessing treatment by 2010. But the

international community seems to have gone out of its way to avoid setting
explicit global treatment targets that would focus attention on specific outcomes,
acknowledge the responsibilities of global institutions as well as countries, and
drive accountability. (excerpt)
Models of Care Project. Linking HIV / AIDS treatment, care and support
in sexual and reproductive health care settings: examples in action.
Abstract: IPPF wishes to showcase different models using a variety of entry points to bring
SRH closer to HIV/AIDS. The three types of examples in action covered in this
booklet use these entry points: Better linking of prevention and care through
providing ARVs and opportunistic infection (OI) services (our case studies on
the Dominican Republic, Kenya and Rwanda); Working with and developing
programmes to reach specific populations (our case study on Colombia);
Strengthening programming to address HIV/AIDS vulnerability and young
people (our youth course). (excerpt)
Newer approaches to HIV prevention [editorial].

Source: Lancet. 2007 Feb 24; 369(9562):615.
Abstract: The publication of two randomised trials in today's Lancet signals a new era for
HIV prevention. The studies, in Uganda and Kenya, show that male circumcision
halves the risk of adult males contracting HIV through heterosexual intercourse.
This success is extremely welcome news. The results of these trials, along with
the findings of a preliminary South African trial published in 2005, now provide
a solid evidence-base to inform health policy. Large-scale implementation of
male circumcision has the potential to substantially reduce HIV transmission,
particularly in sub-Saharan Africa. But, as an accompanying Comment and
Viewpoint highlight, this new intervention presents many opportunities but also
raises many questions. One such question is the effect of male circumcision on
women. Initially, wide-scale implementation of male circumcision will lower
HIV infection in men. But modelling studies suggest that over time women could
benefit from an effect similar to the herd immunity seen with mass
immunisation. Male circumcision might also directly protect against male-to-
female transmission of HIV. A trial to test this hypothesis is under way in
Uganda, with results expected in 2008. (excerpt)
295
Prevention and Treatment Access (PTA): a comprehensive HIV / AIDS

program for Kenyan teachers. Award Number 623-A-00-05-00006-00.
Final performance report.
Abstract: The Prevention and Treatment Access (PTA) project of the American Federation
of Teachers Educational Foundation (AFTEF) is a public-private partnership
designed to increase the capacity of the Kenya National Union of Teachers
(KNUT) to address HIV and AIDS issues among teachers and learners in Kenya.
The two year project begun in November 2004 was extended by five months for
the purpose of conducting an end-of-project evaluation, which was completed in
March 2007. The project ended on April 30, 2007. In addition to providing direct
technical assistance to KNUT, several joint interventions were used to achieve
the project goal, including: establishing teacher peer education (study circles) in
647 primary, secondary and teacher training colleges in 14 high risk
administrative districts (Meru Central, Busia, Malindi, Bondo, Kakamega,
Machakos, Garrisa, Nairobi, Kericho, Uasin Gishu, Kirinyaga, Kisumu, Nakuru
and Mombasa); training and supporting head teachers, principles and teachers
implementing theMinistry of Education's policy on HIV and AIDS in 636
educational institutions; conducting a national HIV and AIDS policy advocacy
campaign under the leadership of the KNUT National Executive Council; and,
integrating HIV and AIDS issues into KNUT negotiations with the Ministry of
Education (MOE) and the Teachers Service Commission (TSC). (excerpt)
Quantification workbook for GOK NASCOP ARVs.

Abstract: This quantification workbook is a tool to assist the pharmacy staff at Coast
Provincial General Hospital (CPGH) to quantify needs of ARVs for the GOK
ART Program. The workbook is designed to take the pharmacy staff through the
process step by step. Each step has a table to be completed which either requires
data to be collected or a calculation to be done. Some of the tables require data to
be collected over a number of months (usually the last six months). It is
anticipated that during the scale up phase that CPGH will place an order for
ARVs every month – therefore a quantification workbook will be completed
every month. Use the data collected for the previous workbook to complete the
data collection tables for each new workbook to minimise work. Some of the
calculations e.g. for estimating the quantities needed for new patients, will not
need to be done every month. Once the program has stabilised you can use the
same estimates from month to month making adjustments for fluctuations in
recruitment if needed. It is suggested that you review this data every 3 to 6
months after the program has stabilised. When instructed to round up or down
to the nearest whole number, for numbers where the first decimal place is 0.5 or
higher round up (e.g. for 6.7 round up to 7) and where the first decimal place is
less than 0.5 round down (e.g. for 3.3 round down to 3). When instructed to
round up or down to 2 decimal places, for numbers where the third decimal
place is 0.005 or higher round up (e.g. for 1.008 round up to 1.01) and where the
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third decimal place is less than 0.005 round down (e.g. for 0.033 round down to
0.03) (excerpt)
Refocusing on HIV prevention. Operations research in Kenya and South

Africa targets key populations.
Source: Horizons Report. 2005 Dec; [2] p.
Abstract: In 2005 AIDS claimed another 3 million lives, and it relentlessly threatens
millions more. Despite global and national efforts to quell the pandemic, 40.3
million people are currently living with HIV--the highest level ever. Nearly 5
million new cases occur each year, with almost every region of the world
reporting increasing numbers. Yet amid the grim statistics there are some
encouraging signs. Although far below the World Health Organization's target
goal of reaching 3 million people by 2005, about one million people in low- to
middle-income countries are receiving antiretroviral therapy, which has
prevented an estimated 250,000 to 300,000 deaths this year. Further, a few
countries, including Kenya and Zimbabwe, were able to lower their HIV
prevalence rates through a heavy investment in prevention programs. (excerpt)
Rescued from the grip of death.

2.
Abstract: Grace Aoko Onyango's story is heartbreaking. Since 1999, her family has been
stalked by death, which has claimed her husband, daughter, cowife, and her
brother in-law and his wife. With too many graves around her house, she had to
move to a new place to escape the curse of death. According to her Luo culture,
one is not supposed to live near a graveyard lest he or she dies too. No sooner
had she settled in her new home than the spell of sickness started afflicting her.
Grace knew her co-wife, husband and two women he had inherited had died of
HIV/AIDS. So when she fell ill, she knew her turn to die had come. "My illness
defied all forms of treatment and I knew I would soon die,'' she says. (excerpt)
Responding to HIV / AIDS through health system strengthening: results

and lessons.
Abstract: Strengthening health systems is essential to establish, expand, and sustain
preventive and curative services for HIV/AIDS. There has been a lack of
recognition and understanding of the links between the provision of HIV/AIDS
services and the broader health system requirements to ensure an effective
response to the epidemic over the long term. PHRplus has contributed to the
fight against HIV/AIDS by: Providing policymakers with tools and technical
297
assistance to design programs and mobilize resources needed to mount

responses to combat HIV/AIDS; Building financial analysis skills to improve
effective use of scarce resources; Increasing access to HIV/AIDS services through
community-based health financing (CBHF); Assisting countries with their
proposals to the Global Fund to Fight AIDS, Tuberculosis (TB) and Malaria
(Global Fund); Promoting evidence-based antiretroviral treatment (ART) policy
development in low-resource countries; and Studying the effects of the sudden
surge in donor funding for HIV/AIDS on country health systems. (excerpt)
Reuniting families.
11.
Abstract: George Owino's wife ran away when he became very ill and he was left alone,
bedridden and heart-broken. He lost all hope and thought he would die soon.
For days, he led a solitary life in his hut, wondering when his time to die would
come. "It was the most difficult time in my life. I lost a lot of weight and I knew
only God's intervention would save me from dead,'' says George. However,
when volunteers of DADRA, a HACI-supported community-based organization
in Migori District of Kenya's Nyanza Province learnt of his predicament, they
helped nurse him back to health and assisted him get back his wife. "DADRA is a
good friend. It not only stood by me when I was going through difficult times,
but it also helped me get back my wife. Through counseling, my wife and I have
been able to have a harmonious relationship once again," he says. Today, George
has turned into voluntary work, assisting people affected by HIV/AIDS. "I
realized that if it were not for DADRA, I would be dead by now. It gave me hope
when I thought my world had collapsed, and I feel obliged to assist those who
are facing tough situations, especially those infected with HIV/AIDS.'' (excerpt
Shaping children's future.

9.
Abstract: When Tom Omondi Oselu joined the Fish Group, a church-based organization in
western Kenya's Kisumu City, his motive was to benefit from its spiritual and
social guidance. "Members of the Fish Group were always associated with good
virtues and deeds and I wanted to be like them,'' he says. Ten years later, Oselu
has found himself with the daunting task of not only transferring the good
virtues to the youth, but also providing guidance as well as emotional and
psychological support to children impacted by HIV/AIDS. Everyday, he sets out
in the morning to homes and schools to see the children, some of whom have no
adults to look up to for guidance and protection. "Most orphans have a lot of
problems. They often go without food, and suffer emotional and psychological
problems, which are exacerbated by lack of parental guidance and protection.
298
Even those who are lucky enough to go to school always lag behind in their
school work because of numerous challenges which take away their attention
from class work,'' he says. (excerpt)
Statement on Kenyan and Ugandan trial findings regarding male

circumcision and HIV. Male circumcision reduces the risk of becoming
infected with HIV, but does not provide complete protection.
Abstract: The Joint United Nations Programme on HIV/AIDS and its Cosponsors, WHO,
UNFPA, UNICEF and the World Bank, note with considerable interest today's
announcement by the US National Institutes of Health that two trials assessing
the impact of male circumcision on HIV risk are being stopped on the
recommendation of the NIH Data Safety and Monitoring Board (DSMB). The two
trials, funded by the US National Institutes of Health, were carried out in
Kisumu, Kenya, among men aged 18-24 years and in Rakai, Uganda, among men
aged 15-49 years. The trials, which completed enrolment of patients in 2005, were
stopped by the DSMB evaluating the results of interim analyses. The role of the
DSMB is to assess progress of the trials and recommend whether to continue,
modify or terminate them. Although no detailed results have been released at
this time, the National Institutes of Health statement makes it clear that the
studies are being stopped because they revealed an approximate halving of risk
of HIV infection in men who were circumcised. The results support the findings
of the South Africa Orange Farm Intervention Trial, funded by the French
Agence Nationale de Recherches sur le SIDA (ANRS) and published in late 2005,
which demonstrated at least a 60% reduction in HIV infection among
circumcised men. (excerpt
UN System HIV workplace programmes. HIV prevention, treatment and

care for UN System employees and their families.
Abstract: Today, more than 20 years since the first cases of HIV infection were recognized,
the epidemic continues to expand relentlessly. Despite early and ongoing efforts
to contain its spread and to find a cure, 20 million people have died and an
estimated 40.3 million people worldwide are living with HIV. In the latter half of
2004, the number of people on antiretroviral therapy in low-income and
transitional countries increased dramatically, but still only about 12% of the 5.8
million people in developing and transitional countries who need treatment are
getting treatment. The far-reaching social and economic consequences of the
epidemic are having an impact on individuals, communities and the workplace.
The UN, like many employers all over the world, is faced with major challenges
related to the direct and indirect costs of the epidemic: increasing medical costs,
absenteeism related to illness, high staff turnover, increasing recruitment and
training costs, strained labour relations and the ever-increasing erosion of human
capital. Many UN staff come from and/or work in countries with high HIV
prevalence and perform duties that may put them at increased risk of exposure
299
to the virus. The UN recognizes its duty as a socially responsible employer and
has thus committed to protecting the rights of its staff by making HIV in the UN
workplace a priority. (excerpt
Paediatric HIV and neurodevelopment in sub-Saharan Africa: a

systematic review.
Author: Abubakar, A.; Van Baar, A.; Van de Vijver, F. J.; Holding, P., and Newton, C. R.
Source: Trop Med Int Health. 2008 Jul; 13(7):880-7.
To determine the degree of motor, cognitive, language and social-emotional
impairment related to HIV infection in children living in sub-Saharan Africa
(SSA).
Methods:
Literature searches using MEDLINE and PsycINFO. Additionally, the reference
lists of previous reviews were checked to ensure that all eligible studies were
identified. Cohen's d, a measure of effect size, was computed to estimate the
level of impairment.
Results:
Six reports met the inclusion criteria. In infancy a consistent delay in motor
development was observed with a median value of Cohen's d = 0.97 at 18
months, indicating a severe degree of impairment. Mental development showed
a moderate delay at 18 months, with a median value d = 0.67. Language delay
did not appear until 24 months of age, d = 0.91. Less clear findings occurred in
older subjects.
Conclusion:
Although HIV has been shown to affect all domains of child functioning, motor
development is the most apparent in terms of severity, early onset, and
persistence across age groups. However, motor development has been the most
widely assessed domain while language development has been less vigorously
evaluated in SSA, hence an accurate quantitative estimate of the effect cannot yet
be made.
300
Men's condom use in higher-risk sex: Trends and determinants in five

Sub-Saharan countries.
Author: Adair, T.
Abstract: This paper examines men's condom use at last higher-risk sex (i.e., nonmarital,
noncohabiting partner) in five sub-Saharan countries: Burkina Faso, Cameroon,
Kenya, Tanzania, and Zambia. The two most recent Demographic and Health
Surveys (DHS) in each country are analyzed to show trends in various indicators.
Condom use is an important way to prevent the transmission of HIV, the virus
that causes AIDS. Encouragingly, use of condoms has increased substantially in
Burkina Faso, Cameroon, and Tanzania, with smaller increases in Kenya and
Zambia. At the same time, levels of higher-risk sex have declined in four of the
five countries, although use of a condom at last higher-risk sex remains below 50
percent in Kenya and Zambia. Multivariate analysis shows that higher education
is a consistently strong, positive predictor of condom use at last higher-risk sex,
whereas higher wealth status is not significant in most surveys. Knowledge that
use of condoms can reduce the risk of HIV transmission is a consistently strong,
positive predictor of condom use, but urban-rural residence and region are
significant only in some surveys. Comparing the two most recent DHS surveys in
each of the five countries, there are no clear patterns of change in the predictive
strength of explanatory variables. However, there is evidence of widening gaps
in condom use by level of education in Cameroon and by urban-rural residence
in Kenya. One important policy finding that emerged from this study is that low
wealth status is not a barrier to condom use in most countries, but lack of
education is. (author's)
Male circumcision in Siaya and Bondo Districts, Kenya: prospective

cohort study to assess behavioral disinhibition following circumcision.
Auhthor: Agot, K. E.; Kiarie, J. N.; Nguyen, H. Q.; Odhiambo, J. O.; Onyango, T. M., and
Weiss, N. S.
Source: J Acquir Immune Defic Syndr. 2007 Jan 1; 44(1):66-70.
Evidence for efficacy of male circumcision as an HIV prevention measure is
increasing, but there is serious concern that men who are circumcised may
subsequently adopt more risky sexual behaviors.
Methods:
Using a prospective cohort study, we compared sexual behaviors of 324 recently
circumcised and 324 uncircumcised men at 1, 3, 6, 9, and 12 months after
circumcision/study enrollment. The main outcome indicators were incidence of
sexual behaviors known to place men at increased risk of acquiring HIV,
301
namely, having sex with partners other than their wife/wives for married men
or other than "regular" girlfriends for unmarried men.
Results:
During the first month following circumcision, men were 63% and 61% less
likely to report having 0 to 0.5 and >0.5 risky sex acts/week, respectively, than
men who remained uncircumcised. This difference disappeared during the
remainder of follow-up, with no excess of reported risky sex acts among
circumcised men. Similar results were observed for risky unprotected sex acts,
number of risky sex partners, and condom use.
Discussion:
During the first year post-circumcision, men did not engage in more risky sexual
behaviors than uncircumcised men, suggesting that any protective effect of male
circumcision on HIV acquisition is unlikely to be offset by an adverse behavioral
impact.
Characterization of CD8 T-cell responses in HIV-1-exposed seronegative

commercial sex workers from Nairobi, Kenya.
Author: Alimonti, J. B.; Kimani, J.; Matu, L.; Wachihi, C.; Kaul, R.; Plummer, F. A., and
Fowke, K. R.
Source: Immunol Cell Biol. 2006 Oct; 84(5):482-5.
Abstract: CD8+ T-lymphocyte responses are crucial to the control of HIV-1; therefore,
studying the CD8+ immune response in a naturally resistant population could
provide valuable insights into an effective anti-HIV response in healthy
uninfected individuals. Approximately 5-10% of the women in the Pumwani
Commercial Sex Worker cohort in Nairobi, Kenya, have been highly exposed to
HIV-1 yet remain HIV-IgG-seronegative and HIV-PCR negative (HIV(ES)). As
IFN-gamma production correlates to cytotoxic function, the CD8+ T-lymphocyte
IFN-gamma response to HIV p24 peptides was compared in HIV(ES) and HIV-
infected (HIV+) individuals. Almost 40% of the HIV(ES) had a CD8+ IFN-
gamma+ response that was five times lower in magnitude than that of the HIV+
group. The breadth of the response in HIV(ES) was very narrow and focused
primarily on one peptide that is similar to the protective KK10 peptide. In the
HIV+ group, low peripheral CD4+ counts negatively influenced the number of
CD8+ cells producing IFN-gamma, which may undermine the ability to control
HIV. Overall, many of the HIV(ES) women possess a HIV-1 p24-specific CD8+
IFN-gamma response, providing evidence to the specificity needed for an
effective HIV vaccine.
CD4+ T cell responses in HIV-exposed seronegative women are

qualitatively distinct from those in HIV-infected women.
302
Author: Alimonti, J. B.; Koesters, S. A.; Kimani, J.; Matu, L.; Wachihi, C.; Plummer, F. A.,
and Fowke, K. R.
Abstract: The immune response of human immunodeficiency virus (HIV)-exposed

seronegative (ESN) women may be qualitatively different from that in those
infected with HIV (HIV(+)). In a cohort of female commercial sex workers in
Nairobi, Kenya, we found significantly lower (P< or =.01) levels of CD4(+)-
specific immune activation and apoptosis in the ESN women compared with
those in the HIV(+) women. Compared with the HIV(+) women, a lower
proportion of the ESN women showed p24 peptide pool responses by the short-
term, CD4(+)-specific, interferon (IFN)- gamma intracellular cytokine staining
assay, whereas the proportion showing responses by the long-term, CD8(+)-
depleted T cell proliferation assay was similar. Interestingly, the ESN responders
had a 4.5-fold stronger proliferation response (P=.002) than the HIV(+) group.
These data suggest that, compared with those in HIV(+) women, CD4(+) T cells
in ESN women have a much greater ability to proliferate in response to p24
peptides.
Widowhood in the era of HIV/AIDS: a case study of Siaya District,

Kenya.
Author: Ambasa-Shisanya, C. R.
Abstract: Luo women are believed to acquire contagious cultural impurity after the death
of their husbands that is perceived as dangerous to other people. To neutralise
this impure state, a sexual cleansing rite is observed. In the indigenous setting,
the ritual was observed by a brother-in-law or cousin of the deceased husband
through a guardianship institution. However, with the emergence of HIV/AIDS,
many educated brothers-in-law refrain from the practice and instead hire
professional cleansers as substitutes. If the deceased spouses were HIV positive,
the ritual places professional cleansers at risk of infection. Thereafter, they could
act as a bridge for HIV/AIDS transmission to other widows and to the general
population. This paper provides insights into reasons for continuity of
widowhood rites in Siaya District. Twelve focus group discussions and 20 in-
depth interviews were conducted.The cultural violence against Luo widows
could spread HIV/AIDS, but Christianity and condoms act as coping
mechanisms.
Putting on a brave face: the experiences of women living with HIV and
AIDS in informal settlements of Nairobi, Kenya.
303
Author: Amuyunzu-Nyamongo M; Okeng'o L; Wagura A, and Mwenzwa, E.
Source: AIDS Care. 2007 Feb; 19 Suppl 1:S25-S34.
Abstract: This paper examines two key dimensions of HIV and AIDS in sub-Saharan
Africa, namely poverty and gender, within the particular context of informal
settlements. The study, conducted in five informal settlements of Nairobi, Kenya
explored the challenges facing women living with HIV and AIDS (WLWA) in
informal settlements in Nairobi in terms of the specific risk environments of
informal settlements, the support they receive and their perceptions of their
future. The data were gathered through an interviewer-based questionnaire
administered to 390 WLWA and 20 key informant interviews with Kenya
Network of Women with AIDS (KENWA) project personnel. The results show
that for WLWA in informal settlements, poverty and poor living conditions
combine to increase the risk environment for HIV infection and other
opportunistic infections and that the WLWA then face HIV- and AIDS-related
problems that are exacerbated by poverty and by the poor living environments.
In response, the WLWA had devised coping strategies that were largely centred
on survival, including commercial sex work and the sale of illicit liquor, thus
increasing their susceptibility to re-infections. Insecurity in informal settlements
curtailed their participation in income generating activities (IGAs) and increased
their risk of rape and HIV reinfection. Recognising the disadvantaged position of
communities in informal settlements, the non-governmental organizations
(NGOs), community-based organizations (CBOs) and faith-based organizations
(FBOs) provide a range of services including HIV and AIDS information and
therapy. Paradoxically, living in urban informal settlements was found to
increase WLWA's access to HIV and AIDS prevention and treatment services
through NGOs and social networks that are not found in more established
residential areas. The sustainability of these services is, however, questioned,
given the lack of local resources, weak state support and high donor
dependency. We suggest that the economic and tenure insecurity found among
WLWA demands in response consistent support through comprehensive,
sustainable HIV and AIDS services complemented by social networks and
community sensitisation against stigma and discrimination. Fundamentally, the
upgrading of informal settlements would address the wider risk environments
that exacerbate the poor health of the WLWA who line in them. (author's)
304
Integrating family planning into VCT services.

Author: Aradhya, K. W.
Source: Guest editorial. Pop Reporter. 2005 Jan 31; 5(5):1-2.
Abstract: As efforts begin to integrate family planning into HIV/AIDS services, voluntary
counseling and testing (VCT) centers are emerging as primary targets for
integration. Research from Africa and the Caribbean shows that such integration
is feasible and acceptable, and large-scale integration efforts are being launched
and expanded there. VCT services have become one of the most common means
of preventing, detecting, and improving access to care and support for
HIV/AIDS. And VCT services are likely to greatly expand with support from the
five-year U.S. President's Emergency Plan for AIDS Relief (PEPFAR), which
focuses on fighting the HIV/AIDS epidemic in 15 resource-poor countries,
mostly in Africa and the Caribbean. (excerpt)
Clinical screening for HIV in a health centre setting in urban Kenya: an

entry point for voluntary counselling, HIV testing and early diagnosis of
HIV infection?
Author: Arendt, V.; Mossong, J.; Zachariah, R.; Inwani, C.; Farah, B.; Robert, I.;
Waelbrouck, A., and Fonck, K.
Source: Trop Doct. 2007 Jan; 37(1):45-7.
Abstract: A study was conducted among patients attending a public health centre in
Nairobi, Kenya in order to (a) verify the prevalence of HIV, (b) identify clinical
risk factors associated with HIV and (c) determine clinical markers for clinical
screening of HIV infection at the health centre level. Of 304 individuals involved
in the study,107(35%) were HIV positive. A clinical screening algorithm based
on four clinical markers, namely oral thrush, past or present TB, past or present
herpes zoster and prurigo would pick out 61 (57%) of the 107 HIV-positive
individuals. In a resource-poor setting, introducing a clinical screening algorithm
for HIV at the health centre level could provide an opportunity for targeting
voluntary counselling and HIV testing, and early access to a range of prevention
and care interventions
305
Behaviour change in clients of health centre-based voluntary HIV

counselling and testing services in Kenya.
Author: Arthur, G.; Nduba, V.; Forsythe, S.; Mutemi, R.; Odhiambo, J., and Gilks, C.
Source: Sex Transm Infect. 2007 Dec; 83(7):541-6.
To explore behaviour change, baseline risk behaviour, perception of risk, HIV
disclosure and life events in health centre-based voluntary counselling and
testing (VCT) clients.
Design and setting:

Single-arm prospective cohort with before-after design at three (one urban and
two rural) government health centres in Kenya; study duration 2 years, 1999-
2001. SUBJECTS: Consecutive eligible adult clients.

Numbers of sexual partners, partner type, condom use, reported symptoms of
sexually transmitted infection, HIV disclosure and life events.
Results:
High rates of enrollment and follow-up provided a demographically
representative sample of 401 clients with mean time to follow-up of 7.5 months.
Baseline indicators showed that clients were at higher risk than the general
population, but reported a poor perception of risk. Clients with multiple partners
showed a significant reduction of sexual partners at follow-up (16% to 6%;
p<0.001), and numbers reporting symptoms of sexually transmitted infection
decreased significantly also (from 40% to 15%; p<0.001). Condom use improved
from a low baseline. Low rates of disclosure (55%) were reported by HIV-
positive clients. Overall, no changes in rates of life events were seen.
Conclusion:
This study suggests that significant prevention gains can be recorded in clients
receiving health centre-based VCT services in Africa. Prevention issues should be
considered when refining counselling and testing policies for expanding
treatment programmes.
306
Potential impact of infant feeding recommendations on mortality and

HIV-infection in children born to HIV-infected mothers in Africa: a
simulation.
Author: Atashili, J.; Kalilani, L.; Seksaria, V., and Sickbert-Bennett, E. E.
Although breast-feeding accounts for 15-20% of mother-to-child transmission
(MTCT) of HIV, it is not prohibited in some developing countries because of the
higher mortality associated with not breast-feeding. We assessed the potential
impact, on HIV infection and infant mortality, of a recommendation for shorter
durations of exclusive breast-feeding (EBF) and poor compliance to these
recommendations.
Methods:
We developed a deterministic mathematical model using primarily parameters
from published studies conducted in Uganda or Kenya and took into account
non-compliance resulting in mixed-feeding practices. Outcomes included the
number of children HIV-infected and/or dead (cumulative mortality) at 2 years
following each of 6 scenarios of infant-feeding recommendations in children born
to HIV-infected women: Exclusive replacement-feeding (ERF) with 100%
compliance, EBF for 6 months with 100% compliance, EBF for 4 months with
100% compliance, ERF with 70% compliance, EBF for 6 months with 85%
compliance, EBF for 4 months with 85% compliance
Results:
In the base model, reducing the duration of EBF from 6 to 4 months reduced HIV
infection by 11.8% while increasing mortality by 0.4%. Mixed-feeding in 15% of
the infants increased HIV infection and mortality respectively by 2.1% and 0.5%
when EBF for 6 months was recommended; and by 1.7% and 0.3% when EBF for
4 months was recommended. In sensitivity analysis, recommending EBF resulted
in the least cumulative mortality when the a) mortality in replacement-fed
infants was greater than 50 per 1000 person-years, b) rate of infection in
exclusively breast-fed infants was less than 2 per 1000 breast-fed infants per
week, c) rate of progression from HIV to AIDS was less than 15 per 1000 infected
infants per week, or d) mortality due to HIV/AIDS was less than 200 per 1000
infants with HIV/AIDS per year.
Conclusion:
Recommending shorter durations of breast-feeding in infants born to HIV-
infected women in these settings may substantially reduce infant HIV infection
but not mortality. When EBF for shorter durations is recommended, lower
mortality could be achieved by a simultaneous reduction in the rate of
progression from HIV to AIDS and or HIV/AIDS mortality, achievable by the
use of HAART in infants.
307
Estimating the resources needed and savings anticipated from roll-out of

adult male circumcision in Sub-Saharan Africa.
Author: Auvert, B.; Marseille, E.; Korenromp, E. L.; Lloyd-Smith, J.; Sitta, R.; Taljaard, D.;
Pretorius, C.; Williams, B., and Kahn, J. G.
Trials in Africa indicate that medical adult male circumcision (MAMC) reduces
the risk of HIV by 60%. MAMC may avert 2 to 8 million HIV infections over 20
years in sub-Saharan Africa and cost less than treating those who would have
been infected. This paper estimates the financial and human resources required
to roll out MAMC and the net savings due to reduced infections.
Methods:
We developed a model which included costing, demography and HIV
epidemiology. We used it to investigate 14 countries in sub-Saharan Africa where
the prevalence of male circumcision was lower than 80% and HIV prevalence
among adults was higher than 5%, in addition to Uganda and the Nyanza
province in Kenya. We assumed that the roll-out would take 5 years and lead to
an MC prevalence among adult males of 85%. We also assumed that surgery
would be done as it was in the trials. We calculated public program cost, number
of full-time circumcisers and net costs or savings when adjusting for averted HIV
treatments. Costs were in USD, discounted to 2007. 95% percentile intervals
(95% PI) were estimated by Monte Carlo simulations.
Results:
In the first 5 years the number of circumcisers needed was 2 282 (95% PI: 2 018 to
2 959), or 0.24 (95% PI: 0.21 to 0.31) per 10,000 adults. In years 6-10, the number of
circumcisers needed fell to 513 (95% PI: 452 to 664). The estimated 5-year cost of
rolling out MAMC in the public sector was $919 million (95% PI: 726 to 1 245).
The cumulative net cost over the first 10 years was $672 million (95% PI: 437 to
1,021) and over 20 years there were net savings of $2.3 billion (95% PI: 1.4 to 3.4).
Conclusion:
A rapid roll-out of MAMC in sub-Saharan Africa requires substantial funding
and a high number of circumcisers for the first five years. These investments are
justified by MAMC's substantial health benefits and the savings accrued by
averting future HIV infections. Lower ongoing costs and continued care savings
suggest long-term sustainability.
Wealth status and risky sexual behaviour in ghana and kenya.

Author: Awusabo-Asare, K. and Annim, S. K.
308
Source: Appl Health Econ Health Policy. 2008; 6(1):27-39.
Emerging evidence seems to suggest that there is some association between
individual socioeconomic status and sexual risk-taking behaviour in sub-Saharan
Africa. A number of broad associations have emerged, among them, positive,
neutral and negative relationships between wealth status and sexual risk-taking
behaviour. Reduction in the number of sex partners as a behavioural change has
been advocated as an important tool in HIV prevention, and affecting such a
change requires an understanding of some of the factors that can influence social
behaviour, interactions and activities of subpopulations.
Objectives:
To further explore the determinants of sexual risk-taking behaviour (individuals
having multiple sex partners), especially the effects that variations in household
wealth status, gender and different subpopulation groups have on this
behaviour.
Methods:
The relationship between wealth status and sexual risk-taking behaviour in the
context of HIV/AIDS infection in Ghana and Kenya was assessed using raw data
from the 2003 Demographic and Health Surveys of each country. Wealth
quintiles were used as a proxy for economic status, while non-marital and non-
cohabiting sexual partnerships were considered indicators for risky sexual
behaviour.
Results:
For females, there appears to be an increasing probability of sexual risk taking by
wealth status in Kenya, while, in Ghana, an inverted J-shaped relationship is
shown between wealth status and sexual risk taking. When controlled for other
variables, the relationship between wealth status and sexual risk-taking
behaviour disappears for females in the two countries. For males, there is no
clearly discernable pattern between wealth status and sexual risk-taking
behaviour in Ghana, while there is a general trend towards increasing sexual
risk-taking behaviour by wealth status in Kenya. For Ghana, the highest
probabilities are among the highest and the middle wealth quintiles; in Kenya,
high probabilities were found for the two highest wealth quintiles. Controlling
for the effects of other factors, the pattern for Ghana is further blurred (not
statistically significant), but the relationship continues to show in the case of
Kenya, and is significant for the highest quintile. In general, for both Ghana and
Kenya, men in the highest wealth quintile were found to be more likely to have
multiple sexual partners than the other groups.
Conclusion:
The changing phases of HIV infection indicate that it is no longer poverty that
drives the epidemic. Rather, it is wealth and a number of other
sociodemographic factors that explain sexual risk-taking behaviour that puts
people at risk. Understanding local specific factors that predispose individuals
309
towards sexual risk taking could help to expand the range of information and
services needed to combat the HIV pandemic.
HIV-1 subtype D infection is associated with faster disease progression

than subtype A in spite of similar plasma HIV-1 loads.
Author: Baeten, J. M.; Chohan, B.; Lavreys, L.; Chohan, V.; McClelland, R. S.; Certain, L.;
Mandaliya, K.; Jaoko, W., and Overbaugh, J.
Source: J Infect Dis. 2007 Apr 15; 195(8):1177-80.
Abstract: We investigated the effect of human immunodeficiency virus type 1 (HIV-1)

subtype on disease progression among 145 Kenyan women followed from the
time of HIV-1 acquisition. Compared with those infected with subtype A,
women infected with subtype D had higher mortality (hazard ratio, 2.3 [95%
confidence interval, 1.0-5.6]) and a faster rate of CD4 cell count decline (P=.003).
The mortality risk persisted after adjustment for plasma HIV-1 load. There were
no differences in plasma viral load by HIV-1 subtype during follow-up. HIV-1
subtype D infection is associated with a >2-fold higher risk of death than subtype
A infection, in spite of similar plasma HIV-1 loads.
Female-to-male infectivity of HIV-1 among circumcised and

uncircumcised Kenyan
Author: Baeten, J. M.; Richardson, B. A.; Lavreys, L.; Rakwar, J. P.; Mandaliya, K.; Bwayo,
J. J., and Kreiss, J. K. men.
A lack of male circumcision has been associated with increased risk of human
immunodeficiency virus type 1 (HIV-1) acquisition in a number of studies, but
questions remain as to whether confounding by behavioral practices explains
these results. The objective of the present study was to model per-sex act
probabilities of female-to-male HIV-1 transmission (i.e., infectivity) for
circumcised and uncircumcised men, by use of detailed accounts of sexual
behavior in a population with multiple partnerships.
310
Methods:
Data were collected as part of a prospective cohort study of HIV-1 acquisition
among 745 Kenyan truck drivers. Sexual behavior with wives, casual partners,
and prostitutes was recorded at quarterly follow-up visits. Published HIV-1
seroprevalence estimates among Kenyan women were used to model HIV-1 per-
sex act transmission probabilities.
Results:
The overall probability of HIV-1 acquisition per sex act was 0.0063 (95%
confidence interval, 0.0035-0.0091). Female-to-male infectivity was significantly
higher for uncircumcised men than for circumcised men (0.0128 vs. 0.0051;
P=.04). The effect of circumcision was robust in subgroup analyses and across a
wide range of HIV-1 prevalence estimates for sex partners.
Conclusions:
After accounting for sexual behavior, we found that uncircumcised men were at
a >2-fold increased risk of acquiring HIV-1 per sex act, compared with
circumcised men. Moreover, female-to-male infectivity of HIV-1 in the context of
multiple partnerships may be considerably higher than that estimated from
studies of HIV-1-serodiscordant couples. These results may explain the rapid
spread of the HIV-1 epidemic in settings, found throughout much of Africa, in
which multiple partnerships and a lack of male circumcision are common.
HIV-1 infection alters the retinol-binding protein: transthyretin ratio

even in the absence of the acute phase response.
Author: Baeten, J. M.; . = Wener MH; Bankson DD; Lavreys L, and Richardson BA.
Source: Journal of Nutrition. 2006 Jun; 136(6):1624-1629.
Abstract: The ratio of retinol-binding protein (RBP) to transthyretin (TTR) has been
proposed as an indirect method with which to assess vitamin A status in the
context of inflammation. Few studies have been conducted among adults, and
none examined the effect of HIV-1 infection. Our goal was to assess the RBP:TTR
ratio among adults, including the effects of HIV-1 and the acute phase response.
We used data from a cross-sectional study of 600 Kenyan women, of whom 400
had HIV-1. The effect of vitamin A supplementation among the HIV-1-infected
participants was subsequently assessed in a randomized trial. Among HIV-1-
uninfected women without an acute phase response, a RBP:TTR cut-off value of
0.25 had ~80% sensitivity and specificity to detect vitamin A deficiency (retinol <
0.70 µmol/L). No RBP:TTR cut-off value demonstrated both high sensitivity and
specificity among HIV-1 infected women without evidence of inflammation.
HIV-1 infection and advanced HIV-1 disease were associated with higher
RBP:TTR ratios. The effect of HIV-1 was independent of the acute phase
response, which also increased the RBP:TTR ratio. Serum retinol increased with
vitamin A supplementation among those with a low RBP:TTR ratio, although the
effect was small and was not present among those with concurrent inflammation.
311
Thus, the RBP:TTR ratio has modest ability to predict vitamin A deficiency
among healthy adults, but HIV-1 infection alters the ratio, even in the absence of
the acute phase response. Our results raise questions about the utility of this
measurement given the high prevalence of HIV-1 infection in areas where
vitamin A deficiency is common. (author's)
Assessment of clinical and traditional male circumcision services in

Bungoma District, Kenya: complication rates and operational needs.
Author: Bailey, R. C. and . = Egesah O.
Source: Special report.
Abstract: Over 40 observational studies and one clinical trial have found that male
circumcision (MC) has a protective effect against HIV acquisition of between 40%
and 88%. Most recently, Auvert et al. (2005) found in a randomized controlled
trial (RCT) in Orange Farm, South Africa, that MC had a protective effect of 60%
in intention to treat analysis. When the dissolution effect of cross-overs was
taken into account in a per protocol analysis, the protective effect was found to
be 76%. Currently, there are two additional RCTs of MC underway in sub-
Saharan Africa - one in Rakai, Uganda and the other in Kisumu, Kenya. The
results of these two additional trials are expected to be available in 2006-2007. If
these trials find MC to be effective in reducing HIV incidence, the results,
combined with the evidence from observational studies and biological
investigations showing high susceptibility of human foreskin to HIV infection,
are likely to compel the international health community to consider promotion of
MC in countries where circumcision is little practiced and the epidemic is
primarily among heterosexuals. However, lack of crucial information concerning
the feasibility, safety and costs of implementing MC services is likely to impede
progress toward building support for timely introduction of MC as an HIV
prevention strategy. History has shown repeatedly, whether in the arena of HIV
prevention or other health-related interventions, that the time from discovery to
implementation of effective interventions has been tragically long due to the
years necessary to collect information crucial for addressing operational issues
and for building political will. (excerpt)
312
Cost effectiveness and delivery study for future HIV vaccines.

Author: Barth-Jones, D. C.; Cheng, H.; Kang, L. Y.; Kenya, P. R.; Odera, D.; Mosqueira, N.
R.; Mendoza, W.; Portela, M. C.; Brito, C.; Tangcharoensathien, V.; Akaleephan,
C.; Supantamart, S.; Patcharanarumol, W.; de Macedo Brigido, L. F.; Fonseca, M.
G.; Sanchez, M.; Chang, M. L.; Osmanov, S.; Avrett, S.; Esparza, J., and Griffiths,
U.
Source: AIDS. 2005 Sep 2; 19(13):w1-6.
Abstract: Research teams from five countries, Brazil, China, Kenya, Peru and Thailand,
have initiated a policy-maker survey on vaccine delivery, cost studies for future
HIV vaccination programmes, and associated simulation modeling exercises
analysing the relative cost-effectiveness of potential HIV vaccination strategies.
The survey assesses challenges and opportunities for future country-level HIV
vaccination strategies, providing data on the vaccine characteristics (e.g. vaccine
efficacies for susceptibility, infectiousness and disease progression) and
vaccination programme strategies to be considered in the cost-effectiveness
modeling analyses. The study will provide decision-makers with modeling data
on vaccination policy considerations that will assist in developing country-level
capacities for future HIV vaccine policy adoption and effective delivery systems,
and will help delineate the long-term financial requirements for sustainable HIV
vaccination programmes. The WHO-UNAIDS HIV Vaccine Initiative and the
collaborating researchers welcome comments or questions from policy makers,
health professionals and other stakeholders in the public and private sectors
about this effort to help advance policy and capacity related to future potential
HIV vaccines.
Economic growth, education, and AIDS in Kenya.

Author: Bell C; Bruhns R, and Gersbach, H.
Source: Development Outreach. 2007 Jun; [7] p.
Abstract: An AIDS epidemic threatens Kenya with a long wave of premature adult
mortality, and thus with an enduring setback to the formation of human capital
and economic growth. According to UNAIDS (2004), about 1.2 million Kenyans
were HIV-positive (out of a population of just over 30 million) in 2003, roughly
150,000 died of the disease in that year, and some 650,000 children had been left
as orphans. One independent estimate puts the cumulative number of deaths
due to AIDS in Kenya from 1984 to 2000 at no less than 1.5 million. We
developed a model to analyze the prospects for the formation of human capital
and economic growth in Kenya, even as the AIDS epidemic threatens that
country with a long wave of premature adult mortality. The model is then used
to analyze the social profitability of programs to promote education and combat
the epidemic. (excerpt)
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Economic growth, education and AIDS in Kenya: a long-run analysis.

Abstract: The AIDS epidemic threatens Kenya with a long wave of premature adult
mortality, and thus with an enduring setback to the formation of human capital
and economic growth. To investigate this possibility, we develop a model with
three overlapping generations, calibrate it to the demographic and economic
series from 1950 until 1990, and then perform simulations for the period ending
in 2050 under alternative assumptions about demographic developments,
including the counterfactual in which there is no epidemic. Although AIDS does
not bring about a catastrophic economic collapse, it does cause large economic
costs - and very many deaths. Programs that subsidize post-primary education
and combat the epidemic are both socially profitable - the latter strikingly so, due
to its indirect effects on the expected returns to education - and a combination of
the two interventions profits from a modest long-run synergy effect. (author's)
Quantification of genital human immunodeficiency virus type 1 (HIV-1)

DNA in specimens from women with low plasma HIV-1 RNA levels
typical of HIV-1 nontransmitters.
Author: Benki, S.; McClelland, R. S.; Emery, S.; Baeten, J. M.; Richardson, B. A.; Lavreys,
L.; Mandaliya, K., and Overbaugh, J.
Source: J Clin Microbiol. 2006 Dec; 44(12):4357-62.
Abstract: Studies of human immunodeficiency virus type 1 (HIV-1) transmission suggest

that genital HIV-1 RNA and DNA may both be determinants of HIV-1
infectivity. Despite its potential role in HIV-1 transmission, there are limited
quantitative data on genital HIV-1 DNA. Here we validated an in-house real-
time PCR method for quantification of HIV-1 DNA in genital specimens. In
reactions with 100 genomes to 1 genome isolated from a cell line containing one
HIV-1 provirus/cell, this real-time PCR assay is linear and agrees closely with a
commercially available real-time PCR assay specific for a cellular housekeeping
gene. In mock genital samples spiked with low numbers of HIV-1-infected cells
such that the expected HIV-1 DNA copy number/reaction was 100, 10, or 5, the
average copy number/reaction was 80.2 (standard deviation [SD], 28.3), 9.1 (SD,
5.4), or 3.1 (SD, 2.1), respectively. We used this method to examine genital HIV-1
DNA levels in specimens from women whose low plasma HIV-1 RNA levels are
typical of HIV-1 nontransmitters. The median HIV-1 DNA copy number in
endocervical secretions from these women (1.8 HIV-1 DNA copies/10,000 cells)
was lower than that for women with higher plasma HIV-1 RNA levels (16.6 HIV-
1 DNA copies/10,000 cells) (P=0.04), as was the median HIV-1 DNA copy
number in vaginal secretions (undetectable versus 1.0 HIV-1 DNA copies/10,000
cells). These data suggest that women with low plasma HIV-1 RNA and thus a
predicted low risk of HIV-1 transmission have low levels of genital HIV-1 cell-
314
associated virus. The assay described here can be utilized in future efforts to
examine the role of cell-associated HIV-1 in transmission.
Prevalence of malnutrition in human immunodeficiency virus/acquired

immunodeficiency syndrome orphans in the Nyanza province of Kenya:
a comparison of conventional indexes with a composite index of
anthropometric failure.
Author: Berger, M. R.; Fields-Gardner, C.; Wagle, A., and Hollenbeck, C. B.
Source: J Am Diet Assoc. 2008 Jun; 108(6):1014-7.
Abstract: The prevalence of undernutrition in children is commonly reported using a

conventional index, which identifies three conventional categories: stunting,
underweight, and wasting. Recently, a composite index of anthropometric failure
was developed to categorize undernutrition into seven mutually exclusive
categories, including single failures (stunting, underweight, or wasting) and
multiple failures (stunting and underweight, stunting and wasting, underweight
and wasting, and stunting and underweight and wasting). This cross-sectional
study used baseline data gathered during a feeding program targeting orphans
and vulnerable children impacted by human immunodeficiency virus and/or
acquired immunodeficiency syndrome (HIV/AIDS) in Kenya to compare the
conventional index with the composite index of anthropometric failure. Children
younger than 5 years of age who participated in the feeding trial were included
in the analysis (n=170). The conventional index found that the prevalence of
undernutrition included 31.2% stunted, 14.1% underweight, and 5.9% wasted
children, whereas the composite index of anthropometric failure estimated a
more severe overall prevalence rate (38.2%); thus, the conventional index did not
uncover the complexity of malnutrition experienced. Of the 53 children classified
as stunted by the conventional index, the composite index of anthropometric
failure identified 36 (67.9%) as stunted and 17 (32.1%) as stunted and
underweight. Thus, the composite index of anthropometric failure was able to
distinguish children with multiple anthropometric failures. In total, multiple
anthropometric failures were found in 22 of the 65 children with anthropometric
failure. These data suggest that the complexity and prevalence of undernutrition
may be underestimated using the conventional index because it does not identify
children experiencing multiple anthropometric failures. The ability of the
composite index of anthropometric failure to identify children with multiple
anthropometric failures may have profound implications for prioritizing,
designing, and targeting nutritional interventions.
Mombasa Antiretroviral Therapy Program: monitoring and evaluation

plan for pharmaceutical and laboratory capacity building activities,
February 2004.
315
Author: Bhattarai, H. R. and Walkowiak H.
Abstract: The Mombasa ART Program proposal document, jointly proposed by a

partnership of FHI/IMPACT Project, Population Council/Horizons Project and
MSH/RPM Plus already contains the outline of the overarching monitoring and
evaluation framework and some indicators. This document is intended to
supplement the original proposal to describe in detail the monitoring and
evaluation (M&E) of pharmaceutical and laboratory capacity building activities
for which RPM Plus is responsible. This document outlines the M&E procedures
and indicators for monitoring the pharmaceutical and laboratory capacity
building activities and also the link with the envisaged unified M&E system of
the program. Although this is a supplemental document, primary program goals
and objectives are repeated below so that the document can serve as a stand
alone reference. (excerpt)
Infant feeding practices among HIV infected women receiving

prevention of mother-to-child transmission services at Kitale District
Hospital, Kenya.
To determine the types and modes of infant feeding practices among the HIV
infected mothers on prevention of mother-to-child transmission (PMTCT) and
attending MCH-FP clinic at Kitale District Hospital, Kenya.
Design: Descriptive cross-sectional study.
Setting:
Kitale District Hospital in Western Kenya within the maternal and child health
and family planning (MCH-FP) and comprehensive care clinics.
Subjects:
A total of 146 respondents who had delivered 150 babies were recruited for this
study.
Results:
Thirty five percent (52/150) of the babies were exclusively breastfed while 50%
(75/150) were not breastfed at all and 14% (21/150) of the babies received mixed
feeding. The length of exclusive breastfeeding ranged from 1-6 months with most
(53%) women exclusively breastfeeding for two to three months. Only 13% of the
women exclusively breastfed for five to six months. There was a strong
relationship between mode of infant feeding and spouse's awareness of HIV
status. Mothers who had disclosed their HIV status to their spouses were more
likely not to breastfeed than mothers who had not disclosed their status (p <
0.05%). The choice of infant feeding method was also influenced by the socio-
316
economic status of the mothers and nevirapine uptake. The level of education
did not influence the mode of infant feeding.
Conclusion:
Infant feeding decisions were mainly influenced by the male partner's
involvement and the socio economic status of the mother. Half of the
respondents did not breastfeed at all. The duration of exclusive breastfeeding
rarely reached six months. To encourage women to adhere to good infant feeding
practices, involvement of their partners, family members as well as the
community for support should be encouraged.
Self-reported adherence to single dose nevirapine in the prevention of

mother to child transmission of HIV at Kitale District Hospital.
To evaluate the uptake and adherence to single dose nevirapine among HIV
positive mothers.
Design:
Descriptive cross-sectional study.
Setting:
The maternal and child health and family planning (MCH-FP) clinics in Kitale
district hospital, Western Kenya.
Subjects:
HIV positive postnatal women attending MCH-FP clinic who had gone through
the PMTCT programme.
Results:
A total of 146 respondents were recruited for this study. Most (90%) of them
reported swallowing their nevirapine tablets, however only 55 swallowed their
tablets within 4-12 hours before delivery. The most important factor affecting
nevirapine adherence was place or delivery (p<0.05). Most (71%) of mothers who
did not swallow their nevirapine delivered at home. Women attending ANC for
two times or less young women under 20 years of age and single women were
also less likely to swallow their nevirapine (p < 0.05). Most (91%) of the babies
received their nevirapine syrup with 98% of them getting it within 72 hours of
delivery. Eighty eight percent of babies who did not take their nevirapine were
delivered at home. Babies whose mothers did not take their nevirapine were also
more likely to miss it.
Conclusions:
317
Self reported adherence to take home nevirapine is high. However mothers who
deliver in a health facility were more likely to access nevirapine both for
themselves and their babies than those delivering at home.
Enhancing exposure of HIV-1 neutralization epitopes through mutations

in gp41.
Author: Blish, C. A.; Nguyen, M. A., and Overbaugh, J.
Source: PLoS Med. 2008 Jan 3; 5(1):e9.
The generation of broadly neutralizing antibodies is a priority in the design of
vaccines against HIV-1. Unfortunately, most antibodies to HIV-1 are narrow in
their specificity, and a basic understanding of how to develop antibodies with
broad neutralizing activity is needed. Designing methods to target antibodies to
conserved HIV-1 epitopes may allow for the generation of broadly neutralizing
antibodies and aid the global fight against AIDS by providing new approaches to
block HIV-1 infection. Using a naturally occurring HIV-1 Envelope (Env) variant
as a template, we sought to identify features of Env that would enhance exposure
of conserved HIV-1 epitopes.

Within a cohort study of high-risk women in Mombasa, Kenya, we previously
identified a subtype A HIV-1 Env variant in one participant that was unusually
sensitive to neutralization. Using site-directed mutagenesis, the unusual
neutralization sensitivity of this variant was mapped to two amino acid
mutations within conserved sites in the transmembrane subunit (gp41) of the
HIV-1 Env protein. These two mutations, when introduced into a neutralization-
resistant variant from the same participant, resulted in 3- to >360-fold enhanced
neutralization by monoclonal antibodies specific for conserved regions of both
gp41 and the Env surface subunit, gp120, >780-fold enhanced neutralization by
soluble CD4, and >35-fold enhanced neutralization by the antibodies found
within a pool of plasmas from unrelated individuals. Enhanced neutralization
sensitivity was not explained by differences in Env infectivity, Env concentration,
Env shedding, or apparent differences in fusion kinetics. Furthermore,
introduction of these mutations into unrelated viral Env sequences, including
those from both another subtype A variant and a subtype B variant, resulted in
enhanced neutralization susceptibility to gp41- and gp120-specific antibodies,
and to plasma antibodies. This enhanced neutralization sensitivity exceeded
1,000-fold in several cases.
Conclusions:
Two amino acid mutations within gp41 were identified that expose multiple
discontinuous neutralization epitopes on diverse HIV-1 Env proteins. These
exposed epitopes were shielded on the unmodified viral Env proteins, and
several of the exposed epitopes encompass desired target regions for protective
318
antibodies. Env proteins containing these modifications could act as a scaffold

for presentation of such conserved domains, and may aid in developing methods
to target antibodies to such regions.
Constructing a stigma and discrimination index: hopes, dreams, and

lessons learned.
Author: Bollinger, L.
Abstract: Without a consistent methodology to measure stigma and discrimination (S&D),

it is difficult to monitor and evaluate reduction interventions. Although some
indices have been developed, no standardized method has been adopted that
encompasses all relevant dimensions of S&D. This activity's objectives were to
design an index on HIV/AIDS-related stigma and discrimination based on
existing studies of S&D indicators, prepare and test a survey, field the survey in
various countries, and finally, create an index for each of the countries surveyed.
The indicators were developed in conjunction with the USAID Interagency
Working Group (IWG) on Stigma and Discrimination and formed part of an
effort headed by the UNAIDS Secretariat and International Planned Parenthood
Federation, which were designing a similar index. This index was different than
other indices developed by Futures Group, which are calculated based on expert
opinion obtained through surveys. For this index, much larger samples were
needed, including three different population groups (community,
facility/provider, persons living with HIV). Thus, instead of gathering expert
opinions, existing studies that reported results for the relevant indicators were
reviewed, and the index was constructed based on these results. The survey was
implemented and studies were gathered in Mexico, Kenya, South Africa, and
Tanzania. These countries were selected because they were most likely to have
relevant studies. (excerpt)
Utility of antenatal HIV surveillance data to evaluate prevention of

mother-to-child HIV transmission programs in resource-limited settings.
Author: Bolu, O.; Anand, A.; Swartzendruber, A.; Hladik, W.; Marum, L. H.; Sheikh, A.
A.; Woldu, A.; Ismail, S.; Mahomva, A.; Greby, S., and Sabin, K.
Source: Am J Obstet Gynecol. 2007 Sep; 197(3 Suppl):S17-25.
Abstract: Prevention of mother-to-child human immunodeficiency virus (HIV)

transmission (PMTCT) programs are expanding in resource-limited countries
and are increasingly implemented in antenatal clinics (ANC) in which HIV
sentinel surveillance is conducted. ANC sentinel surveillance data can be used to
evaluate the first visit of a pregnant woman to PMTCT programs. We analyzed
data from Kenya and Ethiopia, where information on PMTCT test acceptance
was collected on the 2005 ANC sentinel surveillance forms. For Zimbabwe, we
319
compared the 2005 ANC sentinel surveillance data to the PMTCT program data.
ANC surveillance data allowed us to calculate the number of HIV-positive
women not participating in the PMTCT program. The percentage of HIV-positive
women missed by the PMTCT program was 17% in Kenya, 57% Ethiopia, and
59% Zimbabwe. The HIV prevalence among women participating in PMTCT
differed from women who did not. ANC sentinel surveillance can be used to
evaluate and improve the first encounter in PMTCT programs. Countries should
collect PMTCT-related program data through ANC surveillance to strengthen
the PMTCT program.
Longitudinal comparison of chemokines in breastmilk early postpartum

among HIV-1-infected and uninfected Kenyan women.
Author: Bosire, R.; Guthrie, B. L.; Lohman-Payne, B.; Mabuka, J.; Majiwa, M.; Wariua, G.;
Mbori-Ngacha, D.; Richardson, B.; John-Stewart, G., and Farquhar, C.
Source: Breastfeed Med. 2007 Sep; 2(3):129-38.
Abstract: Breastmilk chemokines have been associated with increased HIV-1 RNA levels in
breastmilk and altered risk of mother-to-child HIV-1 transmission. To
characterize CC and CXC chemokines in breastmilk postpartum, we collected
breastmilk specimens at regular intervals for 6 months after delivery from
women with and without HIV-1 infection and used commercial ELISA kits to
measure breastmilk concentrations of MIP-1alpha, MIP-1beta, RANTES, and
SDF-1alpha. Among 54 HIV-1-infected and 26 uninfected women, mean
chemokine levels were compared cross-sectionally and longitudinally at days 5
and 10, and months 1 and 3 postpartum. For both HIV-1-infected and uninfected
women, breastmilk chemokine levels were highest at day 5 for MIP-1alpha, MIP-
1beta, and SDF-1alpha, and subsequently decreased. RANTES levels remained
constant over the follow-up period among HIV-1-uninfected women, and
increased moderately among HIV-1-infected women. For MIP-1beta and
RANTES, breastmilk levels were significantly higher among HIV-1-infected
women compared to uninfected women early postpartum. In addition, HIV-1-
infected women transmitting HIV-1 to their infant had consistently higher
breastmilk RANTES levels than those who did not transmit, with the greatest
difference observed at 1 month (2.68 vs. 2.21 log10 pg/mL, respectively; p =
0.007). In summary, all four chemokines were most elevated within the first
month postpartum, a period of high transmission risk via breastmilk. MIP-1beta
and RANTES levels in breastmilk were higher among HIV-1-infected women
than among uninfected women, and breastmilk RANTES was positively
associated with vertical transmission in this study, consistent with results from
our earlier cohort.
Breast milk alpha-defensins are associated with HIV type 1 RNA and CC
chemokines in breast milk but not vertical HIV type 1 transmission.
320
Author: Bosire, R.; John-Stewart, G. C.; Mabuka, J. M.; Wariua, G.; Gichuhi, C.; Wamalwa,
D.; Ruzinski, J.; Goodman, R.; Lohman, B.; Mbori-Ngacha, D. A.; Overbaugh, J.,
and Farquhar, C.
Source: AIDS Res Hum Retroviruses. 2007 Feb; 23(2):198-203.
Abstract: Alpha-defensins are proteins exhibiting in vitro anti-HIV-1 activity that may
protect against mother-to-child transmission of HIV-1 via breast milk. Correlates
of alpha-defensins in breast milk and transmission risk were determined in a
cohort of HIV-1-infected pregnant women in Nairobi followed for 12 months
postpartum with their infants. Maternal blood was collected antenatally and at
delivery for HIV-1 viral load and infant HIV-1 infection status was determined <
48 h after birth and at months 1, 3, 6, 9, and 12. Breast milk specimens collected at
month 1 were assayed for alpha-defensins, HIV-1 RNA, subclinical mastitis, and
CC and CXC chemokines. We detected alpha-defensins in breast milk specimens
from 108 (42%) of 260 HIV-1-infected women. Women with detectable alpha-
defensins (> or =50 pg/ml) had a median concentration of 320 pg/ml and
significantly higher mean breast milk HIV-1 RNA levels than women with
undetectable alpha-defensins (2.9 log(10) copies/ml versus 2.5 log(10) copies/ml,
p = 0.003). Increased alpha-defensins concentrations in breast milk were also
associated with subclinical mastitis (Na (+)/K(+) ratio > 1) and increased breast
milk chemokine levels. Overall, 40 (15%) infants were HIV-1 uninfected at birth
and subsequently acquired HIV-1. There was no significant association between
month 1 alpha-defensins and risk of HIV-1 transmission. In conclusion, alpha-
defensins were associated with breast milk HIV-1 viral load, chemokine levels,
and subclinical mastitis, all of which may alter risk of infant HIV-1 acquisition.
Despite these associations there was no significant relationship between breast
milk alpha-defensins and mother-to-child transmission, suggesting a complex
interplay between breast milk HIV-1, inflammation, and antiinfective factors.
Circumcision-related HIV risk and the unknown mechanism of effect in

the male circumcision trials [letter].
Author: Brewer, D. D.; . = Potterat JJ; Roberts JM Jr, and Brody S.
Source: Annals of Epidemiology. 2007 Nov; 17(11):928-929.
Abstract: We welcome Westreich and colleagues' and Adams and colleagues' comments on
our article, in which we reported that circumcised male and female adolescents
and virgins in Kenya, Lesotho, and Tanzania were consistently and substantially
more likely to be HIV infected than their uncircumcised counterparts. Moreover,
we found that this relationship inverts in adults, such that circumcised adult men
and women are less likely to be infected than uncircumcised adults. Westreich
and colleagues and Adams and colleagues raise objections to our results that
suggest HIV transmission occurs through circumcision practices in eastern and
southern Africa. Specifically, they argue that our measurement of virginity and
321
the number of HIV-infected virgins have probably biased our results. In our
analyses, the positive association between circumcision and HIV infection in
adolescents remained unchanged after statistically adjusting for self-reported
sexual experience. Thus, there is no evidence that underreporting of sexual
experience would affect the interpretation of the positive relationship between
circumcision and HIV infection in virgins or sexually experienced youth. Indeed,
the measurement of sexual behavior is entirely irrelevant to the positive
association between circumcision and HIV infection in Kenyan, Lesothoan, and
Tanzanian adolescents, regardless of virginity status. We also found that
adolescent males who denied sexual experience were as likely or slightly more
likely to be infected as those who acknowledged it. (excerpt)
Effect of CCR2 chemokine receptor polymorphism on HIV type 1

mother-to-child transmission and child survival in Western Kenya.
Author: Brouwer, K. C.; Yang, C.; Parekh, S.; Mirel, L. B.; Shi, Y. P.; Otieno, J.; Lal, A. A.,
and Lal, R. B.
Source: AIDS Res Hum Retroviruses. 2005 May; 21(5):358-62.
Abstract: The effect of CCR2 polymorphism on HIV-1 mother-to-child transmission and

disease progression has not been explored in depth within Africa. As the CCR2-
64I variant of this putative HIV coreceptor has been associated with slower
progression to AIDS in adults, the current study was undertaken to examine the
relationship between CCR2 polymorphism and HIV-1 perinatal transmission and
child survival in western Kenya. CCR2 genotype was determined for 445 HIV-
seropositive mothers and their infants. The CCR2-64I allele frequency of both
mothers and children did not differ by HIV-1 transmission status, regardless of
maternal viral load, viral subtype, immune status, or placental malaria status.
For infants who acquired HIV perinatally (n = 78), there was no association
between CCR2 genotype and viral load upon infection or survival rate over the
2-year follow-up. Our results do not indicate an effect of CCR2-64I on perinatal
HIV transmission and survival in Kenyan children.
Safety, acceptability, and tolerability of 3 topical microbicides among

heterosexual Kenyan men.
Author: Bukusi, E. A.; Steele, M.; Cohen, C. R.; Nguti, R.; Maingi, C. W.; Thomas, K. K.,
and Holmes, K. K.
322
To compare the acceptability, tolerability, and safety of 3 topical microbicide

formulations (62% ethyl alcohol in emollient gel and 0.1% and 0.4%
benzalkonium chloride on a sanitary wipe) for use on male genitalia.
Design:
This triple-randomized crossover study among men attending a sexually
transmitted disease (STD) clinic in Nairobi, Kenya assigned individuals without
clinical evidence of an STD to apply products to the penis in a predetermined
random order, each for a 2-week period with a 1-week washout period between
each product. Men recorded side effects and were examined for adverse events.
Results:
Of 39 participants, 33 (84%) completed 6 clinic visits plus 3 home visits by
community health workers. Participants reported use of 62% ethanol gel and
0.1% and 0.4% benzalkonium on 99%, 99%, and 96% of daily scheduled
applications; 99%, 98%, and 97% of preintercourse applications, and 99%, 94%,
and 98% of postintercourse applications. All participants said they would
recommend all 3 products to a friend; 72% preferred the 62% ethanol gel, 17% the
0.1% benzalkonium, and 11% the 0.4% benzalkonium. One person developed
objective signs of a genital ulcer after 14 days of 0.4% benzalkonium wipe use.
Conclusions:
Two of the 3 topical microbicides had minimal reported adverse effects, and no
adverse effects were observed during use of the ethanol gel, which was preferred
by most men.
Identification of differentially expressed proteins in the cervical mucosa

of HIV-1-resistant sex workers.
Author: Burgener, A.; Boutilier, J.; Wachihi, C.; Kimani, J.; Carpenter, M.; Westmacott, G.;
Cheng, K.; Ball, T. B., and Plummer, F.
Source: J Proteome Res. 2008 Oct; 7(10):4446-54.
Abstract: Novel tools are necessary to understand mechanisms of altered susceptibility to

HIV-1 infection in women of the Pumwani Sex Worker cohort, Kenya. In this
cohort, more than 140 of the 2000 participants have been characterized to be
relatively resistant to HIV-1 infection. Given that sexual transmission of HIV-1
occurs through mucosal surfaces such as that in the cervicovaginal environment,
our hypothesis is that innate immune factors in the genital tract may play a role
in HIV-1 infection resistance. Understanding this mechanism may help develop
microbicides and/or vaccines against HIV-1. A quantitative proteomics
technique (2D-DIGE: two-dimensional difference in-gel electrophoresis) was
used to examine cervical mucosa of HIV-1 resistant women ( n = 10) for
biomarkers of HIV-1 resistance. Over 15 proteins were found to be differentially
expressed between HIV-1-resistant women and control groups ( n = 29), some
which show a greater than 8-fold change. HIV-1-resistant women overexpressed
323
several antiproteases, including those from the serpin B family, and also cystatin
A, a known anti-HIV-1 factor. Immunoblotting for a selection of the identified
proteins confirmed the DIGE volume differences. Validation of these results on a
larger sample of individuals will provide further evidence these biomarkers are
associated with HIV-1 resistance and could help aid in the development of
effective microbicides against HIV-
Our sexuality, our stores: Experiences of HIV-positive women in Kenya.

Author: Burris, M. A. and . = Wanjala M.
Source: Exchange on HIV / AIDS, Sexuality and Gender. 2007; (3):13-15.
Abstract: In July 2006, a group of HIV-positive Kenyan women from Women Fighting
AIDS in Kenya (WOFAK), Society for Orphans Against AIDS (SOAN), and
Kibera Community Self-Help Programme (KICOSHEP) began meeting at the
Trust for Indigenous Culture and Health (TICAH) in Nairobi, Kenya to talk
about their needs. Soon, they realized that the issue of sexuality was central to
their lives and that they yearned to learn more about it and discuss it with other
women. This initiative has now evolved into the establishment of collectives of
women and men who are meeting regularly to talk about sex. Two women
involved in these collectives share their experiences in this article. (author's)
Correlation of CD4 counts and CD4/CD8 ratio with HIV-infection

Author: Butt, F. M.; Vaghela, V. P., and Chindia, M. L.
Source: East Afr Med J. 2007 Aug; 84(8):383-8.
Objective:
Design: A cross-sectional study.
Subjects:
in the study.
324
Results:
73 years (mean=34.81 years). Oral manifestations encountered with highest
simplex (corner of the mouth) 0.5%, persistent oral ulceration (labial mucosa)
0.5%, Parotid enlargement 2% and Kaposis sarcoma (hard/soft palate) 2.9%.
Conclusion:
cell/mm3 and mean CD4/CD8<0.39(95%CI 0.32-0.48).
Integrating nutrition security with treatment of people living with HIV:

lessons from Kenya.
Author: Byron, E.; Gillespie, S., and Nangami, M.
Source: Food Nutr Bull. 2008 Jun; 29(2):87-97.
The increased caloric requirements of HIV-positive individuals, undesirable side
effects of treatment that may be worsened by malnutrition (but alleviated by
nutritional support), and associated declines in adherence and possible increased
drug resistance are all justifications for developing better interventions to
strengthen the nutrition security of individuals receiving antiretroviral
treatment.
Objective:
To highlight key benefits and challenges relating to interventions aimed at
strengthening the nutrition security of people living with HIV who are receiving
antiretroviral treatment.
325
Methods:
Qualitative research was undertaken on a short-term nutrition intervention
linked to the provision of free antiretroviral treatment for people living with HIV
in western Kenya in late 2005 and early 2006.
Results:
Patients enrolled in the food program while on treatment regimens self-reported
greater adherence to their medication, fewer side effects, and a greater ability to
satisfy increased appetite. Most clients self-reported weight gain, recovery of
physical strength, and the resumption of labor activities while enrolled in dual
(food supplementation and treatment) programs. Such improvements were seen
to catalyze increased support from family and community.
Conclusions:
These findings provide further empirical support to calls for a more holistic and
comprehensive response to the coexistence of AIDS epidemics with chronic
nutrition insecurity. Future work is needed to clarify ways of bridging the gap
between short-term nutritional support to individuals and longer-term
livelihood security programming for communities affected by AIDS. Such
interdisciplinary research will need to be matched by intersectoral action on the
part of the agriculture and health sectors in such environments.

Author: Calleja, J. M.; Marum, L. H.; Carcamo, C. P.; Kaetano, L.; Muttunga, J., and Way,
A.
Source: AIDS. 2005 May; 19 Suppl 2:S9-S17.
populations over 50 000.The household response rate was above 90% in all
from each survey.These population-based HIV seroprevalence surveys
326
elements to validate survey results.This review was initiated through an
international meeting on 'New strategies for HIV/AIDS Surveillance in
Resource-constrained Countries' held in Addis Ababa on 26-30 January 2004 to
share and develop recommendations to guide future surveys.
Public-private mix for control of tuberculosis and TB-HIV in Nairobi,

Kenya: outcomes, opportunities and obstacles.
Author: Chakaya, J.; Uplekar, M.; Mansoer, J.; Kutwa, A.; Karanja, G.; Ombeka, V.;
Muthama, D.; Kimuu, P.; Odhiambo, J.; Njiru, H.; Kibuga, D., and Sitienei, J.
Source: Int J Tuberc Lung Dis. 2008 Nov; 12(11):1274-1278.
Abstract: Setting:
Nairobi, the capital of Kenya.
Objective:
To promote standardised tuberculosis (TB) care by private health providers and
links with the public sector.
Design and methods:

A description of the results of interventions aimed at engaging private health
providers in TB care and control in Nairobi. Participating providers are
supported to provide TB care that conforms to national guidelines. The standard
surveillance tools are used for programme monitoring and evaluation.
Results:
By the end of 2006, 26 of 46 (57%) private hospitals and nursing homes were
engaged. TB cases reported by private providers increased from 469 in 2002 to
1740 in 2006. The treatment success rate for smear-positive pulmonary TB treated
by private providers ranged from 76% to 85% between 2002 and 2005. Of the
1740 TB patients notified by the private sector in 2006, 732 (42%) were tested for
human immunodeficiency virus (HIV), of whom 372 (51%) were positive. Of the
372 HIV-positive TB patients, 227 (61%) were provided with cotrimoxazole
preventive treatment (CPT) and 136 (37%) with antiretroviral treatment (ART).
Conclusion:
Private providers can be engaged to provide TB-HIV care conforming to national
norms. The challenges include providing diagnostics, CPT and ART and the
capacity to train and supervise these providers.
327
National scale-up of HIV testing and provision of HIV care to

tuberculosis patients in Kenya.
Author: Chakaya, J. M.; Mansoer, J. R.; Scano, F.; Wambua, N.; L'Herminez, R.; iambo, J.;
Mohamed, I.; Kangangi, J.; Ombeka, V.; Akeche, G.; Adala, S.; Gitau, S.; Maina, J.;
Kibias, S.; Langat, B.; Abdille, N.; Wako, I.; Kimuu, P., and Sitienei, J.
Source: Int J Tuberc Lung Dis. 2008 Apr; 12(4):424-9.
Abstract: Setting:
Kenya, one of the 22 tuberculosis (TB) high-burden countries, whose TB burden
is fuelled by the human immunodeficiency virus (HIV).
Objective:
To monitor and evaluate the implementation of HIV testing and provision of
HIV care to TB patients in Kenya through the establishment of a routine TB-HIV
integrated surveillance system.
Design:
A descriptive report of the status of implementation of HIV testing and provision
of HIV interventions to TB patients one year after the introduction of the revised
TB case recording and reporting system.
Results:
From July 2005 to June 2006, 88% of 112835 TB patients were reported to the
National Leprosy and TB Control Programme, 98773 (87.9%) of whom were
reported using a revised recording and reporting system that included TB-HIV
indicators. HIV testing of TB patients increased from 31.5% at the beginning of
this period to 59% at the end. Of the 46428 patients tested for HIV, 25558 (55%)
were found to be HIV-positive, 85% of whom were provided with cotrimoxazole
preventive treatment and 28% with antiretroviral treatment.
Conclusion:
A country-wide integrated TB-HIV surveillance system in TB patients can be
implemented and provides essential data to monitor and evaluate TB-HIV
related interventions.
Correlates of delayed disease progression in HIV-1-infected Kenyan

children.
Author: Chakraborty, R.; Morel, A. S.; Sutton, J. K.; Appay, V.; Ripley, R. M.; Dong, T.;
Rostron, T.; Ogola, S.; Palakudy, T.; Musoke, R.; D'Agostino, A.; Ritter, M., and
Rowland-Jones, S. L.
Source: J Immunol. 2005 Jun 15; 174(12):8191-9.
328
Abstract: Without treatment most HIV-1-infected children in Africa die before their third
birthday (>89%) and long-term nonprogressors are rare. The mechanisms
underlying nonprogression in HIV-1-infected children are not well understood.
In the present study, we examined potential correlates of delayed HIV disease
progression in 51 HIV-1-infected African children. Children were assigned to
progression subgroups based on clinical characterization. HIV-1-specific
immune responses were studied using a combination of ELISPOT assays,
tetramer staining, and FACS analysis to characterize the magnitude, specificity,
and functional phenotype of HIV-1-specific CD8(+) and CD4(+) T cells. Host
genetic factors were examined by genotyping with sequence-specific primers.
HIV-1 nef gene sequences from infecting isolates from the children were
examined for potential attenuating deletions. Thymic output was measured by T
cell rearrangement excision circle assays. HIV-1-specific CD8(+) T cell responses
were detected in all progression groups. The most striking attribute of long-term
survivor nonprogressors was the detection of HIV-1-specific CD4(+) Th
responses in this group at a magnitude substantially greater than previously
observed in adult long-term nonprogressors. Although long-term survivor
nonprogressors had a significantly higher percentage of CD45RA(+)CD4(+) T
cells, nonprogression was not associated with higher thymic output. No
protective genotypes for known coreceptor polymorphisms or large sequence
deletions in the nef gene associated with delayed disease progression were
identified. In the absence of host genotypes and attenuating mutations in HIV-1
nef, long-term surviving children generated strong CD4(+) T cell responses to
HIV-1. As HIV-1-specific helper cells support anti-HIV-1 effector responses in
active disease, their presence may be important in delaying disease progression.
Evidence for population level declines in adult HIV prevalence in

Kenya.
Author: Cheluget, B.; Baltazar, G.; Orege, P.; Ibrahim, M.; Marum, L. H., and Stover, J.
Abstract: The HIV/AIDS epidemic in Kenya has been tracked through annual sentinel
surveillance in antenatal clinics since 1990. The system started with 13 sites and
now has over 35. Behaviours have been measured through national
Demographic and Health Surveys in 1993, 1998, and 2003. The surveillance data
indicate that prevalence has declined substantially starting in 1998 in five of the
original 13 sites and starting in 2000 in another four sites. No decline is evident in
the other five original sites although the 2004 estimate is the lowest recorded.
Nationally, adult prevalence has declined from 10% in the late 1990s to under 7%
today. Surveys indicate that both age at first sex and use of condoms are rising
and that the percentage of adults with multiple partners is falling. It is clear that
HIV prevalence is now declining in Kenya in a pattern similar to that seen in
Uganda but seven or eight years later. Although the coverage of preventive
interventions has expanded rapidly since 2000 this expansion was too late to
account for the beginnings of the decline in prevalence. More work is needed to
329
understand fully the causes of this decline, but it is encouraging to see Kenya join
the small list of countries experiencing significant declines in HIV prevalence.
Optimizing paediatric HIV care in Kenya: challenges in early infant

diagnosis.
Author: Cherutich, P.; Inwani, I.; Nduati, R., and Mbori-Ngacha, D.
Source: Bull World Health Organ. 2008 Feb; 86(2):155-60.
Abstract: Problem:
In 2003, the goal of the Kenyan Ministry of Health was to avail antiretroviral
treatment (ART) to 50% of the estimated 250 000 eligible individuals by the end
of 2005. By July 2005, 45 000 adults and more than 2000 children were on
treatment. A study was conducted to determine the barriers to identification of
HIV-infected children.
Approach:
Existing government policies were reviewed and the ART register of the Kenya
National AIDS Control Programme was used to identify facilities providing
ART. This paper reports the findings around diagnosis and staging of HIV
infection in children.
Local setting:
At the time of the study, 58 health facilities were providing ART to children.
Only one institution had achieved universal HIV testing in the antenatal clinics.
Six facilities systematically followed up HIV-exposed children. HIV antibody
testing was not readily available to the children. Although four research centres
were capable of carrying out diagnostic HIV polymerase chain reaction (PCR),
the services were restricted to research purposes. Other constraints were
inadequate physical infrastructure, inadequate systems for quality control in the
laboratories and shortage of staff.
Lessons learnt:
The policy framework to support identification of HIV-infected children had
been established, albeit with narrow focus on sick children. The assessment
identified the weaknesses in the structures for systematic diagnosis of HIV
through laboratory or clinical-based algorithms. The researchers concluded that
health staff training and implementation of a systematic standard approach to
identification of HIV-infected children is urgently required.

levels.
330
Author: Chohan, B.; Lang, D.; Sagar, M.; Korber, B.; Lavreys, L.; Richardson, B., and
Overbaugh, J.
Source: J Virol. 2005 May; 79(10):6528-31.

Infant feeding in the time of HIV: rapid assessment of infant feeding

policy and programmes in four African countries scaling up prevention
of mother to child transmission programmes.
Author: Chopra, M. and Rollins, N.
Source: Arch Dis Child. 2008 Apr; 93(4):288-91.
To assess the infant feeding components of prevention of mother to child HIV
transmission (PMTCT) programmes.
Methods:
Assessments were performed across Botswana, Kenya, Malawi and Uganda. 29
districts offering PMTCT were selected by stratified random sampling with rural
and urban strata. All health facilities in the selected PMTCT district were
assessed. The facility level manager and the senior nurse in charge of maternal
care were interviewed. 334 randomly selected health workers involved in the
PMTCT programme completed self-administered questionnaires. 640 PMTCT
counselling observations were carried out and 34 focus groups were conducted
amongst men and women.
Results:
331
Most health workers (234/334, 70%) were unable to correctly estimate the
transmission risks of breastfeeding irrespective of exposure to PMTCT training.
Infant feeding options were mentioned in 307 of 640 (48%) observations of
PMTCT counselling sessions, and in only 35 (5.5%) were infant feeding issues
discussed in any depth; of these 19 (54.3%) were rated as poor. Several health
workers also reported receiving free samples of infant formula in contravention
of the International Code on Breastmilk Substitutes. National HIV managers
stated they were unsure about infant feeding policy in the context of HIV.
Finally, there was an almost universal belief that an HIV positive mother who
breastfeeds her child will always infect the child and intentional avoidance of
breastfeeding by the mother indicates that she is HIV positive.
Conclusion:
These findings underline the need to implement and support systematic infant
feeding policies and programme responses in the context of HIV programmes.
Breast milk HIV-1 suppression and decreased transmission: a

randomized trial comparing HIVNET 012 nevirapine versus short-course
zidovudine.
Author: Chung, M. H.; Kiarie, J. N.; Richardson, B. A.; Lehman, D. A.; Overbaugh, J., and
John-Stewart, G. C.
Source: AIDS. 2005 Sep 2; 19(13):1415-22.
To compare the effect of perinatal regimens of short-course nevirapine (HIVNET
012) and zidovudine [Thai-Centers for Disease Control and Prevention (CDC)
regimen] on breast milk viral shedding and perinatal transmission during the
first 6 weeks postpartum in a randomized clinical trial.
Design: Randomized clinical trial.
Methods:
Pregnant HIV-1 seropositive women in Nairobi, Kenya who planned to
breastfeed were randomized to HIVNET 012 or Thai-CDC regimens. Two to
four breast milk samples were collected each week between delivery and 6 weeks
postpartum. Breast milk HIV-1 RNA was quantified using the Gen-Probe TMA
assay. Infants were tested for HIV-1 DNA at birth and 6 weeks.
332
Results:
From March to October 2003, 76 women were enrolled and 795 breast milk
samples were collected from 60 women who were randomized and followed
after delivery. Between 3 and 21 days postpartum, nevirapine was associated
with significantly greater suppression of breast milk log10 HIV-1 RNA: days 3 to
7 (1.98 versus 2.42, P = 0.1); days 8 to 14 (1.78 versus 2.48, P = 0.005); days 15 to 21
(1.90 versus 2.97, P = 0.003). At 6 weeks, the HIV-1 perinatal transmission rate
was significantly lower among those who took nevirapine than zidovudine (6.8%
versus 30.3%, P = 0.02).
Conclusions:
Compared to a peripartum zidovudine regimen, nevirapine was significantly
more likely to decrease HIV-1 RNA in breast milk during the first week and
through the third week postpartum following single-dose administration, and
corresponded with decreased transmission risk at 6 weeks. Sustained breast milk
HIV-1 suppression may contribute to the ability of nevirapine to decrease
perinatal transmission of HIV-1.
Highly active antiretroviral therapy versus zidovudine/nevirapine effects

on early breast milk HIV type-1 Rna: a phase II randomized clinical trial.
Kinuthia, J.; Njiri, F., and John-Stewart, G. C.
Source: Antivir Ther. 2008; 13(6):799-807.
Defining the effect of antiretroviral regimens on breast milk HIV type-1 (HIV-1)
levels is useful to inform the rational design of strategies to decrease perinatal
HIV-1 transmission.
Methods:
Pregnant HIV-1 seropositive women (CD4+ T-cell count >250 and <500
cells/mm3) electing to breastfeed in Nairobi, Kenya were randomized to highly
active antiretroviral therapy (HAART; zidovudine [ZDV], lamivudine and
nevirapine [NVP]) during pregnancy and 6 months post-partum or to short-
course ZDV plus single-dose NVP (ZDV/NVP). Breast milk samples were
collected two to three times per week in the first month post-partum.
Results:
Between November 2003 and April 2006, 444 breast milk samples were collected
from 58 randomized women during the first month after delivery. Between 3 and
14 days post-partum, women in the HAART and ZDV/NVP arms had a similar
prevalence of undetectable breast milk HIV-1 RNA. From 15 to 28 days post-
partum, women in the HAART arm had significantly lower levels of breast milk
HIV-1 RNA than women randomized to ZDV/NVP (1.7 log10 copies/ml [limit
of detection] versus >2.10 log10 copies/ml, P<0.001). In contrast to breast milk
333
HIV-1 RNA, suppression of plasma HIV-1 RNA during the neonatal period was
consistently several log10 greater in the HAART arm compared with the
ZDV/NVP arm.
Conclusions:
HAART resulted in lower breast milk HIV-1 RNA than ZDV/NVP; however,
ZDV/NVP yielded comparable breast milk HIV-1 RNA levels in the first 2 weeks
post-partum. Breast milk HIV-1 RNA remained suppressed in the ZDV/NVP
arm despite increased plasma HIV-1 levels, which might reflect local drug effects
or compartmentalization.
Independent effects of nevirapine prophylaxis and HIV-1 RNA

suppression in breast milk on early perinatal HIV-1 transmission.
Njiri, F., and John-Stewart, G. C.
Source: J Acquir Immune Defic Syndr. 2007 Dec 1; 46(4):472-8.
The mechanism of action of single-dose nevirapine on reducing mother-to-child
transmission of HIV-1 may involve reduction of maternal HIV-1 or prophylaxis
of infants.
Methods:
In a study that randomized pregnant mothers to HIVNET 012 nevirapine versus
short-course antenatal zidovudine, we compared breast milk HIV-1 RNA viral
shedding and administration of single-dose nevirapine between mothers who
transmitted HIV-1 to their infants at 6 weeks postpartum and those who did not.
Results:
In multivariate analyses, maximum breast milk HIV-1 RNA levels (hazard ratio
[HR] = 2.50, 95% confidence interval [CI]: 1.25 to 4.99; P = 0.01) and nevirapine
use (HR = 0.12, 95% CI: 0.02 to 0.97; P = 0.05) were each independently associated
with perinatal transmission at 6 weeks postpartum. Mothers who transmitted
HIV-1 to their infants had significantly higher HIV-1 RNA levels in their breast
milk between the second day and sixth week postpartum. Among mothers with
maximum breast milk virus levels less than a median of 3.5 log(10) copies/mL,
the administration of nevirapine further decreased HIV-1 transmission risk from
22.2% to 0.0% (P = 0.04).
Conclusions:
Peripartum administration of single-dose nevirapine to mother and infant
decreases early perinatal HIV-1 transmission by means of breast milk HIV-1
RNA suppression and, independently, by providing the infant with exposure
prophylaxis.
334
Male circumcision is not a panacea for HIV prevention.

Source: BMJ. British Medical Journal. 2006 Aug 26; 333(7565):409.
Abstract: Male circumcision was a hot topic at the 16th international conference on AIDS,
on 13-18 August, in Toronto, accompanied by passionate debate on both sides.
Delegates heard from scientists that new HIV infections in men could be
substantially reduced and million of lives saved if male circumcision were to be
introduced. Critics argued that male circumcision will not be the quick fix for
HIV prevention unless cultural beliefs are included in the equation. The World
Health Organization and UNAIDS have so far refused to endorse male
circumcision as a prevention tool until more evidence is produced. Last year the
first clinical trial of male circumcision was halted prematurely because early
results showed that circumcision gave men a 61% protective effect against HIV
infection compared with men who weren't circumcised. All eyes are on two other
trials, one in Uganda and one in Kenya, which are expected to end in 2007.
(excerpt)
Mycoplasma genitalium infection and persistence in a cohort of female

sex workers in Nairobi, Kenya.
Author: Cohen, C. R.; Nosek, M.; Meier, A.; Astete, S. G.; Iverson-Cabral, S.; Mugo, N. R.,
and Totten, P. A.
Source: Sex Transm Dis. 2007 May; 34(5):274-9.
The objective of this study was to assess the risk factors for and persistence of
Mycoplasma genitalium (MG) in a highly exposed female population in Kenya.
Study design:
Two hundred fifty-eight sex workers in Nairobi, Kenya, 18 to 35 years of age,
were enrolled. Every 2 months, cervical samples were collected for MG,
Chlamydia trachomatis (CT), and Neisseria gonorrhoeae (GC) testing by
polymerase chain reaction.
Results:
At enrollment, 16% were infected with MG. Seventy-seven subjects acquired 107
MG infections, giving an incidence of 22.7 per 100 women-years. Incident CT
(adjusted hazard ratio [HR] = 2.4; 95% confidence interval [CI] = 1.5-4.0), GC (HR
= 2.0; 95% CI = 1.2-3.5), and HIV infection (adjusted HR = 2.2; 95% CI = 1.3-3.7)
were associated with an increased risk of MG. Seventeen percent, 9%, and 21% of
MG infections persisted 3, 5, and >or=7 months, respectively.
Conclusion:
335
The high incidence of MG, greater than that for both CT (14.0%) and GC (8%),
association with common sexually transmitted infection risk factors, and
persistence in the female genital tract supports its role as a common sexually
transmitted infection in Kenyan women.
High probability of female-to-male HIV-1 transmission for

uncircumcised men with multiple partners.
Author: Crabb, C.
Source: AIDS. 2005; 19(10):N1.
Abstract: Compared to circumcised men, uncircumcised men are more than twice as likely
to acquire HIV-1 each time they have unprotected sex with an infected woman,
according to a team of researchers in the US and Kenya. The study----the first to
measure infectivity, or the probability of HIV-1 transmission per sex act, in a
context of multiple partnerships----also found that infectivity among men,
whether circumcised or not, who have several female partners is many fold
higher than estimates based on monogamous HIV-1 discordant couples. Jared
Baeten of the University of Washington in Seattle and his colleagues calculated
infectivity from data collected during a 4-year prospective study of 745 male
employees of six trucking companies in Mombasa, Kenya. Ninety-five of the men
were uncircumcised. In quarterly check-ups at a mobile research clinic that
visited the companies on a weekly basis, each participant reported his sexual
behavior with wives, casual partners and prostitutes during the previous 3
months. (excerpt)

Author: Currie, C. S.; Floyd, K.; Williams, B. G., and Dye, C.
Source: BMC Public Health. 2005; 5:130.
and southern Africa. Several strategies have the potential to reduce the burden
of TB in high HIV prevalence settings, and cost and cost-effectiveness analyses
can help to prioritize them when budget constraints exist. However, published
cost and cost-effectiveness studies are limited.
336
Methods:
Results:
The three lowest cost and most cost-effective strategies were improving TB cure
rates, improving TB case detection rates, and improving both together. The
incremental cost of combined improvements to case detection and cure was
below USD 15 million per year (7.5% of year 2000 government health
Conclusion:
CTL epitope distribution patterns in the Gag and Nef proteins of HIV-1
from subtype A infected subjects in Kenya: use of multiple peptide sets
increases the detectable breadth of the CTL response.
Author: Currier, J. R.; Visawapoka, U.; Tovanabutra, S.; Mason, C. J.; Birx, D. L.;
McCutchan, F. E., and Cox, J. H.
Source: BMC Immunol. 2006; 7:8.
Subtype A is a major strain in the HIV-1 pandemic in eastern Europe, central
Asia and in certain regions of east Africa, notably in rural Kenya. While
considerable effort has been focused upon mapping and defining
immunodominant CTL epitopes in HIV-1 subtype B and subtype C infections,
few epitope mapping studies have focused upon subtype A.
337
Results:
We have used the IFN-gamma ELIspot assay and overlapping peptide pools to
show that the pattern of CTL recognition of the Gag and Nef proteins in subtype
A infection is similar to that seen in subtypes B and C. The p17 and p24 proteins
of Gag and the central conserved region of Nef were targeted by CTL from HIV-
1-infected Kenyans. Several epitope/HLA associations commonly seen in
subtype B and C infection were also observed in subtype A infections. Notably,
an immunodominant HLA-C restricted epitope (Gag 296-304; YL9) was
observed, with 8/9 HLA-CW0304 subjects responding to this epitope. Screening
the cohort with peptide sets representing subtypes A, C and D (the three most
prevalent HIV-1 subtypes in east Africa), revealed that peptide sets based upon
an homologous subtype (either isolate or consensus) only marginally improved
the capacity to detect CTL responses. While the different peptide sets detected a
similar number of responses (particularly in the Gag protein), each set was
capable of detecting unique responses not identified with the other peptide sets.
Conclusion:
Hence, screening with multiple peptide sets representing different sequences,
and by extension different epitope variants, can increase the detectable breadth
of the HIV-1-specific CTL response. Interpreting the true extent of cross-
reactivity may be hampered by the use of 15-mer peptides at a single
concentration and a lack of knowledge of the sequence that primed any given
CTL response. Therefore, reagent choice and knowledge of the exact sequences
that prime CTL responses will be important factors in experimentally defining
cross-reactive CTL responses and their role in HIV-1 disease pathogenesis and
validating vaccines aimed at generating broadly cross-reactive CTL responses.
National resource flows for HIV / AIDS in Kenya, Rwanda, and Zambia:
a comparative analysis.
Author: De S and Dmytraczenko, T.
Abstract: An effective fight against HIV/AIDS necessitates a comprehensive

understanding of existing financing of national HIV/AIDS services (including
public, private, and donor components). Yet many countries most affected by the
epidemic lack data, which increases the risk of inappropriate allocation of funds,
and suspension of donor funding. National Health Accounts (NHA) is a policy
tool for tracking national spending on health care. The NHA HIV/AIDS
subaccounts framework allows for more detailed examinations of spending on
HIV/AIDS, which can inform national HIV/AIDS strategic plans and then
measure progress toward planned goals. With the NHA tool rapidly becoming
institutionalized in many countries that also receive major international
HIV/AIDS grants, the subaccount framework can be used for the financial
monitoring that these grants require. This paper reports on subaccount findings
for 2002 from Kenya, Rwanda, and Zambia, all of which face generalized
HIV/AIDS epidemics. Estimates show that their resource envelopes for
HIV/AIDS were quite sizeable even prior to the surge in donor funds for
338
treatment. Expenditures for HIV/AIDS health care - in 2002, primarily treatment

of opportunistic infections and programs for prevention and public health -
represented approximately 1 percent of national gross domestic product (GDP)
levels, this in countries where overall health care resources accounted for only 4-
5 percent of the GDP. Although donor financing accounted for the largest share
of resources (usually more than half), most of these funds were targeted to
programmatic activities, leaving households to pay for at least half of all medical
care services. Indeed, people living with HIV/AIDS paid 3-6 times more out-of-
pocket for health services than did the general population. Perhaps reflective of
the direction in which the response to HIV/AIDS is managed, fund flows in
Rwanda are increasingly channeled through the nongovernmental sector. This
raises questions about government stewardship of the fight against the epidemic.
(author's)
HIV infection among couples in Burkina Faso, Cameroon, Ghana, Kenya,

and Tanzania.
Author: de Walque, D. Discordant couples.
Abstract: Most analyses of the determinants of HIV infection are performed at the
individual level. The recent Demographic and Health Surveys which include
results from HIV tests allow studying HIV infection at the level of the cohabiting
couple. This paper exploits this feature of the data for Burkina Faso, Cameroon,
Ghana, Kenya and Tanzania. The analysis yields two surprising findings about
the dynamics of the HIV/AIDS epidemic which have important implications for
policy. First, at least two-thirds of the infected couples are discordant couples, i.e.
couples where only one of the two partners is infected. This implies that there is
scope for prevention efforts among infected couples. Second, between 30 and 40
percent of the infected couples are couples where the female partner only is
infected. This is at odds with levels of self-reported marital infidelity by females
and with the common perception that unfaithful males are the main link between
high risk groups and the general population. This study investigates and
confirms the robustness of these findings. For example, even among couples
where the woman has been in only one union for ten years or more, the fraction
of couples where only the female partner is infected remains high. These results
indicate that extramarital sexual activity among cohabiting women, whatever its
causes, is a substantial source of vulnerability to HIV that should be, as much as
male infidelity, targeted by prevention efforts. Moreover, this paper uncovers
several inconsistencies between the sexual behaviors reported by male and
female partners, suggesting that, as much as possible, prevention policies should
rely on evidence including objectively measured HIV status. (author's)
339
Do unsafe tetanus toxoid injections play a significant role in the

transmission of HIV/AIDS? Evidence from seven African countries.
Source: Sex Transm Infect. 2008 Apr; 84(2):122-5.
Although sexual transmission is generally considered to be the main factor
driving the HIV/AIDS epidemic in Africa, recent studies have claimed that
iatrogenic transmission should be considered as an important source of HIV
infection. In particular, receipt of tetanus toxoid injections during pregnancy has
been reported to be associated with HIV infection in Kenya. The objective of this
paper is to assess the robustness of this association among women in nationally
representative HIV surveys in seven African countries.
Methods:
The association between prophylactic tetanus toxoid injections during pregnancy
and HIV infection was analysed, using individual-level data from women who
gave birth in the past five years. These data are from the nationally
representative Demographic and Health Surveys, which included HIV testing in
seven African countries: Burkina Faso 2003 (N = 2424), Cameroon 2004 (N =
2600), Ethiopia 2005 (N = 2886), Ghana 2003 (N = 2560), Kenya 2003 (N = 1617),
Lesotho 2004 (N = 1278) and Senegal 2005 (N = 2126).
Results:
Once the odds ratios (OR) were adjusted for five-year age groups and for ethnic,
urban and regional indicators, the association between prophylactic tetanus
toxoid injections during pregnancy and HIV infection was never statistically
significant in any of the seven countries. Only in Cameroon was there an
association between previous tetanus toxoid injection and HIV positivity but it
became weaker (OR 1.53, 95% CI 0.91 to 2.57) once urban location and ethnic
group were adjusted for.
Conclusions:
Although the risk of HIV infection through unsafe injections and healthcare
should not be ignored and should be reduced, it does not seem that there is, at
present and in the seven countries studied, strong evidence supporting the claim
that unsafe tetanus toxoid injections are a major factor driving the HIV epidemic.
Sero-discordant couples in five African countries: Implications for

prevention strategies.
Author: De Walque, D.
Source: Population and Development Review. 2007 Sep; 33(3):501-523.
340
Abstract: THE HIV/AIDS EPIDEMIC is one of the greatest challenges facing Africa.
According to UNAIDS (2006), as of December 2006, between 21.8 and 27.7
million people in sub-Saharan Africa were infected by HIV/AIDS. This
represents around 62.5 percent of the estimated worldwide total and implies that
between 5.2 and 6.7 percent of adults living in that region are HIV positive.
Between 1.8 and 2.4 million sub-Saharan Africans died from the virus in 2006
and between 2.4 and 3.2 million became newly infected. Only recently have
individual-level data, including HIV test results, become available for nationally
representative samples in Africa and other developing regions. Previously,
studies of the HIV epidemic relied either on aggregate data or on HIV status data
from nonrepresentative samples or on data from self-reported sexual behavior.
The new wave of Demographic and Health Surveys (DHS), which include HIV
status, now permits analysis of the socioeconomic determinants of HIV infection
for nationally representative samples. The present study of sero-discordant
couples uses an additional feature of the data available in the Demographic and
Health Surveys. The data make it possible to assess the HIV status of cohabiting
couples (formally married or not) and to compare sexual behavior reported by
the man and the woman. (excerpt)
Quality and quantity of antenatal HIV counselling in a PMTCT

programme in Mombasa, Kenya.
Author: Delva, W.; Mutunga, L.; Quaghebeur, A., and Temmerman, M. 2006 Apr;
18(3):189-93.
Abstract: A recent report from a PMTCT implementation study in Mombasa, Kenya,

points at an important gap between the efficacy in clinical trial circumstances
and the effectiveness of PMTCT programmes when implemented in real life.
Hence, the quality and quantity of antenatal HIV counselling in a routine setting
were appraised. The counsellors' social and communicative skills, duration and
topics covered during pre- and post-test counselling sessions were assessed by
means of the VCT assessment tools published by UNAIDS. A total of 14 group
educational sessions, 66 pre-test counselling sessions and 50 post-test counselling
sessions were observed and assessed. In general, the frequency and duration of
the counselling was low. Crucial topics such as window period and partner
involvement and follow-up support were covered haphazardly. The counsellor's
social and communicative skills were given high marks, yet information was
rarely repeated or summarized. The limited time dedicated to women receiving
antenatal VCT contrasts with the heavy and comprehensive load of health
information and advice they are supposed to receive. Ample pre- and post-test
counselling including follow-up should be pursued for optimal effectiveness of
PMTCT. We propose a number of health system interventions preceded and
guided by ongoing audit.
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The role of sexually transmitted infections in male circumcision

effectiveness against HIV--insights from clinical trial simulation.
Author: Desai, K.; Boily, M. C.; Garnett, G. P.; Masse, B. R.; Moses, S., and Bailey, R. C.
Source: Emerg Themes Epidemiol. 2006; 3:19.
A landmark randomised trial of male circumcision (MC) in Orange Farm, South
Africa recently showed a large and significant reduction in risk of HIV infection,
reporting MC effectiveness of 61% (95% CI: 34%-77%). Additionally, two further
randomised trials of MC in Kisumu, Kenya and Rakai, Uganda were recently
stopped early to report 53% and 48% effectiveness, respectively. Since MC may
protect against both HIV and certain sexually transmitted infections (STI), which
are themselves cofactors of HIV infection, an important question is the extent to
which this estimated effectiveness against HIV is mediated by the protective
effect of circumcision against STI. The answer lies in the trial data if the
appropriate statistical analyses can be identified to estimate the separate
efficacies against HIV and STI, which combine to determine overall effectiveness.
Objectives and methods:

Focusing on the MC trial in Kisumu, we used a stochastic prevention trial
simulator (1) to determine whether statistical analyses can validly estimate
efficacy, (2) to determine whether MC efficacy against STI alone can produce
large effectiveness against HIV and (3) to estimate the fraction of all HIV
infections prevented that are attributable to efficacy against STI when both
efficacies combine.
Results:
Valid estimation of separate efficacies against HIV and STI as well as MC
effectiveness is feasible with available STI and HIV trial data, under Kisumu trial
conditions. Under our parameter assumptions, high overall effectiveness of MC
against HIV was observed only with a high MC efficacy against HIV and was not
possible on the basis of MC efficacy against STI alone. The fraction of all HIV
infections prevented which were attributable to MC efficacy against STI was
small, except when efficacy of MC specifically against HIV was very low. In the
three MC trials which reported between 48% and 61% effectiveness (combining
STI and HIV efficacies), the fraction of HIV infections prevented in circumcised
males which were attributable to STI was unlikely to be more than 10% to 20%.
Conclusion:
Estimation of efficacy, attributable fraction and effectiveness leads to improved
understanding of trial results, gives trial results greater external validity and is
essential to determine the broader public health impact of circumcision to men
and women.
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The evidence for health-care transmission of HIV in Africa should

determine prevention priorities [letter].
Author: Deuchert E and Brody, S.
Source: International Journal of STD and AIDS. 2007 Apr; 18(4):290-291.
Abstract: Our results are consistent with many other sources of evidence, including the
recent report by St. Lawrence et al. of HIV risks in Zambian women: 'Medically
administered intramuscular(IM) or intravenous injections in the past five years
(but not blood transfusions) were overwhelmingly correlated with HIV
prevalence' (p 607) (OR for IM/ intravenous injections in the past five years =
2.59 [95% CI = 2.15-3.11]). In the multivariate model incorporating injection
exposures, they also found that more frequent sexual intercourse was 'protective'
against HIV, which is inconsistent with penile-vaginal intercourse being a risk
per se. Further support was provided by the finding that condom use with non-
primary partners was not protective against HIV (their finding that 'occasional',
but not frequent or always use with the primary partner was protective argues
against a direct effect and in favour of being a marker for other, perhaps non-
sexual factors). Other recent research has also shown a significant HIV risk
associated with medical injections but not number of sexual partners in India.
Thus, our recommendation to reallocate resources to address health-care
transmission of HIV/AIDS in sub-Saharan Africa is not only supported by our
data but also by that of other well-conducted studies. This evidence should
determine prevention priorities. (excerpt).
The protective effect of male circumcision on HIV infection in a sample

of Kenyan men.
Author: Djamba, Y. K. and . = Davis LS.
Source: African Journal of AIDS Research. 2007; 6(3):199-204.
Abstract: This article examines the association between male circumcision and HIV
infection in a national sample. The analysis is based on the 2003 Kenya
Demographic and Health Survey (KDHS), a nationally representative household-
based population survey of adults, in which male respondents self-reported their
circumcision status. In addition, in some households eligible for individual
interview, blood samples were subsequently anonymously obtained for HIV
testing, making this the first study linking socio-demographic information to
HIV status at the national level. The study sample is limited to 3 413 men aged
15-54 years who gave valid information on their circumcision and HIV statuses.
Nearly 5% of the men were HIV-positive, and 86% had been circumcised. HIV
prevalence was significantly higher among the uncircumcised men (12%) than
among the circumcised men (3%). This indication of the protective effect of male
circumcision on HIV infection remained statistically significant (OR 0.15; 95%CI:
343
0.09-0.23) even after controlling for the effects of socio-demographic variables,

age at first sexual intercourse, and use of paid sex. Based on these results, we
recommend that HIV-prevention advocates and activists, scholars, bio-medical
communities and political leaders find ways to include this oldest surgical
procedure in their HIV/AIDS discourses and programmes in sub-Saharan
Africa. (author's)
The protective effect of male circumcision on HIV infection in Kenya.

Author: Djamba, Y. K. and . = Davis TS.
Abstract: This paper uses data from the 2003 Kenya Demographic and Health Survey, a
nationally representative sample, to examine the association between male
circumcision and HIV infection. The results show that 4.6 percent of men were
HIV positive; 86 percent of all men in the sample were circumcised. The
prevalence of HIV was significantly higher among uncircumcised men (12%), as
compared to the circumcised ones (3%). We also found significantly higher
prevalence of HIV among richer men. The logistic regression results show that
male circumcision is the most important and significant predictor of HIV in
Kenya. Net of the effects of socio-demographic variables, age at first sexual
intercourse and use of paid sex, uncircumcised men were 86 percent more likely
to be HIV positive than circumcised men. Given this strong protective effect of
male circumcision, we recommend that HIV advocates and activists, scholars,
bio-medical communities, and political leaders find ways to include this oldest
surgical procedure in their HIV/AIDS discourses and programs in sub-Saharan
Africa. (author's)
Herpes simplex virus type 2 and risk of intrapartum human

immunodeficiency virus transmission.
Author: Drake, A. L.; John-Stewart, G. C.; Wald, A.; Mbori-Ngacha, D. A.; Bosire, R.;
Wamalwa, D. C.; Lohman-Payne, B. L.; Ashley-Morrow, R.; Corey, L., and
Farquhar, C.
Source: Obstet Gynecol. 2007 Feb; 109(2 Pt 1):403-9.
To determine whether herpes simplex virus type 2 (HSV-2) infection was
associated with risk of intrapartum human immunodeficiency virus type 1 (HIV-
1) transmission and to define correlates of HSV-2 infection among HIV-1-
seropositive pregnant women.
344
Methods:
We performed a nested case control study within a perinatal cohort in Nairobi,
Kenya. Herpes simplex virus type 2 serostatus and the presence of genital ulcers
were ascertained at 32 weeks of gestation. Maternal cervical and plasma HIV-1
RNA and cervical HSV DNA were measured at delivery.
Results:
One hundred fifty-two (87%) of 175 HIV-1-infected mothers were HSV-2-
seropositive. Among the 152 HSV-2-seropositive women, nine (6%) had genital
ulcers at 32 weeks of gestation, and 13 (9%) were shedding HSV in cervical
secretions. Genital ulcers were associated with increased plasma HIV-1 RNA
levels (P=.02) and an increased risk of intrapartum HIV-1 transmission (16% of
transmitters versus 3% of nontransmitters had ulcers; P = .003), an association
which was maintained in multivariable analysis adjusting for plasma HIV-1
RNA levels (P=.04). We found a borderline association for higher plasma HIV-1
RNA among women shedding HSV (P=.07) and no association between cervical
HSV shedding and either cervical HIV-1 RNA levels or intrapartum HIV-1
transmission (P=.4 and P=.5, [corrected] respectively).
Conclusion:
Herpes simplex virus type 2 is the leading cause of genital ulcers among women
in sub-Saharan Africa and was highly prevalent in this cohort of pregnant
women receiving prophylactic zidovudine. After adjusting for plasma HIV-1
RNA levels, genital ulcers were associated with increased risk of intrapartum
HIV-1 transmission. These data suggest that management of HSV-2 during
pregnancy may enhance mother-to-child HIV-1 prevention efforts. LEVEL OF
EVIDENCE: II.
Seizing the big missed opportunity: linking HIV and maternity care
services in sub-Saharan Africa.
Author: Druce, N. and Nolan, A.
Abstract: This paper draws on two reviews commissioned by the UK Department for
International Development in 2006-2007 that explore progress in linking HIV
prevention and maternity services in sub-Saharan Africa. Although pilot and
demonstration projects have been successful, progress in scaling up PMTCT has
been slow, reaching just 11% of pregnant HIV positive women in much of Africa,
less than half the percentage of coverage achieved by antiretroviral treatment
programmes for adults in need. Despite ongoing efforts to promote
comprehensive approaches, significant policy, financing and institutional
barriers, and weak co-ordination and leadership, continue to hamper progress.
Maternal health services face human and financial resource shortages which
affect their capacity to integrate HIV prevention. Both HIV and maternal health
programmes often receive targeted financial and technical assistance that does
345
not take the other into account. However, proposals in 2007 from a number of
countries to the Global Fund to Fight AIDS, TB and Malaria incorporate sexual
and reproductive health programming that will have an impact on HIV,
including certain maternity services. Moreover, Botswana, Kenya and Rwanda
have shown that progress can be made where national commitment and
increased resources are enabling maternal and newborn care to address HIV.
Education and HIV / AIDS prevention: evidence from a randomized

evaluation in western Kenya.
Author: Duflo E; Dupas P; Kremer M, and Sinei, S.
Abstract: We report results from a randomized evaluation comparing three school-based

HIV/AIDS interventions in Kenya: 1) training teachers in the Kenyan
Government's HIV/AIDS-education curriculum; 2) encouraging students to
debate the role of condoms and to write essays on how to protect themselves
against HIV/AIDS; and 3) reducing the cost of education. Our primary measure
of the effectiveness of these interventions is teenage childbearing, which is
associated with unprotected sex. We also collected measures of knowledge,
attitudes, and behavior regarding HIV/AIDS. After two years, girls in schools
where teachers had been trained were more likely to be married in the event of a
pregnancy. The program had little other impact on students' knowledge,
attitudes, and behavior, or on the incidence of teen childbearing. The condom
debates and essays increased practical knowledge and self-reported use of
condoms without increasing self-reported sexual activity. Reducing the cost of
education by paying for school uniforms reduced dropout rates, teen marriage,
and childbearing. (author's)
Severe gynecomastia in an African boy with perinatally acquired human

immunodeficiency virus infection receiving highly active antiretroviral
therapy.
Author: Dzwonek, A.; Clapson, M.; Withey, S.; Bates, A., and Novelli, V.
Source: Pediatr Infect Dis J. 2006 Feb; 25(2):183-4.
Abstract: Highly active antiretroviral therapy (HAART) slows the progression of human
immunodeficiency virus (HIV) disease and lowers mortality and morbidity in
children. Coincident with these advances, an increasing number of side effects
are being reported. We describe an adolescent boy with perinatally acquired HIV
infection who developed significant bilateral breast enlargement as a result of
HAART. He required bilateral mastectomies. Pediatricians need to be aware of
less common side effects of HAART.
Orphans and schooling in Africa: a longitudinal analysis.
346
Author: Evans, D. K. and Miguel, E.
academic performance.
Pediatric HIV type 1 vaccine trial acceptability among mothers in Kenya.

Author: Farquhar, C.; John-Stewart, G. C.; John, F. N.; Kabura, M. N., and Kiarie, J. N.
Abstract: Vaccination of infants against human immunodeficiency virus type 1 (HIV-1)

may prevent mother-to-child HIV-1 transmission. Successful trials and
immunization efforts will depend on the willingness of individuals to participate
in pediatric vaccine research and acceptance of infant HIV-1 vaccines. In a cross-
sectional study, pregnant women presenting to a Nairobi antenatal clinic for
routine care were interviewed regarding their attitudes toward participation in
research studies and HIV-1 vaccine acceptability for their infants. Among 805
women, 782 (97%) reported they would vaccinate their infant against HIV-1 and
729 (91%) reported willingness to enroll their infant in a research study.
However, only 644 (80%) would enroll their infants if HIV- 1 testing was
required every 3 months and 513 (64%) would agree to HIV-1 vaccine trial
participation. Reasons for not wanting to enroll in a pediatric HIV-1 vaccine trial
included concerns about side effects (75%), partner objection (34%), and fear of
discrimination (10%), HIV-1 acquisition (8%), or false-positive HIV-1 results
(5%). The strongest correlate of pediatric vaccine trial participation was maternal
willingness to be a vaccine trial participant herself; in univariate and multivariate
models this was associated with a 17-fold increased likelihood of participation
(HR 17.1; 95% CI 11.7-25; p < 0.001). We conclude from these results that
immunizing infants against HIV-1 and participation in pediatric vaccine trials
are generally acceptable to women at high risk for HIV-1 infection. It will be
important to address barriers identified in this study and to include male
partners when mobilizing communities for pediatric HIV-1 vaccine trials and
immunization programs.
Mapping transactional sex on the Northern Corridor highway in Kenya.
347
Author: Ferguson, A. G. and Morris, C. N.
Source: Health Place. 2007 Jun; 13(2):504-19.
Abstract: Even in generalized HIV/AIDS epidemics, vulnerable populations such as sex

workers and truckers require special attention in programming. Combining a
number of elicitation methods, centred on Geographical Information Systems
(GIS) mapping, the Kenyan section of the Northern Corridor highway was
studied to characterize the 'hot spots' where transactional sex is concentrated and
to provide estimates of numbers of truckers and sex workers and the volumes of
transactional sex taking place on the highway. An average of 2400 trucks park
overnight at the 39 hot spots identified. These spots have an estimated sex
worker population of 5600 women. Analysis of 403 sex worker diaries shows an
average of 13.6 different clients and 54.2 sex acts in a month. Condom use is 69%
in liaisons with regular clients and 90% with casual clients. The use of GIS is
demonstrated at regional and local scales. The 'bridge population' of clients of
sex workers, containing a wide rage of occupations, supports the concept of
programming for 'vulnerable places' as well as vulnerable groups.
The gradient in sub-Saharan Africa: socioeconomic status and

HIV/AIDS.
Author: Fortson, J. G.
Source: Demography. 2008 May; 45(2):303-22.
Abstract: Using data from the Demographic and Health Surveys (DHS) for Burkina Faso
(2003), Cameroon (2004), Ghana (2003), Kenya (2003), and Tanzania (2003), I
investigate the cross-sectional relationship between HIV status and
socioeconomic status. I find evidence of a robust positive education gradient in
HIV infection, showing that, up to very high levels of education, better-educated
respondents are more likely to be HIV-positive. Adults with six years of
schooling are as much as three percentage points more likely to be infected with
HIV than adults with no schooling. This gradient is not an artifact of age, sector
of residence, or region of residence. With controls for sex, age, sector of
residence, and region of residence, adults with six years of schooling are as
much as 50% more likely to be infected with HIV than those with no schooling.
Education is positively related to certain risk factors for HIV including the
likelihood of having premarital sex. Estimates of the wealth gradient in HIV, by
contrast, vary substantially across countries and are sensitive to the choice of
measure of wealth.
348
Proportion of new HIV infections attributable to herpes simplex 2

increases over time: simulations of the changing role of sexually
transmitted infections in sub-Saharan African HIV epidemics.
Author: Freeman, E. E.; Orroth, K. K.; White, R. G.; Glynn, J. R.; Bakker, R.; Boily, M. C.;
Habbema, D.; Buve, A., and Hayes, R.
To understand the changing impact of herpes simplex 2 (HSV-2) and other
sexually transmitted infections (STIs) on HIV incidence over time in four sub-
Saharan African cities, using simulation models.
Methods:
An individual-based stochastic model was fitted to demographic, behavioural
and epidemiological data from cross-sectional population-based surveys in four
African cities (Kisumu, Kenya; Ndola, Zambia; Yaounde, Cameroon; and
Cotonou, Benin) in 1997. To estimate the proportion of new HIV infections
attributable to HSV-2 and other STIs over time, HIV incidence in the fitted model
was compared with that in model scenarios in which the cofactor effect of the
STIs on HIV susceptibility and infectivity were removed 5, 10, 15, 20 and 25 years
into the simulated HIV epidemics.
Results:
The proportion of incident HIV attributable to HSV-2 infection (the model
estimated population attributable fraction (PAF(M))) increased with maturity of
the HIV epidemic. In the different cities, the PAF(M) was 8-31% 5 years into the
epidemic, but rose to 35-48% 15 years after the introduction of HIV. In contrast,
the proportion of incident HIV attributable to chancroid decreased over time
with strongest effects five years after HIV introduction, falling to no effect 15
years after. Sensitivity analyses showed that, in the model, recurrent HSV-2
ulcers had more of an impact on HIV incidence than did primary HSV-2 ulcers,
and that the effect of HSV-2 on HIV infectivity may be more important for HIV
spread than the effect on HIV susceptibility, assuming that HSV-2 has similar
cofactor effects on HIV susceptibility and infectivity. The overall impact of other
curable STIs on HIV spread (syphilis, gonorrhoea and chlamydia) remained
relatively constant over time.
Conclusions:
Although HSV-2 appears to have a limited impact on HIV incidence in the early
stages of sub-Saharan African HIV epidemics when the epidemic is concentrated
in core groups, it has an increasingly large impact as the epidemic progresses. In
generalised HIV epidemics where control programmes for curable STIs are
already in place, interventions against HSV-2 may have a key role in HIV
prevention.
349
Validity of self-reported "safe sex" among female sex workers in

Mombasa, Kenya -- PSA analysis.
Author: Gall, M. F.; . = Behets FM; Steiner MJ; Thomsen SC, and Ombidi W.
Source: International Journal of STD and AIDS. 2007 Jan; 18(1):33-38.
Abstract: We assessed the validity of self-reported sex and condom use by comparing self-
reports with prostate-specific antigen (PSA) detection in a prospective study of
210 female sex workers in Mombasa, Kenya. Participants were interviewed on
recent sexual behaviours at baseline and 12-month follow-up visits. At both
visits, a trained nurse instructed participants to self-swab to collect vaginal fluid
specimens, which were tested for PSA using enzyme-linked immunosorbent
assay (ELISA). Eleven percent of samples (n¼329) from women reporting no
unprotected sex for the prior 48 hours tested positive for PSA. The proportions of
women with this type of discordant self-reported and biological data did not
differ between the enrolment and 12-month visit (odds ratio [OR] 1.1; 95%
confidence interval [CI] 0.99, 1.2). The study found evidence that participants
failed to report recent unprotected sex. Furthermore, because PSA begins to clear
immediately after exposure, our measures of misreported semen exposure likely
are underestimations. (author's)
Factors associated with self-reported unprotected anal sex among male

sex workers in Mombasa, Kenya.
Author: Geibel, S.; Luchters, S.; King'Ola, N.; Esu-Williams, E.; Rinyiru, A., and Tun, W.
Source: Sex Transm Dis. 2008 Aug; 35(8):746-52.
To identify social and behavioral characteristics associated with sexual risk
behaviors among male sex workers who sell sex to men in Mombasa, Kenya.
Methods:
Using time-location sampling, 425 men who had recently sold, and were
currently willing to sell sex to men were invited to participate in a cross-sectional
survey. A structured questionnaire was administered using handheld computers.
Factors associated with self-reported unprotected anal sex with male clients in
the past 30 days were identified and subjected to multivariate analysis.
Results:
Thirty-five percent of respondents did not know HIV can be transmitted via anal
sex, which was a significant predictor of unprotected anal sex [adjusted odds
ratio (AOR) 1.92; 95% confidence interval (95% CI), 1.16-3.16]. Other associated
factors included drinking alcohol 3 or more days per week (AOR, 1.63; 95% CI,
1.05-2.54), self-report of burning urination within the past 12 months (AOR, 2.07;
350
95% CI, 1.14-3.76), and having never been counseled or tested for HIV (AOR,
1.66; 95% CI, 1.07-2.57). Only 21.2% of respondents correctly knew that a water-
based lubricant should be used with latex condoms.
Conclusions:
Male sex workers who sell sex to men in Mombasa are in acute need of targeted
prevention information on anal HIV and STI transmission, consistent condom
use, and correct lubrication use with latex condoms. HIV programs in Africa
need to consider and develop specific prevention strategies to reach this
vulnerable population.
Total lymphocyte count as a surrogate marker for CD4+ t cell count in

Author: Gitura, B.; Joshi, M. D.; Lule, G. N., and Anzala, O.
Source: East Afr Med J. 2007 Oct; 84(10):466-72.
Design: Cross-sectional descriptive study.
Setting:
Kenyatta National Hospital, HIV treatment and follow-up outpatient facility;
Comprehensive Care Centre, Nairobi, Kenya.
Subjects:
Two hundred and twenty five HIV Elisa positive, ARV naive patients visiting the
Comprehensive Care Centre between January 2006 to March 2006.
Results:
minority of patients who despite a TLC > or = 1900 cells/mm3 are, on basis of
351
settings.
Conclusion:
however the WHO recommended TLC cuto-ff of 1200/mm3 was found to be of
to start antiretroviral therapy.
Short term estimates of adult HIV incidence by mode of transmission:

Kenya and Thailand as examples.
Author: Gouws, E.; White, P. J.; Stover, J., and Brown, T.
Source: Sex Transm Infect. 2006 Jun; 82 Suppl 3:iii51-55.
Patterns of transmission of HIV are different among different regions of the
world and change over time within regions. In order to adapt prevention
strategies to changing patterns of risk, we need to understand the behaviours
that put people at risk of infection and how new infections are distributed among
risk groups.
Methods:
A model is described to calculate the expected incidence of HIV infections in the
adult population by mode of exposure using the current distribution of prevalent
infections and the patterns of risk within different populations. For illustration
the model is applied to Thailand and Kenya.
Results:
New infections in Kenya were mainly transmitted through heterosexual contact
(90%), while a small but significant number were related to injecting drug use
(4.8%) and men who have sex with men (4.5%). In Thailand, the epidemic has
spread over time to the sexual partners of vulnerable groups and in 2005 the
majority of new infections occurred among the low risk heterosexual population
(43%). Men having sex with men accounted for 21% and sex work (including sex
workers, clients, and partners of clients) for 18% of new infections. Medical
interventions did not contribute significantly to new infections in either Kenya
or Thailand.
Conclusions:
The model provides a simple tool to inform the planning of effective,
appropriately targeted, country specific intervention programmes. However,
352
better surveillance systems are needed in countries to obtain more reliable

biological and behavioural data in order to improve the estimates of incidence by
risk group.
Higher pre-infection vitamin E levels are associated with higher

mortality in HIV-1-infected Kenyan women: a prospective study.
Author: Graham, S. M.; Baeten, J. M.; Richardson, B. A.; Bankson, D. D.; Lavreys, L.;
Ndinya-Achola, J. O.; Mandaliya, K.; Overbaugh, J., and McClelland, R. S.
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 <200 cells/muL, and
mortality.
Results:
After controlling for potential confounding factors, each 1 mg/L increase in pre-
infection vitamin E was associated with 0.08 log10 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 pre-infection 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.
A decrease in albumin in early HIV type 1 infection predicts subsequent
disease progression.
Author: Graham, S. M.; Baeten, J. M.; Richardson, B. A.; Wener, M. H.; Lavreys, L.;
Mandaliya, K.; Ndinya-Achola, J. O.; Overbaugh, J., and McClelland, R. S.
353
Abstract: We investigated the association between albumin levels and HIV-1 disease
progression among 78 Kenyan women followed from before infection through a
median of 70 months. With HIV-1 acquisition, median albumin decreased from
38.5 g/liter to 36.8 g/liter (p = 0.07) and the prevalence of hypoalbuminemia
increased from 16% to 32% (p = 0.02). Each 1 g/liter decrease in albumin with
HIV-1 acquisition was associated with a 13% increase (p = 0.01) in the risk of
progressing to a CD4 count <200 cells/mul, after adjustment for set point plasma
viral load. A decrease in albumin of over 10% was associated with a 3.5-fold
increase in the risk of progressing to a CD4 count <200 cells/mul (95% CI 1.4-9.0,
p = 0.008). Trends for an increased risk of mortality were also seen. A greater
decrease in albumin levels accompanying HIV-1 acquisition may be a marker for
changes in early infection associated with more rapid disease progression.
Screening for genital and anorectal sexually transmitted infections in

HIV prevention trials in Africa.
Author: Grijsen, M. L.; Graham, S. M.; Mwangome, M.; Githua, P.; Mutimba, S.;
Wamuyu, L.; Okuku, H.; Price, M. A.; McClelland, R. S.; Smith, A. D., and
Sanders, E. J.
To demonstrate the value of routine, basic sexually transmitted infection (STI)
screening at enrolment into an HIV-1 vaccine feasibility cohort study and to
highlight the importance of soliciting a history of receptive anal intercourse
(RAI) in adults identified as "high risk".
Methods:
Routine STI screening was offered to adults at high risk of HIV-1 upon
enrolment into a cohort study in preparation for HIV-1 vaccine trials. Risk
behaviours and STI prevalence were summarised and the value of microscopy
assessed. Associations between prevalent HIV-1 infection and RAI or prevalent
STI were evaluated with multiple logistic regression.
354
Results:
Participants had a high burden of untreated STI. Symptom-directed management
would have missed 67% of urethritis cases in men and 59% of cervicitis cases in
women. RAI was reported by 36% of male and 18% of female participants. RAI
was strongly associated with HIV-1 in men (adjusted odds ratio (aOR) 3.8; 95%
CI 2.0 to 6.9) and independently associated with syphilis in women (aOR 12.9;
95% CI 3.4 to 48.7).
Conclusions:
High-risk adults recruited for HIV-1 prevention trials carry a high STI burden.
Symptom-directed treatment may miss many cases and simple laboratory-based
screening can be done with little cost. Risk assessment should include questions
about anal intercourse and whether condoms were used. STI screening,
including specific assessment for anorectal disease, should be offered in African
research settings recruiting participants at high risk of HIV-1 acquisition.

Author: Hallett, T. B.; Aberle-Grasse, J.; Bello, G.; Boulos, L. M.; Cayemittes, M. P.;
Cheluget, B.; Chipeta, J.; Dorrington, R.; Dube, S.; Ekra, A. K.; Garcia-Calleja, J.
M.; Garnett, G. P.; Greby, S.; Gregson, S.; Grove, J. T.; Hader, S.; Hanson, J.;
Hladik, W.; Ismail, S.; Kassim, S.; Kirungi, W.; Kouassi, L.; Mahomva, A.;
Marum, L.; Maurice, C.; Nolan, M.; Rehle, T.; Stover, J., and Walker, N.
generalised HIV epidemics are associated with changes in sexual risk behaviour.
Methods:
A mathematical model was developed to explore the relation between
prevalence recorded at antenatal clinics (ANCs) and the pattern of incidence of
infection throughout the population. To create a null model a range of
assumptions about sexual behaviour, natural history of infection, and sampling
biases in ANC populations were explored to determine which factors maximised
declines in prevalence in the absence of behaviour change. Modelled prevalence,
where possible based on locally collected behavioural data, was compared with
the observed prevalence data in urban Haiti, urban Kenya, urban Cote d'Ivoire,
Malawi, Zimbabwe, Rwanda, Uganda, and urban Ethiopia.
Results:
355
show no signs of changed sexual behaviour.
Conclusions:
Changes in patterns of HIV prevalence in urban Kenya, Zimbabwe, and urban
Haiti are quite recent and caution is required because of doubts over the
accuracy and representativeness of these estimates. Nonetheless, the observed
changes are consistent with behaviour change and not the natural course of the
HIV epidemic.
Does cotrimoxazole prophylaxis for the prevention of HIV-associated

Author: Hamel, M. J.; Greene, C.; Chiller, T.; Ouma, P.; Polyak, C.; Otieno, K.;
Williamson, J.; Shi, Y. P.; Feikin, D. R.; Marston, B.; Brooks, J. T.; Poe, A.; Zhou,
Z.; Ochieng, B.; Mintz, E., and Slutsker, L.
Source: Am J Trop Med Hyg. 2008 Sep; 79(3):320-30.
multivitamins. Specimens were collected at baseline, 2 weeks, monthly, and at
sick visits during 6 months of follow-up to compare changes in resistance, with
higher-CD4 as referent. P. falciparum parasitemia incidence density was 16 and
156/100 person-years in lower-CD4 and higher-CD4, respectively (adjusted rate
ratio [ARR] = 0.11; 95% confidence interval [CI] = 0.06-0.15; P < 0.001) and 97/100
Incidence density of triple and quintuple dihydrofolate-
reductase/dihydropteroate-synthetase mutations was 90% reduced in lower-
CD4 compared with referent. Overall, cotrimoxazole non-susceptibility was high
among isolated pneumococcus (92%) and E. coli (76%) and increased
significantly in lower-CD4 subjects by Week 2 (P < 0.005). Daily cotrimoxazole
prevented malaria and reduced incidence of antifolate-resistant P. falciparum but
resistance.
356
Human leukocyte antigen-DQ alleles and haplotypes and their

associations with resistance and susceptibility to HIV-1 infection.
Author: Hardie, R. A.; Luo, M.; Bruneau, B.; Knight, E.; Nagelkerke, N. J.; Kimani, J.;
Wachihi, C.; Ngugi, E. N., and Plummer, F. A.
Source: AIDS. 2008 Apr 23; 22(7):807-16.
To determine the association of DQ antigens with resistance and susceptibility to
HIV-1.
Design:
Despite repeated exposure to HIV-1, a subset of women in the Pumwani Sex
Worker cohort established in Nairobi, Kenya in 1985 have remained HIV-1
negative for at least 3 years and are classified as resistant. Differential
susceptibility to HIV-1 infection is associated with HIV-1 specific CD4 and CD8
T cell responses. As human leukocyte antigen-DQ antigens present viral peptides
to CD4 cells, we genotyped human leukocyte antigen -DQ alleles for 978 women
enrolled in the cohort and performed cross-sectional and longitudinal analyses to
identify associations of human leukocyte antigen -DQ with
resistance/susceptibility to HIV-1.
Methods:
DQA1 and DQB1 were genotyped using taxonomy-based sequence analysis.
SPSS 13.0 was used to determine associations of DQ alleles/haplotypes with
HIV-1 resistance, susceptibility, and seroconversion rates.
Results:
Several DQB1 alleles and DQ haplotypes were associated with resistance to HIV-
1 infection. These included DQB1*050301 (P = 0.055, Odds Ratio = 12.77, 95%
Confidence Interval = 1.44-112), DQB1*0603 and DQB1*0609 (P = 0.037, Odds
Ratio = 3.25, 95% Confidence Interval = 1.12-9.47), and DQA1*010201-DQB1*0603
(P = 0.044, Odds Ratio = 17.33, 95% Confidence Interval = 1.79-168). Conversely,
DQB1*0602 (P = 0.048, Odds Ratio = 0.68, 95% Confidence Interval = 0.44-1.05)
and DQA1*010201-DQB1*0602 (P = 0.039, Odds Ratio = 0.64, 95% Confidence
Interval = 0.41-1.03) were overrepresented in the HIV-1 infected population.
DQA1*0504-DQB1*0201, DQA1*010201-DQB1*0201, DQA1*0402-DQB1*0402 and
DQA1*0402-DQB1*030101 genotypes were only found in HIV-1 positive subjects
(Odds Ratio = 0.30-0.31, 95% Confidence Interval = 0.03-3.70), and these women
seroconverted rapidly. The associations of these DQ alleles and haplotypes with
resistance and susceptibility to HIV-1 were independent of the previously
reported human leukocyte antigen-DRB*01, human leukocyte antigen A2/6802,
and human leukocyte antigen-A*2301.
357
Conclusion:
The associations of DQ alleles and haplotypes with resistance and susceptibility
to HIV-1 emphasize the importance of human leukocyte antigen-DQ and CD4 in
anti-HIV-1 immunity.

workers.
Author: Hirbod, T.; Kaul, R.; Reichard, C.; Kimani, J.; Ngugi, E.; Bwayo, J. J.; Nagelkerke,
N.; Hasselrot, K.; Li, B.; Moses, S.; MacDonald, K. S., and Broliden, K.
Source: AIDS. 2008 Mar 30; 22(6):727-35.
HIV-neutralizing immunoglobulin A (IgA) and HIV-specific cellular immunity
a prospective, nested case-control study to examine the association of genital
IgA and systemic cellular immune responses with subsequent HIV acquisition in
high-risk Kenyan female sex workers (FSWs).
Design and methods:

A randomized trial of monthly antibiotic prophylaxis to prevent sexually
transmitted disease/HIV infection was performed from 1998 to 2002 in HIV-
uninfected Kenyan FSWs. After the completion of trial, FSWs who had acquired
HIV (cases) were matched 1: 4 with persistently uninfected controls based on
study arm, duration of HIV-seronegative follow-up, and time of cohort
enrolment. Blinded investigators assayed the ability at enrolment of genital IgA
to neutralize primary HIV isolates as well as systemic HIV-specific cellular
IFNgamma-modified enzyme-linked immunospot and proliferative responses.
Results:
The study cohort comprised 113 FSWs: 24 cases who acquired HIV and 89
matched controls. Genital HIV-neutralizing IgA was associated with reduced
HIV acquisition (P = 0.003), as was HIV-specific proliferation (P = 0.002), and
these associations were additive. HIV-specific IFNgamma production did not
differ between case and control groups. In multivariable analysis, HIV-
neutralizing IgA and HIV-specific proliferation each remained independently
associated with lack of HIV acquisition. Genital herpes (HSV2) was associated
with increased HIV risk and with reduced detection of HIV-neutralizing IgA.
Conclusion:
Genital HIV-neutralizing IgA and systemic HIV-specific proliferative responses,
assayed by blinded investigators, were prospectively associated with HIV
nonacquisition. The induction of these immune responses may be an important
goal for HIV vaccines.
358
Safety and immunogenicity of recombinant low-dosage HIV-1 A vaccine

candidates vectored by plasmid pTHr DNA or modified vaccinia virus
Ankara (MVA) in humans in East Africa.
Author: Jaoko, W.; Nakwagala, F. N.; Anzala, O.; Manyonyi, G. O.; Birungi, J.; Nanvubya,
A.; Bashir, F.; Bhatt, K.; Ogutu, H.; Wakasiaka, S.; Matu, L.; Waruingi, W.; Odada,
J.; Oyaro, M.; Indangasi, J.; Ndinya-Achola, J.; Konde, C.; Mugisha, E.; Fast, P.;
Schmidt, C.; Gilmour, J.; Tarragona, T.; Smith, C.; Barin, B.; Dally, L.; Johnson, B.;
Muluubya, A.; Nielsen, L.; Hayes, P.; Boaz, M.; Hughes, P.; Hanke, T.;
McMichael, A.; Bwayo, J., and Kaleebu, P.
Source: Vaccine. 2008 May 23; 26(22):2788-95.
Abstract: The safety and immunogenicity of plasmid pTHr DNA, modified vaccinia virus
Ankara (MVA) human immunodeficiency virus type 1 (HIV-1) vaccine
candidates were evaluated in four Phase I clinical trials in Kenya and Uganda.
Both vaccines, expressing HIV-1 subtype A gag p24/p17 and a string of CD8 T-
cell epitopes (HIVA), were generally safe and well-tolerated. At the dosage levels
and intervals tested, the percentage of vaccine recipients with HIV-1-specific cell-
mediated immune responses, assessed by a validated ex vivo interferon gamma
(IFN-gamma) ELISPOT assay and Cytokine Flow Cytometry (CFC), did not
significantly differ from placebo recipients. These trials demonstrated the
feasibility of conducting high-quality Phase 1 trials in Africa.
Johnson A and Witt, H. Adherence to ART practices in resource-

constrained settings.
Abstract: The primary objective of the survey was to compare current practices in
measuring patient adherence to ART and calculating adherence levels and
default rates at health facilities and HIV programs. The secondary objective was
to explore current and potential interventions being used to promote ART
adherence. This report provides an analysis of interventions that the survey
participants indicated are being used at their facilities and recommendation for
additional interventions that were suggested to improve adherence to
antiretroviral therapy in these settings. The survey aimed at answering the
following questions: Are ART programs/providers using adherence promotion
interventions? What kinds of interventions are being used? Are the kinds or
combinations of interventions associated with the types of facilities or the range
of ART services provided? Are ART programs/providers planning for new
adherence promotion interventions? What kinds of interventions health
providers suggest to be effective? What kind of adherence challenges should be
addressed? (excerpt)
359
Risk factors for HIV infection in a national adult population: evidence

from the 2003 Kenya Demographic and Health Survey.
Author: Johnson, K. and Way, A.
To study demographic, social, behavioral, and biological variables as risk factors
for HIV infection among men and women in Kenya.
Methods:
Data from the cross-sectional, population-based 2003 Kenya Demographic and
Health Survey were used. During the course of survey fieldwork, 3,273 women
aged 15 to 49 years and 2,941 men aged 15 to 54 years gave consent to have a few
drops of blood taken for anonymous testing. HIV serostatus data for men and
women were analyzed for their relationships to key characteristics using
bivariate and multivariate techniques to determine factors associated with being
HIV-positive.
Results:
National HIV prevalence in Kenya was found to be 6.7%. In the analysis of the
study sample, uncircumcised men were 4 times more likely to be HIV-positive
than those who were not. Compared with nonpolygynously married women,
widowed women (odds ratio [OR] = 10.9), divorced women (OR = 2.3), and
women who were 1 of 3 or more wives (OR = 3.4) were all at higher risk for
being HIV-positive. Both men and women from Nyanza province were at a
significantly higher risk for infection with HIV (OR = 2.9 and 2.3, respectively)
than were the men and women from Nairobi. Men aged 35 to 44 years had the
highest risk of being HIV-positive, whereas the ages of highest risk for women
were 25 to 29 years. Increased wealth was positively related to risk for HIV: the
wealthiest women were 2.6 times more likely than the poorest women to be
HIV-positive. A key finding was that both men and women who considered
themselves to be at low risk for contracting HIV were, in fact, the most likely to
be HIV-positive.
Conclusions:
This analysis demonstrates that HIV is a multidimensional epidemic, with
demographic, residential, social, biological, and behavioral factors all exerting
influence on individual probability of becoming infected with HIV. Although all
of these factors contribute to the risk profile for a given individual, the results
suggest that differences in biological factors such as circumcision and sexually
transmitted infections may be more important in assessing risk for HIV than
differences in sexual behavior.
360
HIV serostatus and infant feeding counseling and practice: findings

from a baseline study among the urban poor in Kenya.
Author: Kaai S; Baek C; Geibel S; McOdida P, and Benson, U.
Abstract: In 2003, an estimated 630,000 children worldwide became infected with HIV, the
vast majority of them during their mother's pregnancy, labor, and delivery, or as
a result of breastfeeding. In the absence of any intervention, a third to a half of
mother-to-child transmission occurs through breastfeeding. Infant feeding
guidelines on the prevention of mother-to-child HIV transmission (PMTCT) in
Kenya recommend that HIV-infected mothers be counseled about the risks of
breast milk transmission of HIV and be given three options for feeding: (a)
exclusive breastfeeding for six months and abrupt cessation, (b) replacement
feeding with commercial infant formula, and (c) replacement/home modified
formula (cow, goat, or camel milk or soy protein) (NASCOP 2002). The objective
of counseling on HIV and infant feeding is to assess the mother's personal
circumstances in order to help her select the best feeding option for her and her
baby. Infant feeding counseling is crucial because normative practices in Kenya,
such as mixed feeding, can be detrimental to an infant of an HIV-positive
mother. (excerpt)
Knowledge, attitude and practice towards HIV/AIDS in a rural Kenyan

community.
Author: Karama, M.; Yamamoto, T.; Shimada, M.; Orago, S. S., and Moji, K.
Source: J Biosoc Sci. 2006 Jul; 38(4):481-90.
Abstract: The aim of this research was to explore people's knowledge, attitude, behaviour
and practice towards HIV/AIDS and sexual activity in rural Kenya, where HIV
is widespread. The study community was located in south-eastern Kenya, 50 km
north of Mombassa, and had an estimated population of 1500. Subjects aged
between 16 and 49 were recruited using a stratified cluster-sampling method and
they completed self-administered questionnaires.Almost all respondents knew
the word 'IV' Around 50% knew of a person living with HIV. About 80% gave
'death' or 'fear' as words representing their image of AIDS. With regard to sexual
activity, the distribution of answers to the question 'how many partners have you
ever had in your life' was bimodal in males but had only one peak in females,
indicating that some men have a large number of sexual partners in their
lifetime. First sexual intercourse was at around 12-13 years for both sexes, but
female teenagers were more sexually experienced than their male counterparts.
The HIV / AIDS epidemic in Kenya. HIV / AIDS policy fact sheet.
Author: Kates J and Leggoe, A. W.
361
Abstract: Kenya has more than one million people estimated to be living with HIV/AIDS
(1.2 million as of the end of 2003). Kenya's HIV/AIDS prevalence rate (the
percent of people living with the disease) is just below that of the sub-Saharan
African region overall (6.7% compared to 7.5%). Recent data indicate that the
country's HIV prevalence rate may be on the decline in some areas. However, the
HIV/AIDS epidemic poses significant challenges to this low-income country.
The Government of Kenya first established a National AIDS Control Council
(NACC) in 1999, and has a National Strategic Framework for HIV/AIDS for
2005-2010. (excerpt)
Prevalent herpes simplex virus type 2 infection is associated with altered

vaginal flora and an increased susceptibility to multiple sexually
transmitted infections.
Author: Kaul, R.; Nagelkerke, N. J.; Kimani, J.; Ngugi, E.; Bwayo, J. J.; Macdonald, K. S.;
Rebbaprgada, A.; Fonck, K.; Temmerman, M.; Ronald, A. R., and Moses, S.
Prevalent herpes simplex virus type 2 (HSV-2) infection increases human
immunodeficiency virus acquisition. We hypothesized that HSV-2 infection
might also predispose individuals to acquire other common sexually transmitted
infections (STIs). Methods: We studied the association between prevalent HSV-2
infection and STI incidence in a prospective, randomized trial of periodic STI
therapy among Kenyan female sex workers. Participants were screened monthly
for infection with Neisseria gonorrhoeae and Chlamydia trachomatis, and at
least every 6 months for bacterial vaginosis (BV) and infection with Treponema
pallidum, Trichomonas vaginalis, and/or HSV-2.
Results:
Increased prevalence of HSV-2 infection and increased prevalence of BV were
each associated with the other; the direction of causality could not be
determined. After stratifying for sexual risk-taking, BV status, and antibiotic use,
prevalent HSV-2 infection remained associated with an increased incidence of
infection with N. gonorrhoeae (incidence rate ratio [IRR], 4.3 [95% confidence
interval {CI}, 1.5-12.2]), T. vaginalis (IRR, 2.3 [95% CI, 1.3-4.2]), and syphilis (IRR,
4.7 [95% CI, 1.1-19.9]). BV was associated with increased rates of infection with C.
trachomatis (IRR, 2.1 [95% CI, 1.1-3.8]) and T. vaginalis (IRR, 8.0 [95% CI, 3.2-
19.8]).
Conclusion:
Increased prevalences of HSV-2 infection and BV were associated with each
other and also associated with enhanced susceptibility to an overlapping
spectrum of other STIs. Demonstration of causality will require clinical trials that
suppress HSV-2 infection, BV, or both.
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Drug evaluation: DNA/MVA prime-boost HIV vaccine.

Author: Kent, S.; De Rose, R., and Rollman, E.
Source: Curr Opin Investig Drugs. 2007 Feb; 8(2):159-67.
Abstract: Oxford University and Nairobi University are jointly developing a

HIVA.DNA/modified vaccinia Ankara (MVA) prime-boost vaccine for the
potential prevention of infection with HIV subtype A. The vaccination strategy
consists of priming with a DNA vaccine made from HIV-1 clade A gag p24/p17
consensus sequence (pTHr.HIVA) then boosting with a MVA virus expressing
HIVA (MVA.HIVA). Phase II clinical trials of the vaccine are underway in Kenya
and the UK.
Rapid Identification of Infants for Antiretroviral Therapy in a Resource

Poor Setting: The Kenya Experience.
Author: Khamadi, S.; Okoth, V.; Lihana, R.; Nabwera, J.; Hungu, J.; Okoth, F.; Lubano, K.,
and Mwau, M.
Source: J Trop Pediatr. 2008 May 29.
Abstract: In Kenya, HIV diagnosis is not routinely carried out in infants, and yet rapid
diagnosis could improve access to lifesaving interventions. A cheap and readily
accessible service can resolve this problem, if feasible. In this pilot study the
feasibility and costs of provision of an infant HIV diagnosis service in Kenya are
evaluated. Dried blood spots (DBS) were collected from infants exposed to HIV,
sent to a central testing laboratory and tested using the Roche Amplicor v. 1.5
DNA PCR kit. The results were then dispatched to health facilities within a week.
A total of 15.4% of the samples tested HIV+ despite the widespread access to
prevention of mother to child transmission (PMTCT) programs in Kenya. The
cost per test at 21.50 USD is prohibitive and will limit access to diagnosis. It
remains to be seen whether the increase in testing will immediately lead to an
increase in access to antiretroviral therapy (ART) services for infants.

Author: Khamadi, S. A.; Ochieng, W.; Lihana, R. W.; Kinyua, J.; Muriuki, J.; Mwangi, J.;
Lwembe, R.; Kiptoo, M.; Osman, S.; Lagat, N.; Pelle, R.; Muigai, A.; Carter, J. Y.;
Oishi, I.; Ichimura, H.; Mwaniki, D. L.; Okoth, F. A.; Mpoke, S., and Songok, E.
M.
Source: AIDS Res Hum Retroviruses. 2005 Sep; 21(9):810-4.
363
Kenya, which borders Ethiopia, Somalia, and Sudan. From the analysis of partial
env sequences, it was determined that 50% were subtype A, 39% subtype C, and
11% subtype D. This shows that in the northern border region of Kenya
subtypes A and C are the dominant HIV-1 subtypes in circulation. Ethiopia is
dominated mainly by HIV-1 subtype C, which incidentally is the dominant
subtype in the town of Moyale, which borders Ethiopia. These results show that
cross-border movements play an important role in the circulation of subtypes in
Northern Kenya.
ABCs: not as simple as they sound. Kenya study highlights how adults
and youth interpret key messages.
Author: Khan, H.
Abstract: It is widely accepted that the "ABC" behaviors--being abstinent or delaying sex
until marriage, being faithful to one sexual partner, and consistently using
condoms during sex--are key to reducing the sexual transmission of HIV and
that there is a need to tailor messages about the ABCs to fit different audiences
and cultural contexts. Yet considerable debate surrounds how best to deliver the
messages and apply them to prevention efforts. Furthermore, questions remain
about how well the terms are actually understood by the various groups they are
meant to target. Are they clear or confusing? Seen as useful or irrelevant? Viewed
as complementary or contradictory? Horizons and the IMPACT Project of Family
Health International (FHI) collaborated on a study in 2004 to explore how
different groups in two communities in Kenya, Naivasha and Molo, perceive
ABC terms and behaviors. Self-administered questionnaires were given to
groups of youth and adults--working adults at flower farms and in-school youth
ages 13-19. Interviewers were available to help respondents, if needed, fill out the
questionnaires. Focus group discussions were also held with flower farm
workers and in-school youth, as well as with female sex workers and male truck
drivers. The study findings highlight attitudes and norms around the ABC
behaviors, as well as barriers to and facilitators of the behaviors, and the role of
important actors in transmitting messages about them. (excerpt)
Alcohol and HIV services: Study finds Kenyan counselors need support
to handle alcohol use among clients.
Source: Horizons Report. 2006 Jun; [3] p.
364
Abstract: Voluntary counseling and testing (VCT) services play a vital role in HIV
prevention and care. By determining and discussing an individual's serostatus,
VCT can promote the adoption of HIV prevention behaviors and facilitate early
initiation of antiretroviral therapy (ART). However, an important challenge
facing VCT service providers surrounds the use of alcohol among their clients.
Alcohol use has been associated with high-risk sexual behavior; it reduces
inhibitions and self-control, which makes it easier for individuals to engage in
risky behavior, such as multiple sex partners and unprotected sex. A study
among clients of rural public clinics in Kenya found that more than half reported
"hazardous" drinking behavior, suggesting that alcohol use is a serious problem.
Horizons, in partnership with Liverpool VCT and Care Inc and The Steadman
Group, conducted a study in December 2005 to explore the need for integrating
alcohol counseling and referral into VCT services, and the preparedness of
service providers to address alcohol use among clients accessing Kenyan
facilities. The study also queried providers who counsel patients about ART
because alcohol use can have a major impact on people living with HIV; drinking
alcohol is associated with poor adherence to ART. (excerpt)
On the frontlines: Kenyan health workers confront HIV-related

challenges at work and home.
Souce: Horizons Report. 2006 Jun; [3] p.
Abstract: Health workers are the backbone of HIV services and key to their successful
delivery. But findings from a national study of health workers in Kenya reveal
that many are ill equipped to cope with occupational exposure to HIV and the
demands of caring for HIV patients both at work and at home. The study,
conducted by the Kenya Ministry of Health National AIDS and STI Control
Program with support from Horizons and CDC Kenya, consisted of interviews
with a nationally representative sample of 1,897 medical personnel in 245 health
facilities located in 28 districts in Kenya. In addition, researchers held 24 focus
group discussions with health workers in selected facilities. The vast majority of
health workers in Kenya are worried about occupational exposure to HIV.
Ninety-three percent reported that they were "very concerned" about getting
infected with HIV on the job. This may be due to the fact that for many, potential
exposure to HIV is a reality that they have already faced. Nearly one in five
health workers reported a recent event where they could have been exposed to
HIV at work, and among these, half had experienced multiple exposures. To add
to their concern, more than half of the health workers indicated that their facility
did not have written guidelines about what to do in case of occupational
exposure to HIV. (excerpt)
Closer to home: Community-based activities complement PMTCT

programs in Kenya.
365
Author: Khan H; Kaai S; Baek C; Geibel S, and Omondi, P.
Source: Horizons Report. 2007 Jun; 6-8.
Abstract: In Kenya, an estimated 270 new pediatric HIV infections occur each day.
Maternal-to-child transmission of the virus is the cause of most HIV infections in
children. To address this problem, the Kenyan government has implemented
prevention of mother-to-child transmission (PMTCT) services throughout the
country. These services include routine HIV counseling and testing (CT),
improved obstetric practices, antiretroviral therapy, counseling and support for
safer infant feeding practices, and family planning. However, making PMTCT
services available to the women who need them has proven to be only half of the
battle. Research has shown that the medical recommendations made by PMTCT
programs can be overshadowed by community norms, values, and beliefs. In
Kenya, fear of disclosure and stigma prevent many women from following
recommended practices, and a lack of resources and motivation limit women's
abilities to access available PMTCT services. (excerpt)
Prevention for positives. Study in Kenya underscores need to include

people living with HIV / AIDS in prevention efforts.
Author: Khan H; Sarna A; Kaai S, and Luchters, S.
Abstract: A comprehensive approach to prevention requires that HIV-positive persons do

not fall outside the scope of prevention efforts. Instead, these individuals need to
take protective and preventive measures since they run the risk of both infecting
their sexual partners and reinfecting themselves with different strains of the
virus. As access to treatment expands, many HIV-positive people on
antiretroviral therapy (ART) are living longer, healthier, and more sexually
active lives. Those results, while encouraging, raise new concerns within the
public health community. Do HIV-positive persons receiving ART engage in
more risky sexual behaviors after feeling better in response to the therapy? Even
if unsafe behaviors do not increase after treatment, do patients on ART continue
to have unprotected sex with their partners? (excerpt)
Initiating HIV diagnostic testing and counseling.

Author: Khan H and Weiss, E.
Source: Horizons Report. 2006 Dec; 2-4.
Abstract: In Kenya, a country noted for achievements in battling the HIV epidemic and a
recent decline in national prevalence, the vast majority of adults living with HIV
still do not know their status. According to the 2003 Kenya Demographic and
366
Health Survey, only 14 percent of men and 13 percent of women ages 15-49 have
tested for HIV. Despite massive national campaigns, there remains a large unmet
need for HIV testing and counseling. To address the challenge of increasing
testing levels, the World Health Organization recommends that individuals who
present to health care facilities, including hospitals and clinics, should receive
HIV testing and counseling as part of their diagnostic assessment and clinical
evaluation (2006). This is particularly relevant in Kenya because estimates
suggest that up to 60 percent of all medical ward hospital beds are occupied by
HIV-infected patients (NASCOP 2004). Provider-initiated testing and counseling,
which includes "diagnostic testing and counseling" (DTC), can be a gateway to
appropriate care and treatment services as well as an opportunity to boost HIV
prevention efforts. (excerpt)
Genetic analysis of HIV-1 subtypes in Nairobi, Kenya.

Author: Khoja, S.; Ojwang, P.; Khan, S.; Okinda, N.; Harania, R., and Ali, S.
Genetic analysis of a viral infection helps in following its spread in a given
population, in tracking the routes of infection and, where applicable, in vaccine
design. Additionally, sequence analysis of the viral genome provides information
about patterns of genetic divergence that may have occurred during viral
evolution.
Objective:
In this study we have analyzed the subtypes of Human Immunodeficiency Virus
-1 (HIV-1) circulating in a diverse sample population of Nairobi, Kenya.
Methodology:
69 blood samples were collected from a diverse subject population attending the
Aga Khan University Hospital in Nairobi, Kenya. Total DNA was extracted from
peripheral blood mononuclear cells (PBMCs), and used in a Polymerase Chain
Reaction (PCR) to amplify the HIV gag gene. The PCR amplimers were partially
sequenced, and alignment and phylogenetic analysis of these sequences was
performed using the Los Alamos HIV Database.
Results:
Blood samples from 69 HIV-1 infected subjects from varying ethnic backgrounds
were analyzed. Sequence alignment and phylogenetic analysis showed 39
isolates to be subtype A, 13 subtype D, 7 subtype C, 3 subtype AD and
CRF01_AE, 2 subtype G and 1 subtype AC and 1 AG. Deeper phylogenetic
analysis revealed HIV subtype A sequences to be highly divergent as compared
to subtypes D and C.
Conclusion:
367
Our analysis indicates that HIV-1 subtypes in the Nairobi province of Kenya are
dominated by a genetically diverse clade A. Additionally, the prevalence of
highly divergent, complex subtypes, intersubtypes, and the recombinant forms
indicates viral mixing in Kenyan population, possibly as a result of dual
infections.
Domestic violence and prevention of mother-to-child transmission of

HIV-1.
Author: Kiarie, J. N.; Farquhar, C.; Richardson, B. A.; Kabura, M. N.; John, F. N.; Nduati,
R. W., and John-Stewart, G. C.
Source: AIDS. 2006 Aug 22; 20(13):1763-9.
To determine the prevalence of life-time domestic violence by the current partner
before HIV-1 testing, its impact on the uptake of prevention of mother-to-child
transmission (PMTCT) interventions and frequency after testing.
Design: A prospective cohort.
Methods:
Antenatally, women and their partners were interviewed regarding physical,
financial, and psychological abuse by the male partner before HIV-1 testing and 2
weeks after receiving results.
Results:
Before testing, 804 of 2836 women (28%) reported previous domestic violence,
which tended to be associated with increased odds of HIV-1 infection [univariate
odds ratio (OR) 1.7, 95% confidence interval (CI) 1.3-2.2; P < 0.0001, adjusted OR
1.2, 95% CI 0.9-1.6; P = 0.1], decreased odds of coming with partners for
counseling (adjusted OR 0.7, 95% CI 0.5-1.0; P = 0.04), and decreased odds of
partner notification (adjusted OR 0.7, 95% CI 0.5-1.1; P = 0.09). Previous domestic
violence was not associated with a reduced uptake of HIV-1 counseling, HIV-1
testing, or nevirapine. After receiving results, 15 out of 1638 women (0.9%)
reported domestic violence. After notifying partners of results, the odds of HIV-
1-seropositive women reporting domestic violence were 4.8 times those of HIV-
1-seronegative women (95% CI 1.4-16; P = 0.01). Compared with women, men
reported similar or more male-perpetrated domestic violence, suggesting a
cultural acceptability of violence.
Conclusion:
Domestic violence before testing may limit partner involvement in PMTCT.
Although infrequent, immediate post-test domestic violence is more common
among HIV-1-infected than uninfected women. Domestic violence prevention
programmes need to be integrated into PMTCT, particularly for HIV-1-
seropositive women.
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Reference ranges for the clinical laboratory derived from a rural

population in Kericho, Kenya.
Author: Kibaya, R. S.; Bautista, C. T.; Sawe, F. K.; Shaffer, D. N.; Sateren, W. B.; Scott, P.
T.; Michael, N. L.; Robb, M. L.; Birx, D. L., and de Souza, M. S.
Source: PLoS ONE. 2008; 3(10):e3327.
Abstract: The conduct of Phase I/II HIV vaccine trials internationally necessitates the
development of region-specific clinical reference ranges for trial enrollment and
participant monitoring. A population based cohort of adults in Kericho, Kenya, a
potential vaccine trial site, allowed development of clinical laboratory reference
ranges. Lymphocyte immunophenotyping was performed on 1293 HIV
seronegative study participants. Hematology and clinical chemistry were
performed on up to 1541 cohort enrollees. The ratio of males to females was 1.9:1.
Means, medians and 95% reference ranges were calculated and compared with
those from other nations. The median CD4+ T cell count for the group was 810
cells/microl. There were significant gender differences for both red and white
blood cell parameters. Kenyan subjects had lower median hemoglobin
concentrations (9.5 g/dL; range 6.7-11.1) and neutrophil counts (1850
cells/microl; range 914-4715) compared to North Americans. Kenyan clinical
chemistry reference ranges were comparable to those from the USA, with the
exception of the upper limits for bilirubin and blood urea nitrogen, which were
2.3-fold higher and 1.5-fold lower, respectively. This study is the first to assess
clinical reference ranges for a highland community in Kenya and highlights the
need to define clinical laboratory ranges from the national community not only
for clinical research but also care and treatment.
Adverse Events in HIV-Infected Persons Receiving Antiretroviral Drug

Regimens in a Large Urban Slum in Nairobi, Kenya, 2003-2005.
Author: Kim, A. A.; Wanjiku, L.; Macharia, D. K.; Wangai, M.; Isavwa, A.; Abdi, H.;
Marston, B. J.; Ilako, F.; Kjaer, M.; Chebet, K.; De Cock, K. M., and Weidle, P. J.
Source: J Int Assoc Physicians AIDS Care (Chic Ill). 2007 Sep; 6(3):206-9.
This article describes toxicities to antiretroviral therapy (ART) among HIV-
infected patients receiving care at a clinic in a large urban slum in Nairobi,
Kenya.
Methods:
369
Patients were treated with nonnucleoside reverse transcriptase inhibitor-based

ART and followed at scheduled intervals. Frequencies and cumulative
probabilities of toxicities were calculated.
Results:
Among 283 patients starting ART, any and severe clinical toxicity were recorded
as 65% and 6%, respectively. Cumulative probabilities for remaining free of any
and severe clinical toxicities at 6, 12, and 18 months, were 0.47, 0.26, and 0.17,
respectively and 0.98, 0.95, and 0.89, respectively. The probability of remaining
free from elevated and grade 3 or 4 serum aminotransferase (AST) at 6, 12, and
18 months were 0.62, 0.42, and 0.21, respectively, and 0.99 at 6, 12, and 18
months.
Conclusions:
ART toxicities were frequent, but severe toxicities were less common. In
resource-limited settings, ART toxicity should not represent a barrier to care.

Author: Kimani, J.; Kaul, R.; Nagelkerke, N. J.; Luo, M.; MacDonald, K. S.; Ngugi, E.;
Fowke, K. R.; Ball, B. T.; Kariri, A.; Ndinya-Achola, J., and Plummer, F. A.
Source: AIDS. 2008 Jan 2; 22(1):131-7.
Female sex workers (FSWs) form a core group at high risk of both sexual HIV
Kenya.
Methods:
An open cohort of FSWs followed since 1985. Behavioral and clinical data were
collected six monthly from 1985 to 2005, and sexually transmitted infection (STI)
diagnostics and HIV serology performed. A Cox proportional hazards model
with time-dependent covariables was used to estimate infection risk as a function
of calendar time.
Results:
HIV prevalence in new FSW enrollees peaked at 81% in 1986, and was
consistently below 50% after 1997. Initially uninfected FSWs remained at high
risk of acquiring HIV throughout the study period, but the rate of HIV
acquisition during unprotected sex with a casual client declined by over four-
fold. This reduction correlated closely with decreases in gonorrhea prevalence,
370
and predated reductions in the Kenyan HIV population prevalence by over a

decade.
Conclusions:
The per-act rate of HIV acquisition in high-risk Nairobi FSWs fell dramatically
between 1985 and 2005. This decline may represent the impact of improved STI
prevention/therapy, immunogenetic shifts in at-risk women, or changes in the
proportion of HIV exposures occurring with clients who had acute HIV infection.
Declining HIV incidence in high-risk cohorts may predict and/or be causally
related to future reductions in population prevalence.
A note from the field: Kenya HIV / AIDS and microfinance training.
USAID-AMAP financial services knowledge generation project.
Author: Kiyaga E and Sebageni, G.
Abstract: Edward Kiyaga of MED-Net—a microfinance affiliate of World Vision Uganda—

and Grace Tiberondwa Sebageni of World Relief Rwanda submitted this week’s
Note on the training they provided to Kenyan microfinance institution managers.
Addressing an urgent need for microfinance strategies to cope with HIV/AIDS
in Africa, the Kenya Microfinance and HIV/AIDS workshop complemented the
one held in August 2004 in Addis Ababa, Ethiopia, which was the subject of the
Note from Ethiopia. Both workshops were managed by ECIAfrica, and
Development Alternatives, Inc. (DAI). DAI leads the Accelerated Microenterprise
Advancement Project’s Financial Services Knowledge Generation project. The
Kenyan course brought together 11 participants from seven microfinance
institutions (MFIs). Kiyaga and Sebageni elaborate: “The Joint United Nations
Programme on HIV/AIDS reports that Kenya is one of the nine African countries
hit hardest by the HIV/AIDS epidemic. According to the United Nations, at the
end of 2001 an estimated 2.5 million Kenyan adults were living with HIV/AIDS,
a prevalence rate of 15 percent. Largely because of AIDS, life expectancy in
Kenya dropped from 60 years in 1990 to 49 years in 2000. In addition to the
increase in prevalence, a number of studies from Kenya’s Ministry of Health
indicate that high health care costs and lost income from HIV/AIDS will be a
major burden on the Kenyan economy. By 2005, Kenya’s gross domestic product
is projected to be 14.5 percent lower than it would have been in the absence of
AIDS.” (excerpt)
IL-7Ralpha expression on CD4+ T lymphocytes decreases with HIV

disease progression and inversely correlates with immune activation.
Author: Koesters, S. A.; Alimonti, J. B.; Wachihi, C.; Matu, L.; Anzala, O.; Kimani, J.;
Embree, J. E.; Plummer, F. A., and Fowke, K. R.
Source: Eur J Immunol. 2006 Feb; 36(2):336-44.
371
Abstract: Many factors can influence the rate of HIV disease progression, including those
that maintain T cell homeostasis. One key homeostatic regulator is the IL-7
receptor (IL-7R). Previous studies have shown IL-7R expression levels decrease
in HIV infection, but effects on memory subtypes, CD4(+) T cells, and cell
function have not been explored. The present study examined the expression of
the IL-7Ralpha chain on naive and memory T lymphocyte subsets of both HIV-
positive and HIV-negative individuals from Nairobi, Kenya to assess the role of
IL-7Ralpha in HIV disease. Expression of IL-7Ralpha was significantly reduced
in all CD4(+) and CD8(+) T cell subsets in HIV-positive individuals. This
reduction was further enhanced in those with advanced HIV progression.
Expression of IL-7Ralpha was inversely correlated to immune activation, and
apoptosis, and was positively correlated with CD4 count in both bivariate and
multivariate analysis. Expression of IL-7Ralpha did not correlate with HIV viral
loads, indicating the elevated immune activation seen in HIV-infected
individuals may be impacting expression of IL-7Ralpha, independent of viral
loads. Signaling via the IL-7R is essential for T cell homeostasis and maintenance
of T cell memory. Reduction of this receptor may contribute to the homeostatic
disruption seen in HIV.


372

373

District, Kenya.
populations.

Results:
Conclusion:
Etiology and resistance patterns of respiratory isolates in Kenyan adults

with AIDS from slum population.
Author: Krcmery, V.; Benca, J.; Liskova, A.; Mitterpachova, E.; Kolenova, A.; Sladeckova,
V.; Horvathova, D., and Kiwou, M.
Source: Neuro Endocrinol Lett. 2007 Nov; 28 Suppl 3:37-9.
374
Abstract: We investigated regularly swabs of adults dispenzarised at Mary Immaculate

Clinic of Trnava University in Nairobi providing free health care for about 50 000
population of Mukuru Slums. 20 patients who were treated for AIDS by our
clinic (those who started HAART before Free National AIDS Cooperation
Programme - NASCOP) were assessed after 1, 2 and 3 years (18 of 20 completed
the survey, other 2 loss of follow up, probably died. Exposure to other molecules
can select resistant mutants. Previous exposure to TMP/SMX was similar in
both groups and therefore was not responsible for the difference between
resistance patterns

District, Kenya.
populations.

Results:
Conclusion:
375

Adult Male Circumcision: Effects on Sexual Function and Sexual

Satisfaction in Kisumu, Kenya.
Author: Krieger, J. N.; Mehta, S. D.; Bailey, R. C.; Agot, K.; Ndinya-Achola, J. O.; Parker,
C., and Moses, S.
Source: J Sex Med. 2008 Aug 28.
Abstract: Introduction. Male circumcision is being promoted for HIV prevention in high-
risk heterosexual populations. However, there is a concern that circumcision may
impair sexual function. Aim. To assess adult male circumcision's effect on men's
sexual function and pleasure. Methods. Participants in a controlled trial of
circumcision to reduce HIV incidence in Kisumu, Kenya were uncircumcised,
HIV negative, sexually active men, aged 18-24 years, with a hemoglobin >/=9.0
mmol/L. Exclusion criteria included foreskin covering less than half the glans, a
condition that might unduly increase surgical risks, or a medical indication for
circumcision. Participants were randomized 1:1 to either immediate circumcision
or delayed circumcision after 2 years (control group). Detailed evaluations
occurred at 1, 3, 6, 12, 18, and 24 months. Main Outcome Measures. (i) Sexual
function between circumcised and uncircumcised men; and (ii) sexual
satisfaction and pleasure over time following circumcision. Results. Between
February 2002 and September 2005, 2,784 participants were randomized,
including the 100 excluded from this analysis because they crossed over, were
not circumcised within 30 days of randomization, did not complete baseline
interviews, or were outside the age range. For the circumcision and control
groups, respectively, rates of any reported sexual dysfunction decreased from
23.6% and 25.9% at baseline to 6.2% and 5.8% at month 24. Changes over time
were not associated with circumcision status. Compared to before they were
circumcised, 64.0% of circumcised men reported their penis was "much more
sensitive," and 54.5% rated their ease of reaching orgasm as "much more" at
month 24. Conclusions. Adult male circumcision was not associated with sexual
dysfunction. Circumcised men reported increased penile sensitivity and
enhanced ease of reaching orgasm. These data indicate that integration of male
circumcision into programs to reduce HIV risk is unlikely to adversely effect
male sexual function.
376

Author: Land, A. M.; Ball, T. B.; Luo, M.; Pilon, R.; Sandstrom, P.; Embree, J. E.; Wachihi,
C.; Kimani, J., and Plummer, F. A.
Source: J Virol. 2008 Aug; 82(16):8172-82.

purposes
Full-length HIV type 1 proviral sequencing of 10 highly exposed women

from Nairobi, Kenya reveals a high proportion of intersubtype
recombinants.
Author: Land, A. M.; Ball, T. B.; Luo, M.; Rutherford, J.; Sarna, C.; Wachihi, C.; Kimani, J.,
and Plummer, F. A.
Abstract: Phylogenetic analysis has revealed that the current HIV/AIDS pandemic consists
of a multitude of different viral clades and recombinant viruses. The
predominant circulating HIV-1 clade in Kenya is A1; however, Kenya borders
countries where different subtypes are prominent, making Kenya a likely
location for recombination. Previous studies have reported significant differences
377
in the proportions of sequences in Kenya that are intersubtype recombinants.

Studies that performed sequence-based typing on multiple HIV-1 genomic
regions or full-length sequences found higher rates of recombination than those
that examined a single gene or gene fragment. In this study, we describe full-
length HIV-1 proviral sequence-based genotyping after limited peripheral blood
mononuclear cell (PBMC) coculture. Ten subjects from a highly exposed cohort
located in Nairobi, Kenya were examined. Pairwise comparison found minimal
difference between sequences generated directly from patient PBMC DNA
compared to sequences from cocultured PBMC DNA. Of the 10 full-length HIV-1
sequences examined, five were nonrecombinant clade A1, while the other five
were unique intersubtype recombinants. Although this frequency of
recombination is higher than previously described in Kenya, this finding is in
agreement with previous full-length sequence data. Interestingly, although all
the nonrecombinant sequences were clade A1, not all the recombinant sequences
contained a clade A1 sequence.
Orphans in Nyanza, Kenya: Coping with the struggles of everyday life in

the context of the HIV / AIDS pandemic.
Author: Landry T; Luginaah I; Maticka-Tyndale E, and Elkins, D.
Source: Journal of HIV / AIDS Prevention in Children and Youth. 2007; 8(1):75-98.
Abstract: This paper examined the everyday challenges, stressors and coping strategies of
orphans affected by HIV/AIDS in Nyanza, Kenya. A thematic analysis of six
focus group discussions with orphans was guided by Stress and Coping
Theoretical Framework. The orphans reported intense stress at the time of their
parents' death with their immediate concern being who would care for them.
Most orphans were separated from their siblings, and this separation only
compounded the stressors and difficulties encountered by orphans. Orphans
reported having problems with schooling and being treated differently as
compared with the children of their caregivers. Orphans adopted various
emotion-focused and problem-foused coping strategies, which were reinforced
by financial and social support provided by their caregivers and community-
based organizations. (author's)
378
Reaching the targets for tuberculosis control: the impact of HIV.

Author: Laserson, K. F. and Wells, C. D.
Source: Bull World Health Organ. 2007 May; 85(5):377-81; discussion 382-6.
Abstract: In 1991, the 44th World Health Assembly set two key targets for global
tuberculosis (TB) control to be reached by 2000: 70% case detection of acid-fast
bacilli smear-positive TB patients under the DOTS strategy recommended by
WHO and 85% treatment success of those detected. This paper describes how TB
control was scaled up to achieve these targets; it also considers the barriers
encountered in reaching the targets, with a particular focus on how HIV infection
affects TB control. Strong TB control will be facilitated by scaling-up WHO-
recommended TB/HIV collaborative activities and by improving coordination
between HIV and TB control programmes; in particular, to ensure control of
drug-resistant TB. Required activities include more HIV counselling and testing
of TB patients, greater use and acceptance of isoniazid as a preventive treatment
in HIV-infected individuals, screening for active TB in HIV-care settings, and
provision of universal access to antiretroviral treatment for all HIV-infected
individuals eligible for such treatment. Integration of TB and HIV services in all
facilities (i.e. in HIV-care settings and in TB clinics), especially at the periphery, is
needed to effectively treat those infected with both diseases, to prolong their
survival and to maximize limited human resources. Global TB targets can be met,
particularly if there is renewed attention to TB/HIV collaborative activities
combined with tremendous political commitment and will.
Higher set point plasma viral load and more-severe acute HIV type 1
(HIV-1) illness predict mortality among high-risk HIV-1-infected African
women.
Author: Lavreys, L.; Baeten, J. M.; Chohan, V.; McClelland, R. S.; Hassan, W. M.;
Richardson, B. A.; Mandaliya, K.; Ndinya-Achola, J. O., and Overbaugh, J.
Source: Clin Infect Dis. 2006 May 1; 42(9):1333-9.
There is limited information on the natural history of human immunodeficiency
virus type 1 (HIV-1) infection in Africa, especially from individuals with well-
defined dates of infection. We used data from a prospective cohort study of
female sex workers in Mombasa, Kenya, who were followed up monthly from
before the date of HIV-1 infection.
Methods:
Antiretroviral-naive women who had a well-defined date of HIV-1 infection
were included in this analysis. The effects of set point plasma viral load
(measured 4-24 months after infection), early CD4+ cell count, and symptoms of
379
acute HIV-1 infection on mortality were assessed using Cox proportional hazards
analysis.
Results:
Among 218 women, the median duration of follow-up after HIV-1 infection was
4.6 years. Forty women died, and at 8.7 years (the time of the last death), the
cumulative survival rate was 51% by Kaplan-Meier analysis. Higher set point
viral load, lower early CD4+ cell count, and more-symptomatic acute HIV-1
illness each predicted death. In multivariate analysis, set point viral load (hazard
ratio [HR], 2.28 per 1 log10 copies/mL increase; P=.001) and acute HIV-1 illness
(HR, 1.14 per each additional symptom; P=.05) were independently associated
with higher mortality.
Conclusion:
Among this group of African women, the survival rate was similar to that for
HIV-1-infected individuals in industrialized nations before the introduction of
combination antiretroviral therapy. Higher set point viral load and more-severe
acute HIV-1 illness predicted faster progression to death. Early identification of
individuals at risk for rapid disease progression may allow closer clinical
monitoring, including timely initiation of antiretroviral treatment.
Impact of HIV / AIDS on trends in major causes of death at a rural

mission hospital in Kenya: Review of 4858 records.
Author: Leblanc, P. A.
Source: Annals of African Medicine. 2006; 5(3):142-148.
Abstract: Acquired Immune Deficiency Syndrome (AIDS), caused by the human

immunodeficiency virus (HIV), is a worldwide public health issue. Hospital
death records can be used to study the impact of HIV in Africa. The explanation
of mortality figures through hospital records identifies the evolution of the
pandemic at that point. This study was framed with the objective, to describe
trends in the leading causes of death from 1980 to 2000 at Kijabe Hospital;
determining the proportion of deaths attributed to HIV/AIDS. Data were
examined from death records stored in an ACCESS database at Kijabe Hospital.
The numbers of deaths in categories of causes of death were used to determine
trends in the most frequent causes of death over the time period. In the case of
HIV/AIDS the frequency of this diagnosis as recorded on the death certificates
was tracked. The study design was a retrospective review of the death records.
Larger proportions of young people died in at Kijabe Hospital over the study
period. HIV/AIDS became the leading cause of death for every year after 1991.
These trends may help rural hospitals plan and allocate resources. The data in
this study may influence local resource distribution and future programs in
similar settings. (author's
380
Commercial sex and HIV transmission in mature epidemics: a study of

five African countries.
Author: Leclerc, P. M. and Garenne, M.
Source: Int J STD AIDS. 2008 Oct; 19(10):660-4.
Abstract: The study compares the association between using the services of commercial sex
workers and male HIV seroprevalence in five African countries: Ghana, Kenya,
Lesotho, Malawi and Rwanda. The HIV seroprevalence among men who 'ever
paid for sex' was compared with controls who 'never paid for sex'. Results were
based on 12,929 eligible men, aged 15-59 years, interviewed in Demographic and
Health Surveys. The odds ratio of HIV seroprevalence associated with ever
paying for sex was 1.89 (95% confidence interval = 1.57-2.28), with only minor
differences by country. The results were stable in multivariate analysis after
controlling for available potential cofactors (data on non-sexual routes of
transmission were not available). Given the relatively small proportion of men
involved, the risk attributable to 'ever paying for sex' remained low: 7.1% in
univariate analysis and 4.4% after adjustment, and it varied among countries
(range 1.3-9.4%). These results match previous observations that commercial sex
seems to play a minor role in the spread of HIV in mature epidemics.
Toll-like receptor expression and responsiveness are increased in

viraemic HIV-1 infection.
Author: Lester, R. T.; Yao, X. D.; Ball, T. B.; McKinnon, L. R.; Kaul, R.; Wachihi, C.; Jaoko,
W.; Plummer, F. A., and Rosenthal, K. L.
Source: AIDS. 2008 Mar 30; 22(6):685-94.
Toll-like receptors (TLR) are important in pathogen recognition and may play a
role in HIV disease. We evaluated the effect of chronic untreated and treated
HIV-1 infection on systemic TLR expression and TLR signalling.
Methods:
Two hundred HIV-infected and uninfected women from a Kenya cohort
participated in the studies. TLR1 to TLR10 messenger RNA expression was
determined by quantitative reverse transcriptase polymerase chain reaction in
peripheral blood mononuclear cells (PBMC). TLR ligand responsiveness was
determined in or using ex-vivo PBMC by cytokine production in culture
supernatants.
Results:
Chronic, untreated HIV-1 infection was significantly associated with increased
mRNA expression of TLR6, TLR7, and TLR8 and when analysis was limited to
381
those with advanced disease (CD4 cell count < 200 cells/ml) TLR2, TLR3, and
TLR4 were additionally elevated. TLR expression correlated with the plasma
HIV-RNA load, which was significant for TLR6 and TLR7. In vitro HIV single-
stranded RNA alone could enhance TLR mRNA expression. PBMC of HIV-
infected subjects also demonstrated profoundly increased proinflammatory
responsiveness to TLR ligands, suggesting sensitization of TLR signalling in
HIV. Finally, viral suppression by HAART was associated with a normalization
of TLR levels.
Conclusion:
Together, these data indicate that chronic viraemic HIV-1 is associated with
increased TLR expression and responsiveness, which may perpetuate innate
immune dysfunction and activation that underlies HIV pathogenesis, and thus
reveal potential new targets for therapy.
Feasibility, acceptability, effect and cost of integrating counseling and

testing for HIV within family planning services in Kenya.
Author: Liambila W; Kibaru J; Warren C; Gathitu M, and Mullick, S.
Abstract: Integrating counseling and testing (CT) for HIV into family planning (FP)
services potentially increases the range of services available for FP clients, many
of whom are at risk of STIs including HIV in high prevalence settings. Systematic
evidence about offering CT in FP settings has remained extremely limited,
despite the widespread interest in this model of FP-HIV integration. FRONTIERS
supported the Division of Reproductive Health (DRH) and the National AIDS
and STI Control Program (NASCOP) of the Kenya Ministry of Health (MOH) to
design, implement and compare two models of integrating CT for HIV within FP
services in 23 health facilities in Nyeri and Thika Districts of Central Province,
Kenya in terms of their feasibility, acceptability, cost and effect on the voluntary
use of CT, as well as the quality of FP services. The study utilized a pre-post
intervention design to obtain information from FP providers and their clients in
2006 to 2007. Data were collected through provider-client observations (554 at
baseline and 530 at endline) and client exit interviews (552 at baseline and 530 at
end line), pre and post intervention interviews and focus group discussions with
health providers, and a health facility assessment of the readiness of facilities to
offer HIV CT within FP services. Introduction and implementation involved: (a)
holding sensitization meetings at national, provincial and district levels; (b)
reviewing and developing training materials; (c) application of the Balanced
Counseling Strategy (BCS) Plus approach; (d) modification of facility registers to
record the required data; and (e) training of health providers. The MOH
provided all required equipment and supplies, including HIV rapid test kits and
FP commodities. Two models were pilot-tested. The "testing" model was
implemented in Nyeri District, an area with relatively few VCT sites. In this
model, FP clients were educated about HIV prevention generally, and CT in
particular, and offered HIV CT during this consultation by the FP provider. The
"referral" model was implemented in Thika district, an area with good
382
accessibility to VCT services. In this model, FP clients were educated about HIV
CT, and those interested were instead referred to a specialized CT service, either
within the same facility or to another CT service (at another health facility or a
stand-alone VCT center). The study demonstrated that both models were feasible
and acceptable to providers and to clients as means of integrating and linking
HIV prevention counseling, condom promotion and counseling and testing with
FP services, and are effective in increasing quality of care and service utilization.
(excerpt)
HIV type 1 subtypes among STI patients in Nairobi: a genotypic study

based on partial pol gene sequencing.
Author: Lihana, R. W.; Khamadi, S. A.; Kiptoo, M. K.; Kinyua, J. G.; Lagat, N.; Magoma,
G. N.; Mwau, M. M.; Makokha, E. P.; Onyango, V.; Osman, S.; Okoth, F. A., and
Songok, E. M.
Source: AIDS Res Hum Retroviruses. 2006 Nov; 22(11):1172-7.
Abstract: Circulating strains of human immunodeficiency virus (HIV) exhibit an

extraordinary degree of genetic diversity and have been classified on the basis of
relationships into distinct lineages called groups, types, subtypes, and
subsubtypes. Sexually transmitted infections (STIs) are known to be a risk factor
for HIV infection. To establish HIV-1 subtype diversity among STI patients in
Nairobi, 140 samples were collected and partial pol gene sequencing done. From
the analysis it was established that subtype A1 was the major subtype (64%)
followed by D (17%), C (9%), G (1%), and recombinants AD (4%), AC (3%),
CRF02()AG (1%), and CRF16()A2D (1%). These results suggest that the HIV-1
epidemic may be evolving toward more virulent and complex subtypes through
transmission of complex recombinants due to viral mixing. Any use of ARVs
may therefore require initial testing for de novo resistance before commencement
of treatment and/or management.
383
Longitudinal assessment of human immunodeficiency virus type 1 (HIV-

1)-specific gamma interferon responses during the first year of life in
HIV-1-infected infants.
Author: Lohman, B. L.; Slyker, J. A.; Richardson, B. A.; Farquhar, C.; Mabuka, J. M.;
Crudder, C.; Dong, T.; Obimbo, E.; Mbori-Ngacha, D.; Overbaugh, J.; Rowland-
Jones, S., and John-Stewart, G.
Source: J Virol. 2005 Jul; 79(13):8121-30.
Abstract: Human immunodeficiency virus type 1 (HIV-1) infection results in different

patterns of viral replication in pediatric compared to adult populations. The role
of early HIV-1-specific responses in viral control has not been well defined,
because most studies of HIV-1-infected infants have been retrospective or cross-
sectional. We evaluated the association between HIV-1-specific gamma
interferon (IFN-gamma) release from the cells of infants of 1 to 3 months of age
and peak viral loads and mortality in the first year of life among 61 Kenyan HIV-
1-infected infants. At 1 month, responses were detected in 7/12 (58%) and 6/21
(29%) of infants infected in utero and peripartum, respectively (P = 0.09), and in
approximately 50% of infants thereafter. Peaks of HIV-specific spot-forming
units (SFU) increased significantly with age in all infants, from 251/10(6)
peripheral blood mononuclear cells (PBMC) at 1 month of age to 501/10(6)
PBMC at 12 months of age (P = 0.03), although when limited to infants who
survived to 1 year, the increase in peak HIV-specific SFU was no longer
significant (P = 0.18). Over the first year of life, infants with IFN-gamma
responses at 1 month had peak plasma viral loads, rates of decline of viral load,
and mortality risk similar to those of infants who lacked responses at 1 month.
The strength and breadth of IFN-gamma responses at 1 month were not
significantly associated with viral containment or mortality. These results
suggest that, in contrast to HIV-1-infected adults, in whom strong cytotoxic T
lymphocyte responses in primary infection are associated with reductions in
viremia, HIV-1-infected neonates generate HIV-1-specific CD8+-T-cell responses
early in life that are not clearly associated with improved clinical outcomes.
Impact of five years of peer-mediated interventions on sexual behavior

and sexually transmitted infections among female sex workers in
Mombasa, Kenya.
Author: Luchters S; Chersich, M. F.; . = Rinyiru A; Barasa MS, and King'ola N.
Source: BMC Public Health. 2008 Apr 29; 8:143.
Abstract: 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
384
treatment. Impact of these interventions was evaluated among those who

attended peer education and at the FSW population level. 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. Over five years, sex work became
predominately a full-time activity, with increased mean sexual partners (2.8
versus 4.9/week; P less than 0.001). Consistent condom use with clients
increased from 28.8% (145/503) to 70.4% (356/506; P less than 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 greater than or equal to 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 (P=0.36).
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. (author's)
Challenges of a pandemic: HIV/AIDS-related problems affecting Kenyan

widows.
Author: Luginaah, I.; Elkins, D.; Maticka-Tyndale, E.; Landry, T., and Mathui, M.
Source: Soc Sci Med. 2005 Mar; 60(6):1219-28.
Abstract: The paper reports the findings of a qualitative study using focus group
discussions and in-depth interviews about the challenges faced by widows as
they confront the direct and indirect impacts of HIV/AIDS in Nyanza, Kenya.
Two focus groups were conducted with widows from two community-based
organizations. This was followed by in-depth interviews with four members and
two leaders from each of the community-based organizations. The contents were
analysed using grounded theory. The findings reveal several challenges
encountered by widows in their struggles with the direct and indirect impacts of
HIV/AIDS. Widows who know or do not know their HIV status are conscious
about the possibility of contracting or transmitting the virus. Wife inheritance (a
Luo custom), emerged as an outstanding issue for the widows in the context of
HIV/AIDS transmission. The widows employ various strategies to resist being
inherited. Widows in the current epidemic navigate issues of sexuality in various
ways, such as insisting their partners use condoms or permanently abstaining
from sexual intercourse.
385
Anti-retroviral drug resistance-associated mutations among non-subtype

B HIV-1-infected Kenyan children with treatment failure.
Author: Lwembe, R.; Ochieng, W.; Panikulam, A.; Mongoina, C. O.; Palakudy, T.;
Koizumi, Y.; Kageyama, S.; Yamamoto, N.; Shioda, T.; Musoke, R.; Owens, M.;
Songok, E. M.; Okoth, F. A., and Ichimura, H.
Source: J Med Virol. 2007 Jul; 79(7):865-72.
Abstract: Recently increased availability of anti-retroviral therapy (ART) has mitigated

HIV-1/AIDS prognoses especially in resource poor settings. The emergence of
ART resistance-associated mutations from non-suppressive ART has been
implicated as a major cause of ART failure. Reverse transcriptase inhibitor (RTI)-
resistance mutations among 12 non-subtype B HIV-1-infected children with
treatment failure were evaluated by genotypically analyzing HIV-1 strains
isolated from plasma obtained between 2001 and 2004. A region of pol-RT gene
was amplified and at least five clones per sample were analyzed. Phylogenetic
analysis revealed HIV-1 subtype A1 (n = 7), subtype C (n = 1), subtype D (n = 3),
and CRF02_AG (n = 1). Before treatment, 4 of 12 (33.3%) children had primary
RTI-resistance mutations, K103N (n = 3, ages 5-7 years) and Y181C (n = 1, age 1
year). In one child, K103N was found as a minor population (1/5 clones) before
treatment and became major (7/7 clones) 8 months after RTI treatment. In 7 of 12
children, M184V appeared with one thymidine-analogue-associated mutation
(TAM) as the first mutation, while the remaining 5 children had only TAMs
appearing either individually (n = 2), or as TAMs 1 (M41L, L210W, and T215Y)
and 2 (D67N, K70R, and K219Q/E/R) appearing together (n = 3). These results
suggest that "vertically transmitted" primary RTI-resistance mutations, K103N
and Y181C, can persist over the years even in the absence of drug pressure and
impact RTI treatment negatively, and that appearing patterns of RTI-resistance
mutations among non-subtype B HIV-1-infected children could possibly be
different from those reported in subtype B-infected children.
Should voluntary counseling and testing counselors address alcohol use

with clients? Findings from an operations research study in Kenya.
Author: Mackenzie C and Kiraju, K.
Abstract: With more than 800 VCT centers spread all over Kenya (NASCOP 2006), VCT
services are now an important entry point for HIV prevention, treatment, and
care. During pre-test counseling, clients are given information on modes of HIV
transmission and triggers of risky behavior. Thus, the VCT setting offers an
optimal venue for discussing alcohol as a factor in HIV transmission and for
helping clients formulate a risk-reduction plan. Because both HIV and alcohol
abuse are stigmatized, VCT centers can offer a supportive atmosphere to bring
up risk behaviors that are otherwise uncomfortable to discuss, and can offer
appropriate referrals. In order to document whether there is an unmet need for
386
alcohol counseling among VCT clients in Kenya, focus group discussions and
exit interviews were conducted in a variety of VCT service delivery points. This
research is part of a larger operations research project being implemented by the
Horizons Program, Liverpool VCT and Care, and the Steadman Group. Its goal is
to provide information on the alcohol and substance use counseling needs of
clients seeking HIV services, and provide guidance on how substance use can be
effectively integrated into HIV counseling and testing. (excerpt)
The link between HIV / AIDS and recent fertility patterns in Kenya.
Author: Magadi M and Agwanda, A.
Abstract: The relationship between fertility and the HIV/AIDS epidemic is not well
understood. Although existing studies elsewhere generally point to the epidemic
resulting in fertility reduction, earlier evidence from the Kenya Demographic
and Health Survey 2003 (Central Bureau of Statistics [CBS], Kenya Ministry of
Health [MOH] & ORC Macro, 2004), hereafter referred to as KDHS, showed
interesting patterns, with regions most adversely affected with the HIV/AIDS
epidemic showing the clearest sign of a reversal trend in fertility decline.
HIV/AIDS may influence fertility through one or more behavioral and/or
biological proximate fertility determinants. In this study, we explore: (i) the
regional variations in the link between HIV/AIDS and fertility; (ii) possible
mechanisms through which HIV/AIDS may influence fertility; and (iii) the effect
of individual and contextual community-level HIV/AIDS factors on fertility. The
study is based on secondary analysis of the 2003 KDHS data, which provides a
unique opportunity to explore the impact of the HIV/AIDS epidemic on the
affected populations, being the fourth survey in the international DHS program
to include HIV testing, and the first to anonymously link the HIV results with
key behavioral, social, and demographic factors at individual and household
level. Multilevel models are used to examine the effect of individual and
contextual community-level HIV/AIDS factors on fertility. The modeling is
carried out in stages, starting with the key variables relating to HIV/AIDS,
before introducing various proximate fertility determinants in successive stages,
to explore possible mechanisms through which HIV/AIDS may influence
fertility. The study corroborates findings of earlier studies on the fertility
inhibiting effect of HIV/AIDS among infected women. HIV/AIDS infected
women have 40 percent lower odds of having had a recent birth than their
uninfected counterparts of similar background characteristics and child mortality
experience. After taking into account proximate determinants of fertility relating
to sexual exposure, breastfeeding duration, and fetal loss, the odds for
HIV/AIDS infected women are 33 percent lower, suggesting that the effect of
HIV/AIDS on fertility is partly through these proximate determinants. However,
there is no evidence of a significant association between community level
HIV/AIDS prevalence and fertility when the background socio-cultural and
demographic factors are controlled for. The results suggest that although recent
trends in sexual exposure factors (e.g. rising age at first sex and age at first
marriage and a decline in the proportion of women in union) might be expected
387
to sustain a declining trend in fertility, trends in some of the proximate

determinants, including reduced duration of breastfeeding and increased child
mortality coupled with reduced desire to stop childbearing may have
contributed to the stalled fertility decline in Kenya. Whilst HIV/AIDS may have
influenced the recent changes in sexual exposure factors, it is also likelythat it has
contributed to increasing infant and child mortality and reduced duration of
breastfeeding, which are partly responsible for the stall in fertility decline. The
regional patterns show that the most notable increase in fertility and the greatest
decline in contraceptive prevalence were observed in Nyanza province, the
region with the highest HIV/AIDS prevalence. The regional patterns of the other
proximate determinants with respect to sexual exposure factors, infant/child
mortality and duration of breastfeeding all show unfavorable patterns for the
region. For instance, Nyanza has consistently recorded the lowest age at first sex,
the lowest age at first marriage, and the highest infant and child mortality in
Kenya across years. The recent trends in Nyanza have not been encouraging
either: it witnessed the least overall rise in age at first sex and first marriage
during the 1993-2003 period; and recorded among the greatest declines in the
duration of breastfeeding. These patterns are likely to have contributed to the
observed reversal of fertility decline in the region. (author's)
Association of HIV infection with poor genital hygiene and medical

treatment for prior serious illness suggests latrogenic transmission.
Authors' reply [letter]. JAIDS.
Author: Magaret, A. S.; . = Bukusi EA; Cohen CR, and Holmes KK.
Source: Journal of Acquired Immune Deficiency Syndromes. 2007 Mar 1; 44(3):366.
Abstract: Brody and colleagues provide a useful critique of our article that questions
whether causation can be attributed to the detected association between genital
hygiene and HIV-1 status among Kenyan males participating in a study of
bacterial vaginosis (BV) in their female partners. They point to a potential
confounder, injection treatment for illness, which they argue could possibly
explain the associations of "ever treated for serious illness" and the hygiene
measure with HIV-1 seropositivity. Previous studies from our group have indeed
implicated penicillin injections as risk factors for hepatitis B virus infection and
for human T-lymphotropic virus type 1 (HTLV-1) infection but not for HIV
infection in female sex workers in another developing country setting. With
regard to the issue of causation, we had stated in our results that "the decreased
odds of HIV-1 infection associated with large values of hygiene component 2
suggest an inverse association between good hygiene and prevalence of HIV-1."
In the discussion section, we further stressed our unwillingness to assert
causation, citing the cross--sectional nature of our study as a limitation.
Considering injection for illness as a plausible confounder and source of HIV-1
acquisition, we can provide additional clarification about the variables
presented. Twenty-one of 150 male participants had been previously treated for a
"serious illness," a self-described condition, which was further specified by
388
respondents: 8 had had tuberculosis (TB); 2 each had had road accidents and
ulcers; and 1 each had had allergies, asthma, arthritis, chronic bronchitis,
diabetes, hypertension, phimosis, pneumonia, and typhoid. In Nairobi, injection
treatment is often used for some but not all of these conditions. It is plausible that
some of the association of treatment for a serious illness could be attributable to
iatrogenic transmission. The chronologic relation of HIV-1 infection and these
illnesses (as with hygiene practices) is not known; however, it is quite likely that
the most common of the serious illnesses reported-TB-and perhaps certain others
simply reflect complications of HIV infection. (excerpt)
Quid pro quo: a journalistic look at NGO-media interaction in Africa.

Author: Malan, M.
Source: Brown Journal of World Affairs. 2005 Winter-2006 Spring; 11(2):173-184.
Abstract: On the opening day of the fifteenth International Conference on HIV/AIDS,

South Africa's Health Minister, Dr. Manto Tshabala-Msimang, addressed
journalists and compatriots at the country's booth. She said, "There is increasing
evidence suggesting that Nevirapine [a cost-effective drug used to prevent
mother-to-child-transmission of HIV] creates resistance in HIV-positive mothers
and their babies, making its use unsafe if they later want to use the drug as an
anti-retroviral." The Minister referred to a preliminary study to support her
statements. This statement, along with an announcement by the country's
Medicines Control Council (MCC) that it is considering the deregistration of
single-dose Nevirapine, raised eyebrows. Two years prior to the conference,
South Africa's highest court had ordered Dr. Tshabalala-Msimang to make drug
available, free of charge, to HIV-positive pregnant women and their babies. The
Minister has displayed resistance to the order ever since. (excerpt)
389
Prevalence of dyslipidemia and dysglycaemia in HIV infected patients.

Author: Manuthu, E. M.; Joshi, M. D.; Lule, G. N., and Karari, E.
Source: East Afr Med J. 2008 Jan; 85(1):10-7.
Highly active antiretroviral therapy (HAART) has dramatically reduced AIDS
morbidity and mortality, however long-term metabolic consequences including
dysglycaemia and dyslipidemia have raised concern regarding accelerated
cardiovascular disease risk.
Objective:
To determine the period prevalence of dyslipidemia and dysglycaemia in HIV-
infected patients.
Design: Cross-sectional comparative group study.
Setting: Kenyatta National Hospital, a tertiary HIV dedicated out-patient facility.
Subjects: Consecutive HIV- positive adult patients.

Dyslipidemia: presence of raised total or LDL cholesterol or low HDL
cholesterol, or raised triglycerides. Dysglycaemia: presence of impaired fasting
glucose or impaired glucose tolerance, or diabetes mellitus.
Results:
Between January and April 2006, out of 342 screened patients, 295 were
recruited and 58% were females. One hundred and thirty four (45%) were on
HAART, 82% of whom were on stavudine, lamivudine and either nevirapine or
efavirenz. Overall prevalence of dyslipidemiawas 63.1% and dysglycaemia was
20.7%. High total cholesterol occurred in 39.2% of HAART and 10.0% HAART
naive patients (p<0.0001, OR 5.18, CI 3.11-10.86), whereas high LDL cholesterol
occurred in 40.8% and in 11.2% respectively (p<0.0001, OR 5.43, CI 2.973-9.917).
HDL levels were low in 14.6% and 51.3% among HAART and HAART naive
patients, respectively, (p<0.0001, OR 0.16, CI 0.091-0.29) while high triglycerides
occurred in 25.6% and 22.5% respectively (p=0.541 OR 1.184 CI 0.688-2.037).
Among patients on HAART compared to HAART naive patients, diabetes was
found in 1.5% against 1.2% (p=0.85), impaired fasting in 2.2% against 0.6%
(p=0.30) and impaired glucose tolerance in 16.4% against 21.1% (p=0.22),
respectively.
Conclusions:
HIV- infected patients demonstrated a high prevalence of dyslipidemia. HAART
use was associated with high levels of total, and LDL cholesterol and high
triglyceride levels, an established athrogenic lipid profile. However, HAART was
390
not associated with low HDL cholesterol and had no significant effect on
dysglycaemia.
Using mass media campaigns to promote voluntary counseling and HIV-

testing services in Kenya.
Author: Marum, E.; Morgan, G.; Hightower, A.; Ngare, C., and Taegtmeyer, M.
Source: AIDS. 2008 Oct 1; 22(15):2019-24.
Kenya, a country with high HIV prevalence, has seen a rapid scale-up of
voluntary counseling and HIV-testing (VCT) services from three sites in 2000 to
585 by June 2005. From 2002 onwards, services were promoted by a four-phase
professionally designed mass media campaign.
Objective:
To assess the impact of a mass media campaign on VCT services. DESIGN:
Observational data from client records.
Methods:
VCT client data from 131 voluntary counseling and testing sites were included.
Descriptive statistics and Poisson regression were used to assess the impact of
campaign phases.
Results:
Client records (381,160) from 131 sites were analyzed. A linear increase in new
sites and an exponential increase in client utilization were observed. Regression
analysis revealed that the first phase of the campaign increased attendance by
28.5% (95% confidence interval = 15.9, 42.5%) and the fourth by 42.5% (95%
confidence interval = 28.4, 64.1%). These two phases, which directly mentioned
HIV, had more impact on utilization than the second and third phases, which did
not have a significant effect.
Conclusion:
The Kenyan experience suggests that a professional, intensive mass media
campaign is likely to contribute to increases in utilization of testing. Expansion of
programs for counseling and HIV testing in developing countries is likely to be
facilitated by mass media promotion of these services.
391
Acceptability of male circumcision and predictors of circumcision

preference among men and women in Nyanza Province, Kenya.
Author: Mattson, C. L.; Bailey, R. C.; Muga, R.; Poulussen, R., and Onyango, T.
Abstract: Numerous epidemiologic studies report significant associations between lack of

male circumcision and HIV-1 infection, leading some to suggest that male
circumcision be added to the limited armamentarium of HIV prevention
strategies in areas where HIV prevalence is high and the mode of transmission is
primarily heterosexual. This cross-sectional survey of 107 men and 110 women in
Nyanza Province, Kenya, assesses the attitudes, beliefs, and predictors of
circumcision preference among men and women in a traditionally non-
circumcising region. Sixty per cent (n=64) of uncircumcised men and 69% (n=68)
of women who had uncircumcised regular partners reported that they would
prefer to be circumcised or their partners to be circumcised. Men's circumcision
preference was associated with the belief that it is easier for uncircumcised men
to get penile cancer, sexually transmitted diseases, and HIV/AIDS, and that
circumcised men have more feeling in their penises, enjoy sex more, and confer
more pleasure to their partners. Women with nine or more years of school were
more likely to prefer circumcised partners. Men who preferred to remain
uncircumcised were concerned about the pain and cost of the procedure, and
pain was a significant deterrent for women to agree to circumcision for their
sons. If clinical trials prove circumcision to be efficacious in reducing risk of HIV
infection, it is likely that the procedure will be sought by a significant proportion
of the population, especially if it is affordable and minimally painful.
Scaling Sexual Behavior or "Sexual Risk Propensity" Among Men at Risk

for HIV in Kisumu, Kenya.
Author: Mattson, C. L.; Campbell, R. T.; Karabatsos, G.; Agot, K.; Ndinya-Achola, J. O.;
Moses, S., and Bailey, R. C.
Abstract: We present a scale to measure sexual risk behavior or "sexual risk propensity" to
evaluate risk compensation among men engaged in a randomized clinical trial of
male circumcision. This statistical approach can be used to represent each
respondent's level of sexual risk behavior as the sum of his responses on multiple
dichotomous and rating scale (i.e. ordinal) items. This summary "score" can be
used to summarize information on many sexual behaviors or to evaluate changes
in sexual behavior with respect to an intervention. Our 18 item scale
demonstrated very good reliability (Cronbach's alpha of 0.87) and produced a
logical, unidimensional continuum to represent sexual risk behavior. We found
no evidence of differential item function at different time points (except for
392
reporting a concurrent partners when comparing 6 and 12 month follow-up

visits) or with respect to the language with which the instrument was
administered. Further, we established criterion validity by demonstrating a
statistically significant association between the risk scale and the acquisition of
incident sexually transmitted infections (STIs) at the 6 month follow-up and HIV
at the 12 month follow-up visits. This method has broad applicability to evaluate
sexual risk behavior in the context of other HIV and STI prevention interventions
(e.g. microbicide or vaccine trials), or in response to treatment provision (e.g.,
anti-retroviral therapy).
A comparison of genital HIV-1 shedding and sexual risk behavior among

Kenyan women based on eligibility for initiation of HAART according
to WHO guidelines.
Author: McClelland, R. S.; Baeten, J. M.; Richardson, B. A.; Lavreys, L.; Emery, S.;
Mandaliya, K.; Ndinya-Achola, J. O., and Overbaugh, J.
Guidelines for initiating antiretrovirals are based on markers of advanced
disease and are not directly linked to markers of HIV-1 transmission such as viral
shedding.
Methods:
We evaluated genital HIV-1 shedding and risk behavior among 650
antiretroviral-naive women stratified by WHO criteria for initiating
antiretrovirals based on CD4 count and symptoms.
Results:
Genital HIV-1 concentrations increased in stepwise fashion with declining CD4
counts and the presence of symptoms. Compared with the reference group
(asymptomatic with CD4 >350 cells/microL), those with advanced
immunosuppression (CD4 <200 cells/microL) had significantly higher cervical
HIV-1 RNA concentrations (2.4 log10 copies/swab vs. 3.8 log10 copies/swab, P <
0.001). However, women with CD4 counts <200 cells/microL were also less
likely than the reference group to report intercourse during the past week (58%
vs. 26%, P < 0.001).
Conclusions:
Antiretroviral guidelines focusing on individuals with the most advanced
immunosuppression will target those with the highest genital HIV-1
concentrations. However, individuals with less advanced immunosuppression
also have high levels of genital HIV-1 and may be more sexually active. The
effect of increased antiretroviral availability on the spread of HIV-1 might be
enhanced by extending treatment, in addition to other risk reduction services, to
those with less advanced disease.
393
HIV-1 acquisition and disease progression are associated with decreased

high-risk sexual behaviour among Kenyan female sex workers.
Author: McClelland, R. S.; Hassan, W. M.; Lavreys, L.; Richardson, B. A.; Mandaliya, K.;
Ndinya-Achola, J.; Jaoko, W.; Kurth, A. E., and Baeten, J. M.
Source: AIDS. 2006 Oct 3; 20(15):1969-73.
Changes in sexual risk behaviour may occur following HIV-1 infection.
Objective:
To test the hypothesis that HIV-1 seroconversion and disease progression are
associated with changes in risk behaviours, using data from a cohort of Kenyan
female sex workers (FSWs).
Methods:
HIV-1-seronegative FSWs were enrolled in a prospective cohort study of risk
factors for HIV-1 acquisition. At monthly visits, standardized interviews were
conducted to assess sexual risk behaviour and HIV-1 serologic testing was
performed. Seroconverters were invited to continue with follow-up. Between
1993 and 2004 (when antiretroviral therapy was introduced in the cohort), 265
women seroconverted for HIV-1 (incidence 7.7/100 person-years) and were
included in this analysis.
Results:
Unprotected intercourse was reported at 546/2037 (27%) pre-seroconversion
visits versus 557/3732 (15%) post-seroconversion visits (P < 0.001). These
findings remained significant after adjustment for potential confounding factors
[adjusted odds ratio (AOR) 0.69; 95% confidence interval (CI), 0.55-0.86].
Compared with HIV-1-seronegative women, there was a progressive stepwise
decrease in unprotected intercourse among HIV-1-seropositive women with CD4
cell counts > or = 500 (AOR, 0.93; 95% CI, 0.62-1.39), 200-499 (AOR, 0.58; 95% CI,
0.41-0.82) and < 200 cells/microl (AOR, 0.45; 95% CI, 0.25-0.82). Decreases in
unprotected intercourse reflected increases in both abstinence and 100% condom
use. Women also reported fewer partners and fewer episodes of intercourse after
HIV-1 seroconversion.
Conclusions:
HIV-1 seroconversion and disease progression were associated with decreases in
sexual risk behaviour among Kenyan FSWs.
Contribution of HIV-1 infection to acquisition of sexually transmitted

disease: a 10-year prospective study.
394
Author: McClelland, R. S.; Lavreys, L.; Katingima, C.; Overbaugh, J.; Chohan, V.;
Mandaliya, K.; Ndinya-Achola, J., and Baeten, J. M.
Sexually transmitted diseases (STDs) enhance human immunodeficiency virus
(HIV)-1 susceptibility, but few studies have examined the reciprocal effect of
HIV-1 on STD acquisition.
Methods:
Data from a prospective cohort study conducted among female sex workers in
Mombasa, Kenya between 1993 and 2003 were used to determine the effect of
HIV-1 infection on STD susceptibility. The cohort included 1215 HIV-1-
seronegative women who underwent monthly HIV-1 and STD screening, of
whom 238 experienced seroconversion to HIV-1 during follow-up. Andersen-Gill
proportional-hazards models were used to compare the incidence rates for
genital-tract infections (syphilis, genital ulcer disease [GUD], Neisseria
gonorrhoeae infection, Chlamydia trachomatis infection, Trichomonas vaginalis
infection, vulvovaginal candidiasis, and bacterial vaginosis) in HIV-1-
seropositive versus HIV-1-seronegative women, after controlling for sexual
behavior and other potential confounding factors.
Results:
HIV-1 infection was associated with a significantly higher incidence of GUD
(hazard ratio [HR], 2.8; 95% confidence interval [CI], 2.0-3.9), gonorrhea (HR, 1.6;
95% CI, 1.1-2.2), and vulvovaginal candidiasis (HR, 1.5; 95% CI, 1.3-1.8). The risks
of GUD and vulvovaginal candidiasis increased with progressive levels of
immunosuppression.
Conclusions:
The increased incidence of genital-tract infections among HIV-1-seropositive
women could promote the spread of both HIV-1 and other STDs, particularly in
areas where these conditions are highly prevalent.

Author: McClelland, R. S.; Richardson, B. A.; Graham, S. M.; Masese, L. N.; Gitau, R.;
Lavreys, L.; Mandaliya, K.; Jaoko, W.; Baeten, J. M., and Ndinya-Achola, J. O.
Source: Sex Transm Dis. 2008 Jun; 35(6):617-23.
Bacterial vaginosis (BV) is common and has been associated with increased HIV-
African women at high risk for acquiring HIV-1.
395
Methods:
We conducted a prospective study among 151 HIV-1-seronegative Kenyan
female sex workers. Nonpregnant women were eligible if they did not have
symptoms of abnormal vaginal itching or discharge at the time of enrollment. At
monthly follow-up, a vaginal examination and laboratory testing for genital tract
infections were performed. Multivariate Andersen-Gill proportional hazards
analysis was used to identify correlates of BV.
Results:
Participants completed a median of 378 (interquartile range 350-412) days of
follow-up. Compared with women reporting no vaginal washing, those who
reported vaginal washing 1 to 14 [adjusted hazard ratio (aHR) 1.29, 95%
confidence interval (CI) 0.88-1.89], 15 to 28 (aHR 1.60, 95% CI 0.98-2.61), and >28
times/wk (aHR 2.39, 95% CI 1.35-4.23) were at increased risk of BV. Higher BV
incidence was also associated with the use of cloth for intravaginal cleansing
(aHR 1.48, 95% CI 1.06-2.08) and with recent unprotected intercourse (aHR 1.75,
95% CI 1.47-2.08). Women using depot medroxyprogesterone acetate
contraception were at lower risk for BV (aHR 0.59, 95% CI 0.48-0.73).
Conclusions:
Vaginal washing and unprotected intercourse were associated with increased
risk of BV. These findings could help to inform the development of novel vaginal
health approaches for HIV-1 risk reduction in women.
Implication of Ariaal sexual mixing on gonorrhea.

Author: McCluskey, C. C.; Roth, E., and van den Driessche, P.
Source: Am J Hum Biol. 2005 May-2005 Jun 30; 17(3):293-301.
Abstract: Recent research on sexual mixing in populations of sub-Saharan Africa raises the
question as to whether STDs can persist in these populations without the
presence of a core group. A mathematical model is constructed for the spread of
gonorrhea among the Ariaal population of Northern Kenya. A formula for the
basic reproduction number R(0) (the expected number of secondary infections
caused by a single new infective introduced into a susceptible population) is
determined for this population in the absence of a core group. Survey data taken
in 2003 on sexual behavior from the Ariaal population are used in the model
which is formulated for their age-set system including four subpopulations:
single and married, female and male. Parameters derived from the data, and
other information from sub-Saharan Africa are used to estimate R(0). Results
indicate that, even with the elevating effect of the age-set system, the disease
should die out since R(0) < 1. Thus, the persistence of gonorrhea in the
population must be due to factors not included in the model, for example, a core
group of commercial sex workers or concurrent partnerships.
396
Cross-clade CD8(+) T-cell responses with a preference for the

predominant circulating clade.
Author: McKinnon, L. R.; Ball, T. B.; Kimani, J.; Wachihi, C.; Matu, L.; Luo, M.; Embree, J.;
Fowke, K. R., and Plummer, F. A.
Abstract: Human immunodeficiency virus (HIV) genetic diversity is a major impediment

to the design of a successful vaccine. Even if an HIV vaccine is proven effective, it
remains to be seen whether this protection will extend to inter-clade, intra-clade,
and recombinant strains. We used recombinant vaccinia-based interferon gamma
(IFN) Elispot assays to test the inter-clade crossreactivity of clades A, B, C, and D
HIV Env in two cohorts of HIV-infected Kenyans. Despite the tremendous
diversity in this HIV protein, a substantial proportion of multi-clade responses
were observed. Although these multi-clade responses correlated well with each
other in regression analyses, clade A responses were seen at a higher frequency
and at greater relative magnitudes in a proportion of these patients, when
compared to the other three clades. Epitope mapping indicates CD8(+) T cell
recognition of conserved regions of Env, accounting for the high degree of cross-
reactivity but not the clade A preference. A better understanding of cross-clade
CD8(+) T cell responses to HIV may help to predict whether a successful vaccine
could be used to stop geographically and genetically distinct HIV epidemics.
Epitope cross-reactivity frequently differs between central and effector

memory HIV-specific CD8+ T cells.
Author: McKinnon, L. R.; Ball, T. B.; Wachihi, C.; McLaren, P. J.; Waruk, J. L.; Mao, X.;
Ramdahin, S.; Anzala, A. O.; Kamene, J.; Luo, M.; Fowke, K. R., and Plummer, F.
A.
Source: J Immunol. 2007 Mar 15; 178(6):3750-6.
Abstract: HIV diversity may limit the breadth of vaccine coverage due to epitope sequence
differences between strains. Although amino acid substitutions within CD8(+) T
cell HIV epitopes can result in complete or partial abrogation of responses, this
has primarily been demonstrated in effector CD8(+) T cells. In an HIV-infected
Kenyan cohort, we demonstrate that the cross-reactivity of HIV epitope variants
differs dramatically between overnight IFN-gamma and longer-term
proliferation assays. For most epitopes, particular variants (not the index
peptide) were preferred in proliferation in the absence of corresponding
overnight IFN-gamma responses and in the absence of the variant in the HIV
quasispecies. Most proliferating CD8(+) T cells were polyfunctional via cytokine
analyses. A trend to positive correlation was observed between proliferation (but
not IFN-gamma) and CD4 counts. We present findings relevant to the
397
assessment of HIV vaccine candidates and toward a better understanding of how

viral diversity is tolerated by central and effector memory CD8(+) T cells.
Herpes simplex virus type 2 infection among young uncircumcised men

in Kisumu, Kenya.
Author: Mehta, S. D.; . = Moses S; Agot K; Agingu W, and Parker C.
Source: Sexually Transmitted Infections. 2008 Feb 1; 84(1):42-48.
Abstract: The objectives were to identify factors associated with herpes simplex virus type
2 (HSV-2) infection among men aged 18-24 in Kisumu, Kenya. Baseline data from
a randomised trial of male circumcision were analysed. Participants were
interviewed for sociodemographic and behavioural risks. The outcome was HSV-
2 by antibody status. Risk factors were considered singly and in combination
through logistic regression models. Among 2771 uncircumcised men, 766 (27.6%;
95% confidence interval (CI) 26.0% to 29.3%) tested antibody positive for HSV-2.
The median age at first sex was 16 years, and the median number of lifetime
sexual partners was four. HSV-2 seroprevalence increased from 19% among 18-
year-olds to 43% among 24-year-olds (p less than 0.001). In multivariable
analysis, statistically significant risks for infection were increasing age (adjusted
odds ratio (AOR)=1.22-2.58), being married or having a live-in female partner
(AOR=1.80; 95% CI 1.28 to 2.53), preferring "dry" sex (AOR=1.39; 95% CI 1.14 to
1.69), reported penile cuts or abrasions during sex (AOR=1.58; 95% CI 1.32 to
1.91), increasing lifetime sex partners (multiple response categories; AORs
ranging from 1.65 to 1.97), and non-student occupation (multiple response
categories; AORs ranging from 1.44 to 1.93). Risk decreased with reported
condom used at last sex (AOR=0.82; 95% CI 0.68 to 0.99). Primary prevention
efforts should be initiated at an early age. The same behavioural interventions
used currently for HIV prevention-abstinence, reducing the number of sex
partners and increasing condom use-should be effective for HSV-2 prevention.
(author's)
398
Identification of novel risks for nonulcerative sexually transmitted

infections among young men in Kisumu, Kenya.
Author: Mehta, S. D.; Moses, S.; Ndinya-Achola, J. O.; Agot, K.; Maclean, I., and Bailey, R.
C.
Source: Sex Transm Dis. 2007 Nov; 34(11):892-9.
STI prevention interventions often aim to reduce HIV incidence. Understanding
STI risks may lead to more effective HIV prevention.
Goal:
To identify STI risks among men aged 18-24 in Kisumu, Kenya.
Study design:
We analyzed baseline data from a randomized trial of male circumcision.
Participants were interviewed for sociodemographic and behavioral risks.
Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) were diagnosed by
polymerase chain reaction assay and Trichomonas vaginalis (TV) by culture. The
outcome for logistic regression analysis was infection with NG, CT, or TV.
Results:
Among 2743 men, 214 (7.8%; 95% CI: 6.8%-8.8%) were infected with any STI. In
multivariable analysis, statistically significant risks for infection were: living
one's whole life in Kisumu (OR = 1.50; 95% CI: 1.12-2.01), preferring "dry" sex
(OR = 1.47; 95% CI: 1.05-2.07), HSV-2 seropositivity (OR = 1.37; 95% CI: 1.01-
1.86), and inability to ejaculate during sex (OR = 2.04; 95% CI: 1.15-3.62). Risk
decreased with increasing age and education, and cleaning one's penis less than
1 hour after sex (OR = 0.51; 95% CI: 0.33-0.80).
Conclusion:
Understanding how postcoital cleaning, "dry" sex, and sexual dysfunction relate
to STI acquisition may improve STI and HIV prevention.
Independent association of hygiene, socioeconomic status, and

circumcision with reduced risk of HIV infection among Kenyan men.
Author: Meier, A. S.; Bukusi, E. A.; Cohen, C. R., and Holmes, K. K.
Abstract: Among Kenyan men recruited as sex partners of women with genital symptoms,
22 of 150 were HIV seropositive. Because male HIV infection and male hygiene
were unexpectedly found to be associated with each other, we examined the
relationship of 5 hygiene variables with HIV infection in the men in a principal
399
components analysis, controlling for socioeconomic status and other potential

confounders. By multivariate analyses, HIV infection in men was not only
independently associated with previous illness (odds ratio [OR], 5.1; 95%
confidence interval [CI], 1.4-19.1) and inversely associated with being
circumcised (OR, 0.12; 95% CI, 0.02-0.91), but also independently associated with
a combined measure of hygiene (OR, 0.41; 95% CI, 0.19-0.90).

Author: Miller, A. N.; Fellows, K. L., and Kizito, M. N.
Source: Health Commun. 2007; 22(3):207-19.
Abstract: This study examined the impact of controllability of onset (i.e., means of
Motivations and methods for self-disclosure of HIV seropositivity in

Nairobi, Kenya.
Author: Miller, A. N. and Rubin, D. L.
Source: AIDS Behav. 2007 Sep; 11(5):687-97.
Abstract: This study employed structured interviews with 307 people living with HIV
(PLHIVs) in Nairobi, Kenya to investigate their serostatus disclosure with respect
to four types of relationships in their lives: partners, friends, family members,
and religious leaders/clergy. Regarding motivations for disclosure, it was found
that a sense of duty and seeking material support motivated disclosure to family
and partners, fear of loss of confidentiality inhibited disclosure to friends, and
400
the need for advice encouraged disclosure to religious leaders. The method of
disclosure most frequently mentioned was direct, with males less likely than
females to use direct methods when disclosing to spouses or partners.
Intermediated disclosure was common in partner/spouse relationships with
around one-third of partners preferring to disclose through a third party.
Methods used to disclose as well as reasons for doing so varied by relationship
type.

Saharan Africa.
Author: Mishra, V.; Assche, S. B.; Greener, R.; Vaessen, M.; Hong, R.; Ghys, P. D.; Boerma,
J. T.; Van Assche, A.; Khan, S., and Rutstein, S.
Source: AIDS. 2007 Nov; 21 Suppl 7:S17-28.
Wealthier populations do better than poorer ones on most measures of health
status, including nutrition, morbidity and mortality, and healthcare utilization.
Objectives:
This study examines the association between household wealth status and HIV
serostatus to identify what characteristics and behaviours are associated with
HIV infection, and the role of confounding factors such as place of residence and
other risk factors.
Methods:
Results:
Conclusion:
401
In sub-Saharan Africa, HIV prevalence does not exhibit the same pattern of
association with poverty as most other diseases. HIV programmes should also
focus on the wealthier segments of the population.
Spatial modeling of HIV prevalence in Kenya.

Author: Montana L; Neuman M, and Mishra, V.
Abstract: A clear understanding of geographic distribution of HIV-infected people and

maintaining up-to-date lists and locations of facilities providing HIV-related
services are essential for monitoring the epidemic and for providing treatment,
care, and support services to the infected and their families. In this study, we
model and map human immunodeficiency virus (HIV) prevalence in Kenya in
relation to its spatial and behavioral determinants, using data from the 2003
Kenya Demographic and Health Survey (DHS). The 2003 Kenya DHS is one of
the first population-based national surveys to link individual HIV test results for
both males (age 15-54) and females (age 15-49) with the full set of behavioral,
social, and demographic indicators included in the survey. The survey also
collected spatial coordinates of the communities where survey respondents lived.
These coordinates have been used to estimate spatial indicators such as distance
to roads, distance to Lake Victoria, and population density. Using these spatial,
social, demographic, and behavioral indicators, we developed a model to predict
HIV prevalence. We apply this model to map HIV concentration areas at sub-
provincial level, and we assess the existing HIV service coverage in relation to
the spatial distribution of HIV prevalence. The study finds large subregional
variations in the prevalence of HIV in Kenya. Areas of high concentration of
HIV-infected people have a disproportionately low density of HIV-related
services. (author's)
Chanuka! Get smart in Kenya: Promoting VCT nationwide in Kenya.

Author: Morgan, G.
Source: VCT in Focus. 2006 Nov; 1(4):3.
Abstract: In 2000, the Government of Kenya (GoK) committed to the rapid scale up of VCT
and by June 2005, registered VCT sites had increased from 3 sites (in 2000) to 585
sites. In order to complement the growth in VCT services, a national
communications committee was formed (MoH, NACC, USAID, CDC) and a
multi-stage promotional campaign was included in the national plan. PSI was
contracted by FHI and CDC as the implementing agency to support the scale-up
of VCT services and to increase public demand. Four mass media campaigns
have been used to promote VCT in Kenya, using a variety of media channels. A
simple, easily recognizable logo was designed and used on all advertising and
print materials. Logo signboards were also provided to registered VCT sites
which encouraged sites to meet quality assurance standards or else face de-
402
registration. The logo has become widely recognized in Kenya, with unregistered
sites trying to display hand painted copies. (excerpt)
Sexual and treatment-seeking behaviour for sexually transmitted

infection in long-distance transport workers of East Africa.
Source: Sex Transm Infect. 2007 Jun; 83(3):242-5.
To investigate the sexual and treatment-seeking behaviour for sexually
transmitted infection (STI) in long-distance transport workers of East Africa.
Methods:
A health-seeking behaviour survey was carried out at four sites on the Mombasa-
Kampala trans-Africa highway (n = 381). The questionnaires probed details of
STI knowledge, symptoms and care-seeking behaviour. In one site at the Kenya-
Uganda border, a sexual patterning matrix was used (n = 202) to measure sexual
behaviour in truck drivers and their assistants over the 12-month period before
the interview.
Results:
Over half of the sexual acts of long-distance transport workers over 12 months
were with female sex workers, with an annual average of 2.8 sexual partners.
Condom use was reported at 70% for liaisons with casual partners. 15% of
truckers had had a self-reported STI and one-third exhibited high-risk sexual
behaviour in the previous year. Of those with an STI, 85% had symptoms when
on the road and 77.2% sought treatment within 1 week of onset of symptoms.
94% of drivers and 56% of assistants sought treatment for STI in a private health
facility or pharmacy. The cost of private facilities and pharmacies was not
significantly higher than in the public sector. Waiting times were three times
longer in the public sector. Only 28.9% of patients completed their medication
courses as prescribed.
Conclusions:
Truck drivers and their assistants in East Africa have high rates of reported STIs
and many continue to exhibit high-risk sexual behaviour. The transport workers
studied here favoured private health facilities because of convenience and
shorter waiting times.
403
Sexual Behavior of Female Sex Workers and Access to Condoms in

Kenya and Uganda on the trans-Africa Highway.
Author: Morris, C. N.; Morris, S. R., and Ferguson, A. G.
Abstract: Female sex workers and their clients remain a high risk core group for HIV in
Africa. We measured sexual behavior of a snowball sample of female sex
workers (FSW) along the Trans Africa highway from Mombasa, Kenya to
Kampala, Uganda and surveyed the availability of male condoms at 1,007 bars
and lodgings in Kenya along the highway trucking stops where transactional sex
occurs. There were 578 FSW one month sex diaries analyzed, 403 from Kenya
and 175 from Uganda. Kenyan FSW had a median of 45 sexual acts per 28 days
compared to 39 sex acts per 28 days by Ugandan FSW (P < 0.05). Condom use by
FSW for all sexual liaisons was 79% in Kenya compared to 74% in Uganda. In
multivariate analysis, adjusting for repeated measures, Kenyan FSW were more
likely to use a condom by an adjusted odds ratio of 2.54 (95% confidence interval
1.89-3.41) compared to Ugandan FSW. Condom use with regular clients was
50.8% in Uganda compared with 68.7% in Kenya (P < 0.01). The number of sex
workers reporting 100% condom use was 26.8% in Kenya and 18.9% in Uganda
(P < 0.01). Bars and lodges in Kenya compared to Uganda were more likely to:
have condom dispensers, 25% versus 1%, respectively (P < 0.01); distribute or sell
condoms, 73.9% versus 47.6% (P < 0.01); and have more weekly condom
distribution, 4.92 versus 1.27 condoms per seating capacity (P < 0.01). Our data
indicate that in both countries condom use for FSW is suboptimal, particularly
with regular partners, and greater condom use by Trans African highway FSW in
Kenya compared to Uganda may be related to availability. Targeted
interventions are warranted for FSW and truck drivers to prevent transmission in
this important core group.

Hospital, Kenya.
Author: Moth, I. A.; Ayayo, A. B., and Kaseje, D. O.
Source: SAHARA J. 2005 Jul; 2(2):244-50.
services at Nyanza Provincial Hospital in Kenya. A crosssectional exploratory
collect primary and secondary data.The study population was 133 clients
registered for PMTCT services. The study revealed that 52.4% of clients received
intervention, 96% waited for more than 90 minutes, and 89% took less than 10
404

information divulged during counselling. In addition, 80% of clients did not
present for follow-up counselling irrespective of HIV status, and 95%, did not
HIV result (31.5%), enrollment (53.6%), and delivery (80.7%). Reasons for
dropout included fear of positive HIV result, chronic illness, stigma and
discrimination, unsupportive spouse and inability to pay for the services.
Kenya HIV / AIDS Service Provision Assessment Survey, 2004.

Author: Muga R; Ndavi P; Kizito P; Buluma R, and Lumumba, V.
Abstract: The 2004 Kenya HIV/AIDS Service Provision Assessment (Kenya HIV/AIDS
SPA) survey determines and provides baseline information on the capacity of the
formal health sector in Kenya to provide both basic and advanced level
HIV/AIDS services and the availability of record keeping systems for
monitoring HIV/AIDS care and support. The survey was conducted in a
representative sample of 440 facilities including hospitals, health centres,
maternities, dispensaries, clinics and stand-alone VCT facilities throughout
Kenya managed by government, nongovernmental organizations (NGOs),
private for-profit and faith-based organizations (FBOs). The HIV/AIDS-related
services that were assessed include: testing capability, care and support services
(CSS), antiretroviral therapy (ART), post-exposure prophylaxis (PEP), prevention
of mother-to-child transmission (PMTCT) and youth friendly services (YFS).
(excerpt)
Effect of human immunodeficiency virus-1 infection on treatment

outcome of acute salpingitis.
Author: Mugo, N. R.; Kiehlbauch, J. A.; Nguti, R.; Meier, A.; Gichuhi, J. W.; Stamm, W. E.,
and Cohen, C. R.
Source: Obstet Gynecol. 2006 Apr; 107(4):807-12.
To examine the effect of human immunodeficiency virus (HIV)-1 infection on
treatment outcome of laparoscopically verified acute salpingitis.
405
Methods:
Women aged 18-40 years with laparoscopically verified acute salpingitis
received antibiotic therapy that included cefotetan 2 g intravenously and
doxycycline 100 mg orally every 12 hours and laparoscopically guided drainage
of tuboovarian abscesses of 4 cm or more. Clinical investigators blinded to HIV-
1 serostatus used predetermined clinical criteria, including calculation of a
clinical severity score and a standard treatment protocol to assess response to
therapy.
Results:
Of the 140 women with laparoscopically confirmed acute salpingitis, 61 (44%)
women had mild, 38 (27%) had moderate, and 41 (29%) had severe disease (ie,
pyosalpinx, tuboovarian abscesses, or both). Fifty-three (38%) were HIV-1-
infected. Severe disease was more common in HIV-1-infected in comparison with
HIV-1-uninfected women (20 [38%] compared with 21 [24%], P = .02). Defined as
time of hospital discharge or 75% or more reduction in baseline clinical severity
score, HIV-1-infected women with severe (6 days [4-16] compared with 5 days [3-
9], P = .09) but not those with either mild (4 days [2-6] compared with 4 days [2-
6] P = .4) or moderate salpingitis (4 days [3-7] compared with 4 days [3-6] P = .32)
tended to take longer to meet criteria for clinical improvement. The need for
intravenous clindamycin or additional surgery was not different in HIV-1-
infected and uninfected cases (15 [28%] compared with 18 [21%], P = .3).
Conclusion:
Although HIV-1 infection may prolong hospitalization in women with severe
salpingitis, all women hospitalized with acute salpingitis responded promptly to
antibiotic therapy and surgical drainage regardless of HIV-1 infection status.
LEVEL OF EVIDENCE: II-2.
Promoting female condoms in HIV voluntary counselling and testing

centres in Kenya.
Author: Mung'ala, L.; Kilonzo, N.; Angala, P.; Theobald, S., and Taegtmeyer, M.
Abstract: Promotion of male condoms and voluntary counselling and testing for HIV
(VCT) have been cornerstones of Kenya's fight against the HIV epidemic. This
paper argues that there is an urgent need to promote the female condom in
Kenya through VCT centres, which are rapidly being scaled-up across the
country and are reaching increasingly large numbers of people. Training of
counsellors using a vaginal demonstration model is needed, as well an adequate
supply of free female condoms. In a study in five VCT centres, however,
counsellors reported that most people they counselled believed female condoms
were "not as good" as male condoms. In fact, many clients had little or no
knowledge or experience of female condoms. Counsellors' knowledge too was
largely based on hearsay; most felt constrained by lack of experience and had
406
many doubts about female condoms, which need addressing. Additional areas
that require attention in training include how to re-use female condoms and the
value of female condoms for contraception. VCT counsellors in Kenya already
promote male condoms as a routine part of risk reduction counselling alongside
HIV testing. This cadre, trained in client-centred approaches, has the potential to
champion female condoms as well, to better support the right to a healthy and
safe sex life.
How feasible is a DAART strategy to promote adherence to ART?

Lessons from Mombasa, Kenya.
Author: Munyao P; Sarna A; Luchters S; Geibel S, and Shikely, K.
Abstract: As HIV treatment programs are implemented across the developing world,
increasing numbers of HIV-infected persons are being treated with highly active
antiretroviral therapy (HAART). For these people, the challenge has changed
from gaining access to life-saving treatment to taking it correctly and consistently
in order to realize the rewards of improved health status, and reduced morbidity
and mortality from HIV. To achieve these health goals patients are required to
take greater than 95 percent of their medications. Adherence to HAART is a
challenge and various interventions to promote adherence are being developed
and tested. In Kenya, researchers from the Horizons Program and the
International Center for Reproductive Health, in collaboration with Coast
Province General Hospital (CPGH), Mkomani Bomu Clinic, and Port Reitz
District Hospital (PRDH), have developed a health-facility based, directly
administered antiretroviral therapy (DAART) strategy to promote adherence.
The strategy builds on formative research findings from health workers and
HIV-positive clients of HIV/AIDS care services. It also reflects field experiences
in promoting adherence to medications to treat tuberculosis (TB) through
directly observed therapy (DOT). (excerpt)
Contraceptive use among HIV infected women attending

Comprehensive Care Centre.
Author: Mutiso, S. M.; Kinuthia, J., and Qureshi, Z.
To determine contraceptive use among HIV infected women attending
Comprehensive Care Centre at Kenyatta National Hospital.
407
Design: Hospital based cross-sectional descriptive study.
Setting: Comprehensive Care Centre (CCC), Kenyatta National Hospital.
Subjects:
The study group was non-pregnant HIV positive women on follow up at the
CCC. A total of 94 HIV infected women were interviewed between May 2006 and
August 2006 through a pretested interviewer administered questionnaire.
Consecutive women willing to participate in the study were interviewed.

Current contraceptive use, contraceptive methods, source of contraception,
reproductive intention and unmet need of family planning.
Results:
The mean age of the respondents was 34 years, 47.9% were married, all had
formal education and 74.6% were employed. Eighty six percent of the
respondents did not have reproduction intentions in the next two years;
however, only 44.2% of the respondents were using contraception. Condoms
were the most popular (81.5%) contraceptive method. Female condom was used
by 10.5% of the respondents. Norplant was the only long-term contraceptive
method and was used by only 2.6%. Dual method of contraception was practiced
by 13.5% of the respondents. Majority of the respondents obtained contraceptives
from private sector (42.9%) with less than 10% getting them from CCC. The
unmet need for family planning among the study group was 30%. Marital status
and regular sexual partner were significantly associated with contraceptive use.
Conclusion:
Although majority of respondents did not have reproduction intentions in the
next two years, use of contraception was low with only 44% being on a method.
Use of long-term contraceptive methods was low among respondents. Majority
of the respondents obtained contraceptives away from CCC. The unmet need for
family planning was high at 30%.

considerations.
Author: Muturi, N.
Source: J Health Commun. 2005 Jan-2005 Feb 28; 10(1):77-98.
Africa in spite of the various efforts and resources put in place to prevent it. In
Kenya, reproductive health programs have used the mass media and other
408

contributing to the lack of change in behavior and sexual practices. I draw on the
theoretical framework of Grunig's model of excellence in communication, the
symmetrical communication contributes toward this understanding and the
maintenance of the newly adopted behaviors and practices.
Case definitions of clinical malaria under different transmission

conditions in Kilifi District, Kenya.
Author: Mwangi, T. W.; Ross, A.; Snow, R. W., and Marsh, K.
Source: J Infect Dis. 2005 Jun 1; 191(11):1932-9.
Clear case definitions of malaria are an essential means of evaluating the
effectiveness of present and proposed interventions in malaria. The clinical signs
of malaria are nonspecific, and parasitemia accompanied by a fever may not be
sufficient to define an episode of clinical malaria in endemic areas. We defined
and quantified cases of malaria in people of different age groups from 2 areas
with different rates of transmission of malaria.
Methods:
A total of 1602 people were followed up weekly for 2 years, and all the cases of
fever accompanied by parasitemia were identified. Logistic regression methods
were used to derive case definitions of malaria.
409
Results:
Two case definitions of malaria were derived: 1 for children 1-14 years old and 1
for infants (<1 year old) and older children and adults (> or =15 years old). We
also found a higher number of episodes of clinical malaria per person per year in
people from an area of low transmission of malaria, compared with the number
of episodes in those from an area of higher transmission (0.84 vs. 0.55
episodes/person/year; incidence rate ratio, 0.66 [95% confidence interval, 0.61-
0.72]; P<.001).
Conclusions:
Case definitions of malaria are bound to be altered by factors that affect
immunity, such as age and transmission. Case definitions may, however, be
affected by other immunity-altering factors, such as HIV and vaccination status,
and this needs to be borne in mind during vaccine trials.
From behavior change communication to strategic behavioral

communication on HIV in Kenya, 1999-2006.
Author: Mwarogo, P.
Abstract: This document describes the design and implementation of IMPACT's BCC
interventions and the evolution to comprehensive SBC. Chapter one delineates
steps followed in designing the communication strategy, including the formative
assessments and creative workshops employed and the communication
strategy's evolution and expansion. Chapter two outlines the implementation
process, including the role of peer education and youth campaigns, and describes
how HIV/AIDS education and behavior change have been communicated in
interactive ways through theatre presentations, murals, and a museum
exhibition. Chapter three details the campaign to promote voluntary counseling
and testing. Chapter four shares results of evaluations of the strategy, and
chapter five synthesizes lessons learned that may assist those designing or
managing HIV communication programs in resource-poor settings. (excerpt)
Modelling the public health impact of male circumcision for HIV

prevention in high prevalence areas in Africa.
Author: Nagelkerke, N. J.; Moses, S.; de Vlas, S. J., and Bailey, R. C.
Recent clinical trials in Africa, in combination with several observational
epidemiological studies, have provided evidence that male circumcision can
reduce HIV female-to-male transmission risk by 60% or more. However, the
410
public health impact of large-scale male circumcision programs for HIV

prevention is unclear.
Methods:
Two mathematical models were examined to explore this issue: a random mixing
model and a compartmental model that distinguishes risk groups associated
with sex work. In the compartmental model, two scenarios were developed, one
calculating HIV transmission and prevalence in a context similar to the country
of Botswana, and one similar to Nyanza Province, in western Kenya.
Results:
In both models, male circumcision programs resulted in large and sustained
declines in HIV prevalence over time among both men and women. Men
benefited somewhat more than women, but prevalence among women was also
reduced substantially. With 80% male circumcision uptake, the reductions in
prevalence ranged from 45% to 67% in the two "countries", and with 50% uptake,
from 25% to 41%. It would take over a decade for the intervention to reach its full
effect.
Conclusion:
Large-scale uptake of male circumcision services in African countries with high
HIV prevalence, and where male circumcision is not now routinely practised,
could lead to substantial reductions in HIV transmission and prevalence over
time among both men and women.
Effect of Placental Malaria and HIV Infection on the Antibody

Responses to Plasmodium falciparum in Infants.
Author: Ned, R. M.; Price, A. E.; Crawford, S. B.; Ayisi, J. G.; van Eijk, A. M.; Otieno, J. A.;
Nahlen, B. L.; Steketee, R. W.; Slutsker, L.; Shi, Y. P.; Lanar, D. E., and
Udhayakumar, V.
Source: J Infect Dis. 2008 Oct 17.
@nbsp; Placental malaria (PM) and maternal infection with human
immunodeficiency virus (HIV) type 1 have been shown to affect infant morbidity
and immune responses to Plasmodium falciparum. We studied the effects of PM
and HIV infection on the antimalarial antibody responses and morbidity
outcomes of infants throughout the first year of life.
Methods:
@nbsp; A total of 411 Kenyan infants who were born to mothers who were
singly or dually infected with PM and/or HIV had their levels of
immunoglobulin G antibody to 6 P. falciparum antigens/epitopes (apical
membrane antigen-1, erythrocyte-binding antigen-175; liver-stage antigen-1
[LSA-1], circumsporozoite protein [CSP], merozoite surface protein-2, and
411
rhoptry-associated protein-1 [RAP-1]) and to tetanus toxoid (TT) tested using

enzyme-linked immunosorbent assay.
Results:
@nbsp; PM had little effect on the antibody responses of infants, whereas
maternal HIV infection resulted in decreased levels of antibody to LSA-1, CSP,
and RAP-1 epitopes at birth, compared with the absence of PM and maternal
HIV infection ([Formula: see text]). Levels of antibodies to TT were significantly
reduced in infants born to mothers coinfected with HIV and PM, compared with
the levels noted in infants born to HIV-negative mothers ([Formula: see text]). In
HIV-infected infants, levels of antibody to TT were reduced, but levels of
antibody to malarial antigens were not. Antimalarial antibody levels were
positively associated with malaria-related morbidity outcomes.
Conclusion:
@nbsp; Infant HIV infection and maternal coinfection with HIV and PM
negatively influence antibody responses to TT, but not those to malarial antigens,
in infants. Antimalarial antibodies rarely showed protective associations with
morbidity in infants and were more often a marker for malaria exposure and risk
of infection.
Sustained changes in sexual behavior by female sex workers after

completion of a randomized HIV prevention trial.
Author: Ngugi, E. N.; Chakkalackal, M.; Sharma, A.; Bukusi, E.; Njoroge, B.; Kimani, J.;
MacDonald, K. S.; Bwayo, J. J.; Cohen, C. R.; Moses, S., and Kaul, R.
Behavioral interventions in female sex workers (FSWs) are associated with
changes in sexual behavior and reduced rates of sexually transmitted infections
(STIs) and HIV We examined the sustainability of such interventions.
Methods:
HIV-uninfected Kenyan FSWs were enrolled in a clinical trial that provided free
male condoms, community and clinic-based counseling, and STI management.
After trial completion, scaled-back community-based resources remained in
place. More than a year later, women were invited to complete a follow-up
behavioral questionnaire and to undergo STI/HIV counseling and testing.
Individual changes in sexual behavior were assessed by paired analysis.
Results:
One hundred seventy-two women participated in the resurvey 1.2 years after
trial termination. Client numbers had risen (paired t test, P < 0.001), but condom
use had also increased (P < 0.001); both remained substantially lower than at
enrollment. Regular partners accounted for a greater proportion of unprotected
412
FSW sexual encounters (35% vs. 10%; P < 0.001). Only 9 (5.2%) of 172 women had
a conventional STI, and the follow-up HIV incidence of 1.6 per 100 person-years
(PYs) was similar to that during the trial period (3.7 per 100 PYs). Incident STIs
and HIV were associated with the frequency of unprotected sex and younger
age.
Conclusions:
Less intensive community-based risk reduction services after clinical trial
termination may support ongoing reductions in STIs and HIV among high-risk
FSWs.
Prevention of mother-to-child HIV transmission.

Author: Ngure, P.
Source: Contact. 2006 Aug; (182):18-21.
Abstract: Recent gains in child survival rates are threatened by the AIDS epidemic. Each
year, approximately 600 000 infants, most of them in Sub-Saharan Africa, are
born with or become HIV-positive as a result of mother-to-child HIV
transmission. The rising number of HIV-positive children places an enormous
burden on families and health care systems. Mother-to-child HIV transmission
can be greatly reduced by expanding high quality antenatal and obstetric care,
voluntary HIV counselling and testing, access to antiretroviral therapy, and the
use of breast milk substitutes or exclusive breastfeeding. In Kenya, AIDS was
declared a national in 1999. Over 2.5 million people are living with HIV, an
estimated 15% of the adult population. In addition to the estimated 220 000 HIV-
positive children, there are almost 1 million AIDS orphans. The social and
economic repercussions are devastating and are reversing hard-won gains in
development and rolling back the child survival gains made since independence.
Kenyan studies show that there is a nine-fold increase in the risk of death for
HIV-positive children compared to HIV-negative children and approximately
50% of HIV-positive children die before their second birthday. In the event that
the mother dies, there is an eight-fold risk of death of an infant irrespective of
HIV status. (excerpt)
413
Providing tools to reliably measure the well being of vulnerable

children.
Author: Nyangara, F.
Abstract: Children who have lost parents or who are losing parents to HIV face a host of
challenges to their longterm health. In addition to having an increased risk of
illness or injury, orphaned and vulnerable children (OVC) often receive
inadequate food or shelter, may live with caregivers that ignore, exploit, or abuse
them, and have to cope with the trauma of seeing their parents get sick and die.
Early methods for monitoring and evaluation (M&E) of OVC aid efforts had two
serious flaws. First, M&E of orphaned and vulnerable children tended to focus
on aspects of their lives that were directly related to HIV/AIDS at the expense of
other equally important variables that affect overall child well-being. Second,
previous M&E efforts have focused on services provided, not on how aid
affected children's overall health, providing effective monitoring but ineffective
evaluation. A new tool developed by MEASURE Evaluation aims to overcome
these two flaws. (excerpt)

Author: Ochieng, W.; Ogoyi, D.; Mulaa, F. J.; Ogola, S.; Musoke, R., and Otsyula, M. G.
Source: Afr Health Sci. 2006 Mar; 6(1):3-13.
children in Africa.
Methods:
Results:
Asymptomatic and symptomatic disease had, respectively, a rise in median
HIV-1 RNA load from 1,195 to 132,543 and from 42,962 to 1,109,281 copies/ml in
children below 6 years. The increase in viral load was 10-fold higher for
had initial median CD4+ T-lymphocyte counts of 647 (22%) cells/muL, declining
414
to 378 (20%) while those above 6 years had initial values of below 335 (15%) but
which increased to 428 (17%). Median viral load correlated significantly with
median CD4+ T-lymphocyte percentage in children above 6 years (p=0.026) but
not below.
Conclusions:
replicating virus. Interventions aimed at boosting the naive immune system may
Modelling a traditional game as an agent in HIV/AIDS behaviour-

change education and communications.
Author: Ogoye-Ndegwa, C.
Source: African Journal of AIDS Research. 2005 Nov; 4(2):91-98.
Abstract: The level of HIV/AIDS awareness among the Luo of western Kenya is at its
highest yet the epidemic continues unabated. While HIV/AIDS is locally
recognised as an emergent deadly condition, people seem unconcerned. Deaths
related to HIV/AIDS are often euphemistically explained in terms of
tuberculosis, respiratory diseases, and 'thinning disease' or chira. The situation is
aggravated by gender-based cultural attitudes that are unfortunately
predisposing to risk of HIV infection. This ethnographic study explores the
potential to model cultural constructs such as traditional games as a means of
health communication and agent of behaviour change. The gender undertones
and implications for HIV/AIDS in the language of the game ajua are significant
in understanding community-specific HIV infection risk. Modelling this
traditional game as an agent in HIV/AIDS behaviour-change education and
communication allows for forging a socially and culturally compatible and
enabling intervention mechanism. The study leads to the conclusion that
behaviour-change education and communication in a complex cultural setting
should be culture specific and internally derived. Significantly, cultural
constructs like traditional games can provide 'rootedness' in terms of HIV/AIDS
communication and intervention. (author's)
415

Hospital, Kenya.
Author: Omwega, A. M.; Oguta, T. J., and Sehmi, J. K.
Source: East Afr Med J. 2006 Nov; 83(11):610-8.
Mother- to- Child Transmission (MTCT) of HIV is a relatively new concept in
methods for infants born to mothers infected with the virus.
Objectives:
To determine maternal knowledge on MTCT of HIV in the rural setting and to
Design: A cross- sectional study, supported by an observational study.
Setting:
A rural district community and Homa-Bay District Hospital in South Western
Kenya.
Subjects:
One hundred and twelve non-tested mothers having infants aged 0-12 months in
the community and a sub-group (10%) of HIV positive mothers from the District
Hospital.
Results:
Maternal knowledge on MTCT of HIV was as low as 8.9% in the study area. The
MTCT knowledge was found to influence the alternative feeding choice as
mentioned by the non-tested mothers (p = 0.001; OR = 1.41; 95%CI, 1.04-3.86).
feeding alternatives other than cowmilk like expressed breastmilk (p = 0.1 5),
0.015; OR = 1.34; 95%CI, 1.13-5.50) than their counterparts with low MTCT
nutritional constraints.
Conclusion:
Maternal MTCT knowledge influences the choice of alternative infant feeding
option but not breastfeeding practices. Cowmilk is the most common, socio-
culturally acceptable and accessible breastmilk alternative in this community. It
is recommended that in order to improve MTCT knowledge, health education
and nutrition counselling be intensified in PMTCT programmes, VCT centers
416
and ANC clinics. Concurrently, effort should be made to increase the supply of
cowmilk within the community so as to make it more readily available and
affordable.
Understanding the HIV / STI prevention needs of men who have sex
with men in Kenya. Research summary.
Author: Onyango-Ouma W; Birungi H, and Geibel, S.
Abstract: Most respondents in a Nairobi study of men who have sex with men are aware
of HIV/STIs and are taking measures to reduce their risk. However, condom use
is not universal and reported STI symptoms are common. Targeted
interventions, such as confidential counseling as part of VCT and STI services,
and peer education to foster partner reduction, condom use, and correct use of
lubricants are needed. Understanding the sexual behaviors of populations who
are vulnerable to HIV is an important component in the battle against the AIDS
pandemic. Yet policymakers in developing countries, particularly in Africa, have
often overlooked men who have sex with men as a vulnerable group because of
stigmatization of homosexual behavior and denial of the existence of men who
have sex with men and the role they may play in HIV transmission. A growing
body of literature, however, not only documents the presence of this population
in Africa but also the importance of reaching them with information and services
to prevent HIV and other sexually transmitted infections (STIs). (excerpt)
Understanding the HIV / STI risks and prevention needs of men who
have sex with men in Nairobi, Kenya.
Abstract: Understanding the sexual behaviors of populations who are vulnerable to HIV is
an important component in the battle against the AIDS pandemic. Yet
policymakers in developing countries, particularly in Africa, have often
overlooked men who have sex with men (MSM) as a vulnerable group because of
stigmatization of homosexual behavior and denial of the existence of MSM and
the role they may play in HIV transmission. A growing body of literature,
however, not only documents the presence of this population in Africa but also
the importance of reaching them with information and services to prevent HIV
and other sexually transmitted infections (STIs). Despite increasing awareness of
the role MSM can play in the dynamics of HIV transmission in Africa, research
on MSM in Kenya has been limited. In response to this gap, researchers from the
Institute of African Studies (IAS) at the University of Nairobi and the Horizons
and FRONTIERS Programs of the Population Council undertook a study of MSM
in Nairobi from 2003 to 2004. The overall goals of the study were to understand
the extent to which MSM are at risk of HIV and other STIs, identify the factors
associated with risk behaviors, and identify MSM sexual health needs in order to
develop appropriate interventions. The study proposal received full ethical
review and clearance from the Population Council Institutional Review Board
417
(IRB) in New York, the Kenya National Council for Science and Technology, and
the Kenyatta National Hospital Ethics and Research Committee in Nairobi.
Approval from all review boards was achieved by November 2003, and research
activities were conducted between February and August 2004. Systematic data
collection methods included (a) a quantitative survey of 500 MSM; (b) in-depth
interviews with MSM, gatekeepers,1 and service providers; and (c) ethnographic
observations in MSM social settings. The quantitative survey was implemented
first, in early 2004, followed by the in-depth interviews and ethnographic
observations; all respondents gave informed consent to participate in the study.
(excerpt)
Capacity building for the clinical investigation of AIDS malignancy in

East Africa.
Author: Orem, J.; Otieno, M. W.; Banura, C.; Katongole-Mbidde, E.; Johnson, J. L.; Ayers,
L.; Ghannoum, M.; Fu, P.; Feigal, E. G.; Black, J.; Whalen, C.; Lederman, M., and
Remick, S. C.
Source: Cancer Detect Prev. 2005; 29(2):133-45.
Abstract: Purpose:
To build capacity in the resource-poor setting to support the clinical investigation
and treatment of AIDS-related malignancies in a region of the world hardest hit
by the AIDS pandemic.
Methods:
An initial MEDLINE database search for international collaborative partnerships
dedicated to AIDS malignancies in developing countries failed to identify any
leads. This search prompted us to report progress on our collaboration in this
aspect of the epidemic. Building on the formal Uganda-Case Western Reserve
University (Case) Research Collaboration dating back to 1987, established NIH-
supported centers of research excellence at Case, and expanding activities in
Kenya, scientific and training initiatives, research capital amongst our
institutions are emerging to sustain a international research enterprise focused
on AIDS and other viral-related malignancies.
Results:
A platform of clinical research trials with pragmatic design has been developed
to further enhance clinical care and sustain training initiatives with partners in
East Africa and the United States. An oral chemotherapy feasibility trial in AIDS
lymphoma is near completion; a second lymphoma trial of byrostatin and
vincristine is anticipated and a feasibility trial of indinavir for endemic Kaposi's
sarcoma is planned.
Conclusions:
In the absence of published reports of evolving international partnerships
dedicated to AIDS malignancy in resource constrained settings, we feel it
418
important for such progress on similar or related international collaborative

pursuits to be published. The success of this effort is realized by the long-term
international commitment of the collaborating investigators and institutions to
sustain this effort in keeping with ethical and NIH standards for the conduct of
research; the provision of formal training of investigators and research personnel
on clinical problems our East African partners are faced with in practice and the
development of pragmatic clinical trials and therapeutic intervention to facilitate
technology transfer and enhance clinical practice.

Study.
Author: Orroth, K. K.; Freeman, E. E.; Bakker, R.; Buve, A.; Glynn, J. R.; Boily, M. C.;
White, R. G.; Habbema, J. D., and Hayes, R. J.
To determine if the differences in risk behaviours, the proportions of males
circumcised and prevalences of sexually transmitted infections (STIs) observed in
two African cities with low prevalence of HIV (Cotonou, Benin, and Yaounde,
Cameroon) and two cities with high prevalence (Kisumu, Kenya, and Ndola,
Zambia) could explain the contrasting HIV epidemics in the four cities.
Methods:
were held constant across the four populations. The probabilities of HIV,
syphilis and chancroid acquisition were assumed to be doubled among
uncircumcised males. A priori plausible ranges for model inputs and outputs
were defined and sexual behaviour characteristics, including those pertaining to
commercial sex workers (CSWs) and their clients, which were allowed to vary
across the sites, were identified based on comparisons of the empirical data from
the four sites. The proportions of males circumcised in the model, 100% in
Cotonou and Yaounde, 25% in Kisumu and 10% in Ndola, were similar to those
observed. A sensitivity analysis was conducted to assess how changes in critical
parameters may affect the model fit.
Results:
Population characteristics observed from the study that were replicated in the
model included younger ages at sexual debut and marriage in east Africa
compared with west Africa and higher numbers of casual partners in the past 12
months in Yaounde than in the other three sites. The patterns in prevalence of
STIs in females in the general population and CSWs were well fitted. HIV
419
prevalence by age and sex and time trends in prevalence in the model were
consistent with study data with the highest simulated prevalences in Kisumu
and Ndola, intermediate in Yaounde and lowest in Cotonou. The sensitivity
analysis suggested that the effect of circumcision on the development of the HIV
epidemics may have been mediated indirectly by its effect on ulcerative STI.
Conclusions:
The contrasting HIV epidemics in east and west Africa could be replicated in our
model by assuming that male circumcision reduced susceptibility to HIV,
syphilis and chancroid. Varying rates of male circumcision may have played an
important role in explaining the strikingly different HIV epidemics observed in
different parts of sub-Saharan Africa.
Vasculitis in HIV: report of eight cases.

Author: Otedo, A. E.; Oyoo, G. O.; Obondi, J. O., and Otieno, C. F.
To describe vasculitis in HIV patients, their CD4 levels, anatomical sites affected
and clinical patterns.
Design: Prospective, descriptive study.
Setting:
Kisumu District Hospital and Nairobi Rheumatology Clinic between January
2002 and May 2005.
Subjects: Eight patients with HIV and vasculitis.
Results:
Eight patients (four males and four females) were recruited with an age range of
24-61 years, mean 33.13 years. Five had central nervous system vasculitis and
three had peripheral vasculitis. The CD4 counts were low, range 2-200
cells/mm3 (mean of 79.25 cells/mm3), normal levels of CD4 are 355-1298
cells/mm3, indicating severe immunosuppression. Two patients tested positive
for HBV (hepatitis B virus).
420
Conclusion:
HIV associated vasculitis is recognised and may be complicated by coinfection
with hepatitis viruses. It occurs at low CD4 counts. Central nervous system
involvement is a common site. Management is multidisciplinary.
Increased severe anemia in HIV-1-exposed and HIV-1-positive infants

and children during acute malaria.
Author: Otieno, R. O.; Ouma, C.; Ong'echa, J. M.; Keller, C. C.; Were, T.; Waindi, E. N.;
Michaels, M. G.; Day, R. D.; Vulule, J. M., and Perkins, D. J.
Source: AIDS. 2006 Jan 9; 20(2):275-80.
Since the primary hematological complication in both pediatric HIV-1 and
malaria is anemia, co-infection with these pathogens may promote life-
threatening severe malarial anemia (SMA). The primary objective of the study
was to determine if HIV-1 exposure [HIV-1(exp)] and/or HIV-1 infection [HIV-
1(+)] increased the prevalence of SMA in children with acute malaria.
Design:
The effect of HIV-1 exposure and HIV-1 infection on the prevalence of SMA
(hemoglobin < 6.0 g/dl), parasitemia (parasites/microl), and high-density
parasitemia (HDP, >or= 10 000 parasites/mul) was investigated in children <or=
2 years of age presenting at hospital with acute Plasmodium falciparum malaria
in a rural holoendemic malaria transmission area of western Kenya.
Methods:
Upon enrollment, a complete hematological and clinical evaluation was
performed on all children. Malaria parasitemia was determined and children
with acute P. falciparum malaria were evaluated for HIV-1 exposure and
infection by two rapid serological antibody tests and HIV-1 DNA PCR,
respectively.
Results:
Relative to HIV-1(-) group (n = 194), the HIV-1(exp) (n = 100) and HIV-1(+) (n =
23) groups had lower hemoglobin concentrations (P < 0.001 and P < 0.001,
respectively), while parasitemia and HDP were equivalent between the three
groups. Multivariate analyses demonstrated that the risk of SMA was elevated in
HIV-1(exp) children (odds ratio, 2.17; 95% confidence interval, 1.25-3.78; P < 0.01)
and HIV-1(+) children (odds ratio, 8.71; 95% confidence interval, 3.37-22.51; P <
0.0001). The multivariate model further revealed that HIV-1 exposure or infection
were not significantly associated with HDP.
421
Conclusions:
Results presented here demonstrate that both HIV-1 exposure and HIV-1
infection are associated with increased prevalence of SMA during acute P.
falciparum infection, independent of parasite density.
Improving national data collection systems from voluntary counselling

and testing centres in Kenya.
Author: Otwombe, K. N.; Wanyungu, J.; Nduku, K., and Taegtmeyer, M.
Source: Bull World Health Organ. 2007 Apr; 85(4):315-8.
Abstract: Problem:
Voluntary counselling and testing (VCT) data from the registered sites in Kenya
have been fraught with challenges, leading to insufficient statistics in the national
office for planning purposes. An exercise was carried out to determine the
barriers to the flow of data in VCT sites in Kenya.
Approach:
A record-based survey was conducted at 332 VCT sites in Kenya. Data from on-
site records were compared with those in the national office. The exercise was
conducted in 2004 between 5 September and 15 October.
Local Setting: All registered VCT sites in Kenya.
Relevant changes:
After the exercise, various measures to enhance VCT data collection and
reporting were implemented. They include the provision of a uniform data
collection and reporting tool to all the districts in the country, the strengthening
of a feedback mechanism to update provinces and districts on their reporting
status and increased support to the data component of the national quality
assurance for VCT.
Lessons learned:
Periodical field visits by the national officials to offer on-the-job training about
data management to data collectors and to address data quality issues can
dramatically improve the quality and completeness of VCT reports. The
perceived relevance of the data and the data collection process to those working
at the sites is the critical factor for data quality and timeliness of reporting
422
Examination of a second region of the HIV type 1 genome reveals

additional cases of superinfection.
Author: Piantadosi, A.; Ngayo, M. O.; Chohan, B., and Overbaugh, J.
Source: AIDS Res Hum Retroviruses. 2008 Sep; 24(9):1221.
Abstract: HIV-1 superinfection may occur at a rate similar to that of initial infection,
raising concerns for HIV-1 vaccine strategies predicated on eliciting immune
responses similar to those in natural infection. Because of the high rate of
recombination during HIV-1 replication, studies examining only one region of
the HIV-1 genome are likely to miss cases of HIV-1 superinfection. We examined
HIV-1 gag sequences from 14 high-risk Kenyan women in whom superinfection
was not detected in a previous study of env sequences. We detected two
additional cases of HIV-1 superinfection: one intersubtype superinfection that
occurred between 1046 and 1487 days postinfection (DPI) and one intrasubtype
superinfection that occurred between 341 and 440 DPI. Our results suggest that
studies that examine only small genome regions may lead to underestimates of
the risk of superinfection, highlighting the need for more extensive studies
examining multiple regions of the HIV-1 genome.
ABCs for HIV prevention in Kenya: messages, beliefs, and barriers.

Research summary.
Abstract: A great deal of attention has been focused recently on the promotion of the
"ABCs" of HIV prevention--being abstinent or delaying sex, remaining faithful to
one sexual partner or reducing the number of sexual partners, and consistently
using condoms during sex. Yet even as programs that focus on the ABCs to
prevent sexual HIV transmission are rolled out, questions remain about how
well different groups in varied cultural contexts actually understand the terms,
as well as how best to address challenges to adopting the ABC behaviors. The
Horizons Program and FHI/IMPACT developed a collaborative research study
in 2004 to explore how adults and youth in Kenya define and perceive the ABC
terms and behaviors. Additional objectives of the study were to identify attitudes
and norms around the ABC behaviors that influence perceptions of them, and
the role of important actors in transmitting messages about them. Findings
highlight potential challenges in promoting each of the ABC behaviors, as well as
some positive elements that can be built upon when developing programs.
(excerpt)
423
Psychological distress symptoms of individuals seeking HIV-related

psychosocial support in western Kenya.
Author: Reece, M.; Shacham, E.; Monahan, P.; Yebei, V.; Ong'or, W. O.; Omollo, O., and
Ojwang, C.
Source: AIDS Care. 2007 Nov; 19(10):1194-200.
Abstract: While researchers in many western countries have documented the nature of
psychological distress that is commonly present among individuals living with
HIV, there has been virtually no research on the same topic among other high
prevalence areas of the world, particularly in countries like Kenya. This study
sought to document the nature of psychological distress among 397 individuals
living with HIV in western Kenya and who were participating in psychosocial
support groups in conjunction with their enrollment in HIV-related treatment.
Psychological distress was assessed using the Brief Symptom Inventory (BSI), a
53-item self-report psychological inventory that asks individuals to recall
symptoms experienced in the prior seven days. The levels of psychological
distress in this sample were moderate with a substantial proportion of
participants meeting the criteria that suggested a need for further psychiatric
evaluation. Findings support the need for further assessments of the range and
nature of psychological distress among the diverse communities of countries like
Kenya and the need for greater attention to the inclusion of mental health
services in the rapidly developing treatment and prevention programs in this
region of the world.
HIV/AIDS: the first 25 years--a view from Nairobi.

Author: Rees, P. H.
Abstract: HIV infections are zoonoses occurring in communities that hunt chimpanzees
(HIV 1) and sooty mangabeys (HIV 2) in the forests of equatorial and West Africa
respectively. Most cross species transmission to man probably fizzles out, but the
transmission of HIV 1 type M around 1930 eventually resulted in a pandemic
that has spread around the world. HIV 2 types A and B have caused epidemics in
West Africa. HIV infections are characterised by three phases (i) an initial,
primary infective phase with rising viraemia, asymptomatic and silent, lasting
for some 10 weeks, (ii) a long quiescent phase with the viraemia and illness
mostly held in check by the immune response and lasting some 10 years in HIV 1
and 20 years or so in HIV 2 and (iii) a terminal third phase lasting some 10
months with rising viraemia, falling CD4 levels and multiple opportunistic
infections recognised in a community by the onset of a florid AIDS epidemic. The
silent primary epidemic reached Nairobi around 1980, with the florid secondary
AIDS epidemic peaking here around 1992 and overwhelming the hospitals and
other health services. The introduction of highly active antiretroviral therapy
424
(HAART) has dramatically improved the prognosis for individual patients with
AIDS, but it has been education and a changing attitude to condoms that has led
to a progressive fall in incidence, so that the worst of the epidemic may now be
over. Modifying the immunological response during the quiescent phase with
the hope of prolonging this phase indefinitely may be the way forward for those
who are already infected. Steroids have been shown to have a possible role here
rather than anti-retroviral drugs (ARVs) which are not curative and prone to the
development of drug resistance. Limited personal experience suggests that
steroids may also have a role in salvaging critically ill AIDS patients, who need
to be treated as emergencies. With an educated public and attention to
alternative routes of infection such as blood transfusion, the epidemic should be
increasingly contained during the next 25 years, and may even fizzle out.
Cost-effectiveness of two interventions to avert HIV-positive births.

Draft.
Author: Reynolds H; Janowitz B; Homan R, and Johnson, L.
Abstract: Prevention of mother-to-child transmission (PMTCT) of HIV efforts focus

primarily on providing voluntary counseling and testing (VCT) services in
prenatal care (PNC) and providing anti-retroviral (ARV) prophylaxis to HIV-
infected mothers. However, HIV-positive births could be averted if HIV-infected
women who did not want to get pregnant used effective contraception. We
compare the cost-effectiveness of increasing contraceptive use among non-
pregnant women versus increasing the coverage of services in PNC that provide
and promote nevirapine for PMTCT. We estimated the number of HIV-positive
births averted by simulating an increase in contraceptive use from none to 50%
among non-contracepting women who do not want to get pregnant. We also
simulated an increase in the availability of nevirapine for HIV-infected mothers
in PNC from current levels (10%) to 50%. Costs included first-year costs of
providing family planning services and outreach to stimulate demand. Program
costs of nevirapine for HIV-infected mothers included costs of promotion,
training, VCT, and nevirapine. At any level of expenditure, increasing
contraceptive use among non-pregnant women averted more HIV-positive births
than increasing the coverage of nevirapine for PMTCT. The relative cost-
effectiveness depended on the cost of crucial services such as VCT and family
planning services. Increasing contraceptive use among non-users of
contraception who do not want to get pregnant is at least as cost-effective as an
equivalent investment in PNC programs that provide and promote nevirapine to
HIV-infected mothers. Our data underscore prevention of unintended
pregnancies as a key strategy to prevent mother-to-child transmission of HIV.
(author's)
Delivering antiretroviral therapy in resource-constrained settings:

lessons from Ghana, Kenya and Rwanda.
425
Author: Ritzenthaler, R.
Abstract: At the United Nations General Assembly Special Session on HIV/AIDS, held in
June 2001, the global community cited ART as a key component of effective
HIV/AIDS programs. In their Declaration of Commitment, heads of state from
189 countries affirmed that "prevention, care, support and treatment for those
infected and affected by HIV/AIDS are mutually reinforcing elements of an
effective response and must be integrated in a comprehensive approach to
combat the epidemic." Tragically, only a small fraction of the estimated 40
million people living with HIV worldwide has access to the full range of services,
including treatment. In Africa, home to approximately 26 million HIV-infected
people, only 8 percent of the more than 4 million people clinically eligible for
ART (ages 15 -49) has access to it. Delivering ART in these settings presents
significant challenges related to drug supply, health infrastructure, provider
availability and capacity, equitable service provision, and drug adherence,
toxicity and resistance. (excerpt)
The private sector and HIV/AIDS in Africa: taking stock of 6 years of

applied research.
Author: Rosen, S.; Feeley, F.; Connelly, P., and Simon, J.
Until recently, little was known about the costs of the HIV/AIDS epidemic to
businesses in Africa or about business responses to the epidemic. This paper
synthesizes the results of a set of studies conducted between 1999 and 2006.
Methods:
Data for the studies included were drawn from human resource, financial, and
medical records of 16 large companies and from 7 surveys of small, medium-
sized, and large companies in South Africa, Uganda, Kenya, Zambia, Ethiopia,
and Rwanda.
Results:
Estimated workforce HIV prevalence ranged from 5 to 37%. The average cost per
employee lost to AIDS varied from 0.5 to 5.6 times the average annual
compensation of the employee affected. Labor cost increases were estimated at
0.6-10.8% but exceeded 3% at only two of 14 companies. Antiretroviral treatment
at a cost of US$360/patient per year was found to have positive financial returns
for most but not all companies. Managers of small and medium-sized
enterprises (SME) reported low AIDS-related employee attrition, little concern
about the impacts of AIDS, and relatively little interest in taking action. AIDS
was estimated to increase the average operating costs of SME by less than 1%.
426
Conclusion:
For most companies, AIDS is causing a moderate increase in labor costs, with
costs determined mainly by HIV prevalence, employee skill level, and
employment policies. Treatment of HIV-positive employees is a good investment
for many large companies. Small companies have less capacity to respond to
workforce illness and little concern about it. Research on the effectiveness of
workplace interventions is needed.
The future of HIV prevention: control of sexually transmitted infections

and circumcision interventions.
Author: Sahasrabuddhe, V. V. and Vermund, S. H.
Source: Infect Dis Clin North Am. 2007 Mar; 21(1):241-57, xi.
Abstract: Prevention and control of sexually transmitted infections (STIs) has proven
effective in reducing HIV infection when treatment is available promptly for
symptomatic persons in conditions of an emerging epidemic. Biologically, it is
assumed that reduced genital tract inflammation reduces infectiousness for HIV
as well as reducing susceptibility in HIV-uninfected persons. Male circumcision
has been demonstrated effective in reducing risk for HIV infection in three
separate trials from South Africa, Kenya, and Uganda. Global expansion of STI
treatment and male circumcision programs are vital tools for control of HIV
infection; current evidence is reviewed and research priorities are presented.
Use of HIV / AIDS information in Kenya.

Author: Salentine S; Gichuhi W, and Hyslop, A.
Abstract: HIV/AIDS information is generated using substantial financial, technical and

organizational resources. The investment in producing high quality HIV/AIDS
data pays off when this information is used beyond reporting to governments
and donors and informs program and policy decisions. The purpose of this
assessment is to support the Kenyan National AIDS Control Council (NACC),
the National AIDS and STD Control Program (NASCOP) and the President's
Emergency Plan for HIV/AIDS Relief (PEPFAR) in Kenya in identifying
opportunities for using information so that program managers and M&E officers
can plan for facilitating the use of this data for better operational and strategic
decision-making while engendering a local commitment to data quality. To
achieve this purpose, the assessment has the following objectives: To identify
gaps and synergies for use of HIV/AIDS information across all users; To identify
existing best practices; To inform the development of strategies for local use of
data; and To provide recommendation of next steps for implementing selected
strategies. (excerpt
427
Short- and long-term efficacy of modified directly observed

antiretroviral treatment in Mombasa, Kenya: a randomized trial.
Author: Sarna, A.; Luchters, S.; Geibel, S.; Chersich, M. F.; Munyao, P.; Kaai, S.;
Mandaliya, K. N.; Shikely, K. S.; Temmerman, M., and Rutenberg, N.
To determine short- and long-term efficacy of modified directly observed
therapy (m-DOT) on antiretroviral adherence.
Design: Randomized controlled trial.
Setting and analytic approach:

From September 2003 to November 2004, 234 HIV-infected adults were assigned
m-DOT (24 weeks of twice weekly health center visits for nurse-observed pill
ingestion, adherence support, and medication collection) or standard care.
Follow-up continued until week 72. Self-reported and pill-count adherence and,
secondarily, viral suppression and body mass index measures are reported.
Generalized estimating equations adjusted for intraclient clustering and
covariates were used.
Results:
During weeks 1-24, 9.1% (9/99) of m-DOT participants reported missing doses
compared with 19.1% (20/105) of controls (P = 0.04) and 96.5% (517/571) of m-
DOT pill-count measures were >or=95% compared with 86.1% (445/517) in
controls [adjusted odds ratio = 4.4; 95% confidence interval (CI) = 2.6 to 7.5; P <
0.001. Adherence with m-DOT was 4.8 times greater (95% CI = 2.7 to 8.6; P <
0.001) with adjustment for depression and HIV-related hospitalization. In weeks
25-48, adherence with m-DOT (488/589) was similar to controls (507/630). Viral
suppression at 48 weeks was 2.0 times (95% CI = 0.8 to 5.2; P = 0.13) as likely in
m-DOT participants as controls. M-DOT patients had larger body mass index
increases at 24 weeks (2.2 vs 1.4 kg/m3; P = 0.014). Viral suppression was more
likely at week 48 (21/25 vs 13/22; P = 0.057) and week 72 (27/30 vs 15/23; P =
0.027) among depressed participants receiving m-DOT.
428
Conclusions:
M-DOT increased adherence, most notably among depressed participants.
Promoting adherence to antiretroviral therapy through a directly

administered antiretroviral therapy (DAART) strategy in Mombasa,
Kenya.
Author: Sarna A; Luchters S; Geibel S; Munyao P, and Kaai, S.
Abstract: A principal concern of antiretroviral therapy (ART) programs is the ability of

patients to maintain a high level of adherence to the medication regimen. Based
on formative research conducted on HIV-infected clients and health workers in
Mombasa, Kenya, and lessons learned from directly observed therapy (DOT)
strategies to encourage adherence to treatment for tuberculosis, a DAART
strategy was developed to promote adherence to ART. This study examines
whether the DAART intervention is more effective in fostering adherence than
standard follow-up strategies among people living with HIV/AIDS in Mombasa.
(excerpt)
Does being treated with HAART affect the sexual risk behavior of
people living with HIV / AIDS? Insights from Mombasa, Kenya.
Author: Sarna A; Luchters S; Kaai S; Munyao P, and Geibel, S.
Abstract: To learn more about the impact of HAART on sexual risk behavior in a
developing country setting, researchers from the Horizons Program, the
International Center for Reproductive Health, and implementation partners at
Coast Province General Hospital, Mkomani Bomu Clinic, and Port Reitz District
Hospital, embarked on a prospective intervention study in Mombasa, Kenya.
One objective of the study was to compare the sexual risk behaviors of HIV
infected persons receiving HAART to those of HIV-infected persons who were
not clinically eligible to be candidates for HAART, but were receiving
prophylaxis or preventive therapy. (excerpt)
Sexual risk behaviour and HAART: a comparative study of HIV-infected

persons on HAART and on preventive therapy in Kenya.
Author: Sarna, A.; Luchters, S. M.; Geibel, S.; Kaai, S.; Munyao, P.; Shikely, K. S.;
Mandaliya, K.; van Dam, J., and Temmerman, M.
Source: Int J STD AIDS. 2008 Feb; 19(2):85-9.
429
the last six months. Participants receiving PT were more likely to report > or =2
partners (13% vs.1%; P = 0.006). Participants receiving PT reported more UPS
with regular partners (odds ratio [OR]: 3.9; 95% confidence interval [CI]: 1.8-8.4)
and also more sexually transmitted infections (STI) symptoms (OR: 1.7; 95% CI:
1.0-2.8; P = 0.059). More than 40% of all participants did not know the HIV-
status of regular partners. Therefore, HAART was not associated with increased
sexual risk behaviours though considerable risk of HIV-transmission remains.
HIV-care services need to emphasize partner testing and consistent condom use
with all partners.
Male circumcision and HIV/AIDS: challenges and opportunities.

Author: Sawires, S. R.; . = Dworkin SL; Fiamma A; Peacock D, and Szekeres G.
Source: Lancet. 2007 Feb 24; 369(9562):708-713.
Abstract: On December 13, 2006, the National Institutes of Health (NIH) announced the
early termination of two randomised controlled trials of male circumcision - in
Kenya and Uganda - on the basis of interim evidence that male circumcision
provided a protective benefit against HIV infection of 53% among the 2784
Kenyan men and 51% among the 4996 Ugandan men enrolled in the respective
studies. The Kenya and Uganda trials replicated the landmark findings of the
South African Orange Farm study, the first randomised controlled trial to report
a greater than 50% protective benefit of male circumcision. Before the availability
of data from these three African randomised controlled trials, multiple
observational studies correlated male circumcision with reduced risk of HIV
infection. Systematic reviews and meta-analysis of observational studies provide
further evidence of the association of male circumcision with reduced risk of HIV
infection and a plausible explanation for the biological mechanism for reduced
risk of infection has been suggested. Recently released longitudinal evidence of
the range of health benefits that male circumcision provides, modelling based on
the South African trials, and cost-effectiveness data in both North America and
Africa provide further evidence to support the health benefits of male
circumcision. Male circumcision is also associated with reduced risk of urinary
tract infections, genital ulcer diseases, penile cancer, and a possible reduction in
transmission of human papillomavirus (HPV) exists. Yet enthusiasm generated
from the three trials might not lead to accelerated scale-up. Regrettably, the
global experience with access to antiretroviral drugs shows that strong science
alone does not result in rapid, widespread roll-out. Not until civil society, non-
governmental organisations, and a chorus of advocacy groups successfully
lobbied for universal access to antiretrovirals did widespread roll-out in areas
430
with a high burden of HIV areas begin in earnest. Rapid implementation of male
circumcision will probably require a similar effort. (excerpt)
Characterization of intersubtype recombinant HIV type 1 genomes using

a nonradioactive heteroduplex tracking assay.
Author: Schroeder, T. L.; Burger, H.; Weiser, B.; Bengualid, V.; Kimani, J.; Anzala, A. O.;
Parker, M. M.; Lamson, D., and Philpott, S. M.
Source: AIDS Res Hum Retroviruses. 2005 Apr; 21(4):314-8.
Abstract: The HIV-1 epidemic is characterized by the dominance of distinct viral subtypes
in different regions of the world, and intersubtype recombinants are common.
Traditional subtyping methods analyze only a small fragment of the HIV-1
genome, so the true extent of diversity and recombination has been difficult to
examine. We developed a heteroduplex tracking assay (HTA) to identify viral
subtypes and rapidly detect recombinant HIV-1 genomes. By using probes that
target seven regions across the HIV-1 genome, HTAs can identify intersubtype
recombinants on the basis of the heteroduplex mobility pattern. We used this
method to analyze HIV-1 strains from 12 patients from the United States and
Kenya, comparing the results with those obtained by sequencing. HTA analysis
correctly identified the subtype of each region of the genome, revealing that
several isolates were recombinants. This method is suitable for studies of HIV-1
diversity and recombination in areas of the world where multiple subtypes are
found.
Anal and dry sex in commercial sex work, and relation to risk for
sexually transmitted infections and HIV in Meru, Kenya.
Author: Schwandt, M.; Morris, C.; Ferguson, A.; Ngugi, E., and Moses, S.
To examine the practices of anal intercourse and dry sex within a cohort of
female sex workers (FSWs) in Kenya, focusing on the prevalence and perceived
risk of the practices, demographic and behavioural correlates, and association
with sexually transmitted infections (STI).
Methods:
A survey was conducted among FSWs in Meru, Kenya, with 147 participants
randomly sampled from an existing cohort of self identified FSWs.
Results:
431
40.8% of participants reported ever practising anal intercourse and 36.1%

reported ever practising dry sex. Although the majority of women surveyed
believed anal intercourse and dry sex to be high risk practices for HIV infection
compared with vaginal sex, about one third of women reported never or rarely
using condoms during anal intercourse, and about 20% never or rarely using
condoms during dry sex. Reported consistent condom use was lower with both
of these practices than with penile-vaginal intercourse. Anal intercourse was
associated with experience of recent forced sexual intercourse, while dry sex was
not. Anal intercourse was almost always initiated by clients, whereas dry sex was
likely to be initiated by the women themselves. Sex workers reported charging
higher fees for both practices than for vaginal intercourse. Both practices were
associated with reported symptoms and diagnoses of STI.
Conclusions:
Both anal intercourse and dry sex were common in this sample, and although
perceived as high risk practices, were not adequately protected with condom use.
Education and other interventions regarding these high risk sexual behaviours
need to be translated into safer practices, particularly consistent condom use,
even in the face of financial vulnerability.
Can data from programs for the prevention of mother-to-child

transmission of HIV be used for HIV surveillance in Kenya?
Author: Seguy, N.; Hladik, W.; Munyisia, E.; Bolu, O.; Marum, L. H., and Diaz, T.
Can data from programs for the prevention of mother-to-child transmission of
HIV be used for HIV surveillance in Kenya?
Source: Public Health Rep. 2006 Nov-2006 Dec 31; 121(6):695-702.
In Africa, HIV surveillance is conducted among antenatal clinic (ANC) attendees
using unlinked-anonymous testing (UAT). In Kenya, the utility of prevention of
mother-to-child transmission (PMTCT) program data for HIV surveillance was
evaluated.
Methods:
UAT and PMTCT data were compared at the same clinics and for the same time
(2003 UAT survey) period. The HIV testing uptake for PMTCT was defined as
the number of ANC attendees tested for HIV out of those who had their first
ANC visit during the ANC surveillance period. Odds ratios and 95% confidence
intervals were calculated to determine associations between demographic
characteristics and HIV testing acceptance.
432
Results:
Of 39 ANC-UAT sites, six had PMTCT data. PMTCT data were recorded across
several logbooks with varying quality. For PMTCT, 2,239 women were offered
HIV testing and 1,258 (56%) accepted; for UAT, 1,852 women were sampled.
Median UAT-based HIV prevalence was 12.8% (range, 8.1%-26.3%) compared
with 14.4% (range, 7.0%-27.2%) in PMTCT. HIV testing acceptance for PMTCT
ranged from 48% to 69% across clinics, and was more likely among
primigravidae than multigravidae.
Conclusion:
Because of varying PMTCT data quality and varying HIV testing acceptance for
PMTCT, PMTCT-based HIV prevalence estimates cannot currently replace UAT-
based estimates in Kenya.
Report and policy brief from the 4th Africa Conference on Social Aspects
of HIV/AIDS Research: innovations in access to prevention, treatment
and care in HIV/AIDS, Kisumu, Kenya, 29 April - 3 May 2007.
Author: Setswe, G.; Peltzer, K.; Banyini, M.; Skinner, D.; Seager, J.; Maile, S.; Sedumedi, S.;
Gomis, D., and van der Linde, I.
Abstract: About 520 delegates from all over Africa and 21 countries attended the
conference.This report and policy brief summarises the key findings and
suggested policy options that emerged from rapporteur reports of conference
proceedings including the following themes: (1) Orphans and vulnerable
children, (2) Treatment, (3) Prevention, (4) Gender and male involvement, (5)
Male circumcision, (6) People living with HIV/AIDS, (7) Food and nutrition, (8)
Socioeconomics, and (9) Politics/policy. Two (11.8%) of the 17 OVC projects from
the three countries were classified as best practice interventions. Of the 83
abstracts that were accepted at the conference, only 7 (8.4%) were dealing with
antiretroviral therapy (ART). There has been tremendous effort by various
organisations to provide information about prevention of HIV/AIDS.
Information received by adolescents has been effective in increasing their
knowledge, but without positive sexual behaviour change. The conference noted
the contribution of gender discrimination and violence to the HIV epidemic and
the different risks that men and women face in relation to the epidemic. Social
scientists need to study the deep cultural meanings attached to male
circumcision among different ethnic groups to be able to guide the debate on the
latest biomedical findings on the protective effect of circumcision against HIV.
Palliative care and support is crucial for coping among people living with
HIV/AIDS (PLWHA) in order to deal with medical and psychological issues.
Results from several countries have helped researchers to explore alternative
ways of examining poverty in the context of HIV and AIDS. Policy frameworks
which are likely to succeed in combating HIV/AIDS need to be updated to cover
issues of access, testing, disclosure and stigma. In general, the conference was
433
successful in identifying innovations in access to prevention, treatment and care

in HIV/AIDS.

Author: Shacham, E.; Reece, M.; Ong'or, W. O.; Omollo, O.; Monahan, P. O., and Ojwang,
C.
friends. Symptoms of psychological distress were more prevalent among
women on multiple measures, including depression, anxiety, paranoid ideation,
434

Author: Shaffer, D. N.; Bautista, C. T.; Sateren, W. B.; Sawe, F. K.; Kiplangat, S. C.;
Miruka, A. O.; Renzullo, P. O.; Scott, P. T.; Robb, M. L.; Michael, N. L., and Birx,
D. L.
Data from prospective cohort studies are helpful in considering generalizability
of RCT results to populations with unique epidemiologic/cultural
characteristics.
Methods:
rate ratios (HRs).
Results:
0.55; 95% CI: 0.20 to 1.49).
Conclusions:
Circumcision by traditional circumcisers offers protection from HIV infection in
adult men in rural Kenya. Data from well-designed prospective cohort studies in
populations with unique cultural characteristics can supplement RCT data in
recommending public health policy.
435
Equitable treatment for HIV/AIDS clinical trial participants: a focus

group study of patients, clinician researchers, and administrators in
Western Kenya.
Author: Shaffer, D. N.; Yebei, V. N.; Ballidawa, J. B.; Sidle, J. E.; Greene, J. Y.; Meslin, E.
M.; Kimaiyo, S. J., and Tierney, W. M.
Source: J Med Ethics. 2006 Jan; 32(1):55-60.
To describe the concerns and priorities of key stakeholders in a developing
country regarding ethical obligations held by researchers and perceptions of
equity or "what is fair" for study participants in an HIV/AIDS clinical drug trial.
Design: Qualitative study with focus groups.
Setting:
Teaching and referral hospital and rural health centre in Western Kenya.
PARTICIPANTS: Potential HIV/AIDS clinical trial participants, clinician
researchers, and administrators.
Results:
Eighty nine individuals participated in a total of 11 focus groups over a four
month period. The desire for continued drug therapy, most often life long,
following an HIV/AIDS clinical trial was the most common priority expressed
in all focus groups. Patients with and without HIV/AIDS also thought
subsidizing of drug therapies and education were critical forms of compensation
for clinical trial participation. Financial incentives were considered important
primarily for purchasing drug therapy as well as obtaining food. Patients noted a
concern for the potential mismanagement of any money offered. Clinician
researchers and administrators felt strongly that researchers have a moral
obligation to participants following a trial to provide continued drug therapy,
adverse event monitoring, and primary care. Finally, clinician researchers and
administrators stressed the need for thorough informed consent to avoid
coercion of study participants.
Conclusions:
Kenyan patients, clinician researchers, and administrators believe that it would
be unfair to stop antiretroviral therapy following an HIV/AIDS clinical trial and
that researchers have a long term obligation to participants.
436
HIV immunosuppression and antimalarial efficacy: sulfadoxine-

pyrimethamine for the treatment of uncomplicated malaria in HIV-
infected adults in Siaya, Kenya.
Author: Shah, S. N.; Smith, E. E.; Obonyo, C. O.; Kain, K. C.; Bloland, P. B.; Slutsker, L.,
and Hamel, M. J.
The altered immune response of persons with human immunodeficiency virus
(HIV) infection could result in increased rates of antimalarial treatment failure.
We investigated the influence of HIV infection on the response to sulfadoxine-
pyrimethamine treatment.
Methods:
Febrile adults with Plasmodium falciparum parasitemia were treated with
sulfadoxine-pyrimethamine and were monitored for 28 days. HIV status and
CD4 cell count were determined at study enrollment.
Results:
Of the adults enrolled in the study, 508 attended all follow-up visits, including
130 HIV-uninfected adults, 256 HIV-infected adults with a high CD4 cell count (>
or =200 cells/ micro L), and 122 HIV-infected adults with a low CD4 cell count
(<200 cells/ micro L). The hazard of treatment failure at day 28 of follow-up was
significantly higher for HIV-infected adults with a low CD4 cell count (20.5%)
than for HIV-uninfected adults (7.7%). Anemia (hemoglobin level, <110 g/L)
modified the effect of HIV status on treatment failure. When we controlled for
fever and parasite density, the hazard of treatment failure for HIV-infected
adults with a low CD4 cell count and anemia was 3.4 times higher than that for
HIV-uninfected adults (adjusted hazard ratio, 3.38; 95% confidence interval,
1.56-7.34).
Conclusions:
HIV-infected persons with a low CD4 cell count and anemia have an increased
risk of antimalarial treatment failure. The response to malaria treatment in HIV-
infected persons must be carefully monitored. Proven measures for the control
and prevention of malaria must be incorporated into the basic package of
services provided by HIV/acquired immunodeficiency syndrome care and
treatment programs in malarious areas.
437
Mucosal Neisseria gonorrhoeae coinfection during HIV acquisition is

associated with enhanced systemic HIV-specific CD8 T-cell responses.
Author: Sheung, A.; Rebbapragada, A.; Shin, L. Y.; Dobson-Belaire, W.; Kimani, J.; Ngugi,
E.; MacDonald, K. S.; Bwayo, J. J.; Moses, S.; Gray-Owen, S., and Kaul, R.
Source: AIDS. 2008 Sep 12; 22(14):1729-37.
The host immune response against mucosally acquired pathogens may be
influenced by the mucosal immune milieu during acquisition. As Neisseria
gonorrhoeae can impair dendritic cell and T-cell immune function, we
hypothesized that coinfection during HIV acquisition would impair subsequent
systemic T-cell responses.
Methods:
Monthly screening for sexually transmitted infections was performed in high
risk, HIV seronegative Kenyan female sex workers as part of an HIV prevention
trial. Early HIV-specific CD8 T-cell responses and subsequent HIV viral load set
point were assayed in participants acquiring HIV, and were correlated with the
presence of prior genital infections during HIV acquisition.
Results:
Thirty-five participants acquired HIV during follow-up, and 16 out of 35 (46%)
had a classical sexually transmitted infection at the time of acquisition. N.
gonorrhoeae coinfection was present during HIV acquisition in 6 out of 35 (17%),
and was associated with an increased breadth and magnitude of systemic HIV-
specific CD8 T-cell responses, using both interferon-gamma gamma and MIP-1
beta as an output. No other genital infections were associated with differences in
HIV-specific CD8 T-cell response, and neither N. gonorrhoeae nor other genital
infections were associated with differences in HIV plasma viral load at set point.
Conclusion:
Unexpectedly, genital N. gonorrhoeae infection during heterosexual HIV
acquisition was associated with substantially enhanced HIV-specific CD8 T-cell
responses, although not with differences in HIV viral load set point. This may
have implications for the development of mucosal HIV vaccines and adjuvants.
Bronchoscopic study on aetiology of chronic cough in HIV-infected

adults with negative sputum smears for Mycobacterium tuberculosis at
Kenyatta National Hospital, Nairobi.
Author: Siika, A. M.; Chakaya, J. M.; Revathi, G.; Mohamed, S. S., and Bhatt, K. M.
438
To establish the aetiology of chronic cough in HIV-infected patients with
negative sputum smears for Acid Fast Bacilli (AFB).
Design: A cross-sectional descriptive study.
Setting: Kenyatta National Hospital, a tertiary referral centre in Kenya
Subjects:
Sixty five HIV-infected adults presenting with chronic cough and negative
sputum smears for AFBs.
Results:
Sixty-two patients were included in the final analysis. Aetiology of chronic cough
was established in 42 (68%) patients. Pneumocystis jiroveci, bacterial pneumonia
and Mycobacterium tuberculosis were diagnosed in 22 (35.5%), 17 (27.4%) and 14
(22.5%) patients respectively. Majority (98%) of patients with a diagnosis had
multiple causes established in them. Ciprofloxacin had activity against 91% of
the isolated organisms while Penicillin was active against 35% only.
Conclusion:
This study documents Pneumocystis jiroveci pneumonia as a common cause of
morbidity in a subset of HIV infected patients with chronic cough and negative
sputum smears for AFB in Kenya.
Modified vaccinia Ankara expressing HIVA antigen stimulates HIV-1-

specific CD8 T cells in ELISpot assays of HIV-1 exposed infants.
Author: Slyker, J. A.; Lohman, B. L.; Mbori-Ngacha, D. A.; Reilly, M.; Wee, E. G.; Dong,
T.; McMichael, A. J.; Rowland-Jones, S. L.; Hanke, T., and John-Stewart, G.
Source: Vaccine. 2005 Sep 7; 23(38):4711-9.
Abstract: Recombinant modified vaccinia virus Ankara expressing HIV-1 antigens

(MVA.HIVA) was used in ELISpot assays to monitor HIV-1-specific T cell
responses in infants. Responses to MVA.HIVA and HIV-1 peptides were
examined in 13 infected and 81 exposed uninfected infants in Nairobi, Kenya.
Responses to MVA.HIVA (38%) and peptide stimulation (38%) were similar in
frequency (p=1.0) and magnitude (mean 176 versus 385 HIVSFU/10(6), p=0.96)
in HIV-1 infected infants. In exposed uninfected infants, MVA.HIVA detected
more positive responses and higher magnitude responses as compared to
peptide. MVA.HIVA ELISpot is a sensitive method for quantification of HIV-1-
specific CD8+ T cell responses in HIV-1 exposed infants. These results
demonstrate the relevance of HIV-1 clade A consensus-derived immunogen
HIVA for the viruses currently circulating in Nairobi.
439
Efficacy of highly active antiretroviral therapy in HIV-1 infected children

in Kenya.
Author: Song, R.; Jelagat, J.; Dzombo, D.; Mwalimu, M.; Mandaliya, K.; Shikely, K., and
Essajee, S.
Source: Pediatrics. 2007 Oct; 120(4):e856-61.
Few studies have investigated the efficacy of antiretroviral therapy among HIV-
infected children in resource-poor settings. This observational, retrospective
analysis describes the clinical, immunologic, and virologic effects of highly active
antiretroviral therapy in treatment-naive, HIV-infected children in Mombasa,
Kenya. In keeping with a public health approach, all children were treated by
using a simplified, nationally approved, triple-drug regimen.
Methods:
Clinical data and stored plasma samples from 29 children who were followed
prospectively between April 2003 and October 2004 were analyzed. All children
received generic formulations of nevirapine, zidovudine, and lamivudine and
were evaluated at baseline and at 3, 6, 9, 12, and 15 months. At each visit, weight
and CD4 lymphocyte counts were measured and plasma samples were stored for
analysis. HIV RNA load was determined retrospectively at baseline and 9
months after initiation of therapy.
Results:
The mean age of the children was 8.5 years (range: 2-16 years). At baseline, the
mean CD4 count (+/-SD) was 182.3 x 10(6) cells per microL (+/-145.6). On
treatment, CD4 counts increased step-wise by a mean of 187 x 10(6) cells per
microL at 3 months, 293 cells per microL at 6 months, 308 cells per microL at 9
months, 334 cells per microL at 12 months, and 363 cells per microL at 15
months. The mean plasma viral load decreased from a baseline level of 622,712 to
35,369 copies per mL, and at 9 months was undetectable in 55% of the patients.
Mean z scores for weight for age increased from a baseline of -1.61 to -1.12 at 12
months into therapy.
Conclusions:
A public health approach using 1 treatment regimen in generic form showed
excellent efficacy among treatment-naive, HIV-infected children in a resource-
limited country. Clinical and immunologic improvement occurred in all patients,
but 9 months after the start of therapy, only 55% of the children had an
undetectable viral load.
Implementation of an antiretroviral access program for HIV-1-infected

individuals in resource-limited settings: clinical results from 4 African
countries.
440
Author: Sow, P. S.; Otieno, L. F.; Bissagnene, E.; Kityo, C.; Bennink, R.; Clevenbergh, P.;
Wit, F. W.; Waalberg, E.; Rinke de Wit, T. F., and Lange, J. M.
We assessed the effectiveness and safety of highly active antiretroviral therapy
(HAART) in HIV-1-infected patients in resource-limited African countries. HIV-1
screening, therapy, counseling, monitoring, training, and education were
provided free of charge.
Methods:
In an open-label cohort program, 206 antiretroviral-naive HIV-1-infected patients
who could not afford HAART were recruited in 4 urban clinics in Senegal, Cote
d'Ivoire, Uganda, and Kenya and were treated with saquinavir boosted with
ritonavir (1600/100 mg once daily), lamivudine (150 mg twice daily), and
zidovudine (300 mg twice daily). The primary outcome was a plasma viral load
(pVL) of <400 copies/mL after 96 weeks of treatment. Secondary analyses
included CD4 cell count changes and the occurrence of treatment-emergent
adverse events.
Results:
The median age of the patient group was 36 years, 38% were male, 35% of the
patients had AIDS, the median CD4 count was 119 cells/microL, and the median
pVL was 304,210 copies/mL. Overall, 65%/52% (on treatment [OT]/intent to
treat [ITT]) of the patients had a pVL <400 copies/mL after 96 weeks of follow-
up. This proportion varied significantly between sites, however; although in
Nairobi and Dakar, 51%/40% and 56%/46% (OT/ITT) were found, respectively,
Abidjan and Kampala showed proportions of 69%/54% and 83%/69% (OT/ITT),
respectively. The median increase in the CD4 count was 198 cells/microL
(interquartile range: 86-319 cells/microL), ranging from 191 to 292 cells/microL
between the sites. Fourteen patients (6.8%) died between 8 and 96 weeks of
follow-up, whereas 18 (9%) developed an AIDS-defining event between 8 and 96
weeks of follow-up. Non-HIV-related serious adverse events occurred in 55
patients (26.7%), of whom 13 were diagnosed with severe anemia. Thirty-five
patients (17%) changed treatment for toxicity reasons.
Conclusions:
Although a statistically significant difference was observed between sites with
respect to virologic success, overall virologic and immunologic responses to
HAART in resource-limited African settings can be as good as in Western
settings. There were some difficulties (eg, laboratory, logistics, proper training)
during the early phase of the program. Therefore, provision of adequate medical
care, counseling, proper instruction, and education of patients and medical staff
during the entire study is warranted in such programs, with special care in the
early phase.
441
Analysis of HIV-1 sequences vertically transmitted to infants in Kisumu,

Kenya.
Author: Steain, M. C.; Wang, B., and Saksena, N. K.
Source: J Clin Virol. 2006 Aug; 36(4):298-302.
HIV-1 prevalence in Kenya among women aged between 15-19 years is
approximately 23%. These women are prospective mothers and therefore can
play an important role in mother-to-child transmission of HIV. The risk of a
seropositve mother transmitting the virus to her infant is 25-35% in developing
countries, such as Kenya, where antiretroviral drugs are not readily available.
Objectives:
This study was undertaken to evaluate the molecular nature of HIV-1 strains,
assess recombination and it's relevance in mother-to-child transmission in Kenya.
Study design:
HIV-1 gag and gp120 sequences were derived from peripheral blood
mononuclear cells (PBMC) of 16 infected mothers and infants, from Kisumu,
Kenya. PCR, cloning, and phylogenetic analyses were conducted to examine any
sequence differences between HIV-1 strains derived from mother-infant pairs.
Results:
The cohort consisted of seven pairs harboring possible subtype A/D
recombinants, eight pairs with apparent pure A or D strains and one possible
dual infection. This dual infection comprised of a pure subtype A region and an
A/D recombinant, and was detected in one of the mother's sample.
Interestingly, only the recombinant virus was detected in the paired baby
sample.
Conclusions:
This study shows that HIV-1 inter-subtype recombinants can be effectively
transmitted vertically to infants, and could possibly be favored in this setting
where multiple subtypes infect women. Together, dual infections and the co-
existence of multiple HIV-1 subtypes is encouraging the emergence of
recombinant HIV strains and their rapid dispersal.
442
HIV type 1 sequence diversity and dual infections in Kenya.

Author: Steain, M. C.; Wang, B.; Yang, C.; Shi, Y. P.; Nahlen, B.; Lal, R. B., and Saksena, N.
K.
Abstract: As vertical transmission of HIV-1 is an ongoing problem in East Africa, we

analyzed HIV-1 strains of infected mothers, from Kisumu, Kenya. We sequenced
the gag and gp120 regions from peripheral blood mononuclear cells (PBMC) of
15 HIV-infected mothers attending an antenatal clinic. PCR, cloning,
bootscanning, using the program Simplot, and phylogenetic analyses were
conducted to assign subtypes and identify recombinants. Our analyses showed
two dual infections from patients who had infections with pure subtypes and
recombinants subtype D. In addition, we also noted the presence of subsubtype
A1 and A2, as well as unique recombinants in this area. These results imply that
the HIV epidemic in western Kenya is a dynamic one and is continually
evolving. Therefore, continued monitoring of the epidemic in this region is
necessary if a vaccine for the area is to be developed.
Evaluation of two commercially available alternatives for HIV-1 viral

load testing in resource-limited settings.
Author: Steegen, K.; Luchters, S.; De Cabooter, N.; Reynaerts, J.; Mandaliya, K.; Plum, J.;
Jaoko, W.; Verhofstede, C., and Temmerman, M.
Source: J Virol Methods. 2007 Dec; 146(1-2):178-87.
Abstract: There is an urgent need for low-cost assays for HIV-1 quantitation to ensure
adequate follow-up of HIV-infected patients on antiretroviral therapy (ART) in
resource-limited countries. Two low-cost viral load assays are evaluated, a
reverse transcriptase activity assay (ExavirLoad v2, Cavidi) and a real-time
reverse transcriptase PCR assay (Generic HIV viral load, Biocentric). Both tests
were compared with the ultrasensitive HIV Amplicor Monitor assay. Samples
were collected in Mombasa, Kenya, from 20 HIV-1 seronegative and 150 HIV-1
seropositive individuals of whom 50 received antiretroviral treatment (ART). The
ExavirLoad and the Generic HIV viral load assay were performed in a local
laboratory in Mombasa, the Amplicor Monitor assay (version 1.5, Roche
Diagnostics) was performed in Ghent, Belgium. ExavirLoad and Generic HIV
viral load reached a sensitivity of 98.3% and 100% and a specificity of 80.0% and
90.0%, respectively. Linear regression analyses revealed good correlations
between the Amplicor Monitor and the Generic HIV viral load (r=0.935, p<0.001)
with high accuracy (100.1%), good precision (5.5%) and a low percent similarity
coefficient of variation (5.4%). Bland-Altman analysis found 95% of the samples
within clinically acceptable limits of agreement (-1.19 to 0.87logcopies/ml).
Although, the ExavirLoad also showed a good linear correlation with the
Amplicor Monitor (r=0.901, p<0.001), a problem with false positive results was
443
more significant. The cost per test remains relatively high (US$ 30 for ExavirLoad
and US$ 20 for the Generic HIV viral load). Hence, false positive results and the
need for an expensive PCR instrument for the Generic HIV viral load assays still
limit the implementation of these tests in less equipped, less experienced
laboratories.
Circumcision and HIV.

Author: Szpir M; Behrend L, and Stalker, M. S. Men's health:
Source: Mera. 2007 Mar; (28):iii-iv, vi.
Abstract: There is now clear evidence that male circumcision reduces the transmission of
HIV from women to men. In December 2006, the National Institutes of Health
(NIH) in the United States halted two clinical trials, in Kenya and Uganda, on the
grounds that it would be unethical not to offer circumcision to all the men taking
part in the studies. Circumcised men in both trials had dramatically reduced
rates of HIV infection -a reduction of 53% in Kenya and 48% in Uganda-
compared to controls who were uncircumcised. These results confirm a similar
trial in South Africa, which showed that circumcised men were 60 % less likely to
be infected with HIV during heterosexual sex. The Data Safety and Monitoring
Board of the NIH stopped the South African trial during an interim analysis in
2005 and asked the clinicians to offer circumcision to the control group. (excerpt).
Taravella, S. Comprehensive care centers and antiretroviral drugs:

bringing new life to Kenyans with HIV.
Abstract: A 34-year-old teacher, crying uncontrollably, was brought into Kakamega
Provincial General Hospital in Kenya's Western Province in January 2004 by a
relative. The teacher, who was HIV-positive, was suffering in many ways. Much
of her hair had fallen out. She had pneumocystis carinii pneumonia. And
tuberculosis. And a troubling skin condition. And an alarming CD-4 count of 44.
And she had just lost a dear friend to AIDS. But none of this is why she was
crying. She was crying because, overwhelmed by despair, she had taken leave
from her job for the specific purpose of allowing herself to die. But her leave had
now come to an end and she found herself still very much alive. The anguish of
expecting to die but instead facing a return to work was too much for her to bear.
At the hospital that day, she encountered Beth Barasa, who supervises
counselors in the hospital's voluntary counseling and testing (VCT) service.
Barasa spent time educating the woman about antiretroviral therapy (ART),
helping her see that her life need not end now. The teacher went on ART in
February 2004. By August 2004, her CD-4 count had risen to 206. She was
receiving treatment for her TB, she had regained weight and even her hair had
regained most of its luster. Barasa, who supported the teacher with follow-up
home visits, says, "When she looks at me now, she just laughs because she had
given up on life." Antiretroviral drugs (ARVs) are transforming HIV care in the
444
developing world, and Kenyans are benefiting in profound ways. What

happened to this teacher is happening across this country of more than 32
million people, a nation with an HIV infection rate of about 6.7 percent. And the
U.S. Office of the Global AIDS Coordinator is playing a leadership role
throughout. (excerpt)
The Kenyan workplace: a strong tool for HIV prevention and treatment.
Abstract: Zacharia Akhonya is a tall, strikingly handsome 29-year-old with a captivating
smile. He makes his living as a Boda Boda driver, the local term for the young
men who transport residents of Kakamega about town on the rear of bicycles.
But Akhonya sees each passenger encounter as more than a source of income; it's
an opportunity to educate and inform. From the front of his bicycle, cars
whizzing past him on Kakamega's dusty roads, he talks with his passengers
about AIDS. Discussing matters such as HIV testing and proper condom use, he
has turned his job into a mechanism for helping his neighbors maintain their
own health. Akhonya is one of about 200 Boda Boda drivers who have completed
a five-day, peer-education training program on HIV/AIDS since October 2003,
enabling them to spread prevention messages in the towns of Bungoma, Busia,
Kakamega, Mumias, Nzoia and Webuye. The Boda Boda effort is one of many
peer-education programs funded by the U.S. Agency for International
Development (USAID) that use Kenyan work settings to increase AIDS
knowledge, reduce AIDS stigma, and improve services to those who are HIV-
positive. These programs have grown from simple awareness efforts to
comprehensive programs that in some cases even provide life-saving
antiretroviral drugs (ARVs). (excerpt)
Food and nutrition implications of antiretroviral therapy (ART) in

Kenya. A formative assessment.
Author: Thuita, F. M.
Source: Final report.
Abstract: Kenya is one of the 15 countries scaling up HIV/AIDS programs with support
from the President's Emergency Plan for AIDS Relief (PEPFAR). Due to the
interactions that can occur between ART and food and nutrients, managing
nutritional implications of ART is an important component in the success of ART
services in resource limited settings. Nutrition interventions in the context of
ART focus on assisting PHA and caregivers to make dietary choices that manage
drug side effects and promote drug efficacy and adherence. This formative
assessment was undertaken to increase understanding of the food and nutrition
needs of clients on ART and the kind of messages that may be needed by service
providers to integrate nutrition in ART care. It is anticipated that the findings of
this report will facilitate incorporation of relevant nutrition content into ART
management training materials in Kenya and will inform the development of
445
tools and materials to support effective nutritional counseling of ART clients. The
study was conducted by a consultant in partnership with a team from NASCOP.
The study was carried out in 5 sites - Nairobi, Thika, Kiambu, Eldoret and
Mombasa - at government and nongovernment health facilities and other
programs providing ART. A total of 13 facilities in the 5 sites including public,
private and mission hospitals, as well as NGOs and networks of PHA were
visited. A combination of systematic formative research methods were utilized
including focus group discussions, in-depth key informant interviews, case
studies, and expert informational meetings. (excerpt)
Community-Based HIV / AIDS Prevention, Care and Support Program.

Author: Thurman, T. R.; . = Hoffman A; Chatterji M, and Brown L.
Source: A case study.
Abstract: An estimated 12 million children aged 17 and under have lost one or both
parents to AIDS in sub-Saharan Africa. Despite recognition of the magnitude and
negative consequences of this problem, there is little evidence on "what works" to
improve the well being of children affected by HIV and AIDS. In an attempt to
fill this knowledge gap, MEASURE Evaluation is conducting targeted
evaluations of five programs for orphans and vulnerable children (OVC) in five
unique settings - two in Kenya and three in Tanzania. Case studies are the first
phase of MEASURE Evaluation's targeted evaluations and begin the process of
information sharing on lessons learned in programming for OVC. Additional
evaluation activities under the MEASURE Evaluation targeted evaluation
activity include an impact assessment and costing activity of each of the five
selected programs. This case study was conducted to impart a thorough
understanding of U.S. Pathfinder in Kenyal's OVC program model and to
document lessons learned that could be applied to other initiatives. This case
study is based upon a program document review; program site visits, including
discussions with local staff, volunteers, beneficiaries and community members;
as well as observations of program activities. The primary audience for this case
study includes OVC program implementers in Kenya and elsewhere in Africa, as
well as relevant policymakers and funding agencies addressing OVC needs.
(excerpt)
446
Kilifi Orphans and Vulnerable Children Project.

Abstract: This case study was conducted to impart a thorough understanding of Catholic
Relief Services' (CRS) OVC program model in Kenya and to document lessons
learned that could be applied to other OVC initiatives. This case study is based
upon a program document review; program site visits, including discussions
with local staff, volunteers, beneficiaries and community members; as well as
observations of program activities. The primary audience for this case study
includes OVC program implementers in Kenya and elsewhere in Africa, as well
as relevant policy makers and funding agencies addressing OVC needs. The
Kilifi OVC project of CRS was selected as a priority program for the evaluation.
Program goals are to: increase the capacity of communities and families and
orphans to respond to the needs of OVC; and increase the institutional capacity
of local partners to deliver high quality and sustainable interventions. (excerpt)
Integrated AIDS program, Thika, Kenya.

Author: Thurman, T. R. and . = Neudorf K.
Abstract: The purpose of this case study is to gain a better understanding of one of the
programs selected for the evaluation - Integrated AIDS Program-Thika
(IAPThika) supported by Pathfinder International - as well as identify lessons
learned that could be applied to other initiatives. The case study is based upon
program document review; program site visits, including discussions with local
staff, volunteers, beneficiaries, and community members; and observations of
program activities. The primary audience for this case study includes OVC
program implementers in Kenya and elsewhere in Africa, as well as relevant
policy makers, funding agencies addressing OVC needs, and other local and
international stakeholders. (excerpt)
Effects of HIV/AIDS on maternity care providers in Kenya.

Author: Turan, J. M.; Bukusi, E. A.; Cohen, C. R.; Sande, J., and Miller, S.
Source: J Obstet Gynecol Neonatal Nurs. 2008 Sep-2008 Oct 31; 37(5):588-95.
To explore the impact of HIV/AIDS on maternity care providers in labor and
delivery in a high HIV-prevalence setting in sub-Saharan Africa.
447
Design:
Qualitative one-on-one in-depth interviews with maternity care providers.
Setting:
Four health facilities providing labor and delivery services (2 public hospitals, a
public health center, and a small private maternity hospital) in Kisumu, Nyanza
Province, Kenya.
Participants:
Eighteen maternity care providers, including 14 nurse/midwives, 2 physician
assistants, and 2 physicians (ob/gyn specialists).
Results:
The HIV/AIDS epidemic has had numerous adverse effects and a few positive
effects on maternity care providers in this setting. Adverse effects include
reductions in the number of health care providers, increased workload, burnout,
reduced availability of services in small health facilities when workers are absent
due to attending HIV/AIDS training programs, difficulties with confidentiality
and unwanted disclosure, and maternity care providers' fears of becoming HIV
infected and the resulting stigma and discrimination. Positive effects include
improved infection control procedures on maternity wards and enhanced
maternity care provider knowledge and skills.
Conclusion:
A multifaceted package including policy, infrastructure, and training
interventions is needed to support maternity care providers in these settings and
ensure that they are able to perform their critical roles in maternal healthcare
and prevention of HIV/AIDS transmission.
HIV/AIDS and maternity care in Kenya: how fears of stigma and

discrimination affect uptake and provision of labor and delivery
services.
Author: Turan, J. M.; Miller, S.; Bukusi, E. A.; Sande, J., and Cohen, C. R.
Source: AIDS Care. 2008 Sep; 20(8):938-45.
Abstract: Although policies and programs exist to promote safe motherhood in sub-
Saharan Africa, maternal health has not improved and may be deteriorating in
on maternity care. We conducted a study in Kisumu, Kenya to explore how fears
related to HIV/AIDS affect women's uptake and health workers' provision of
labor and delivery services. In-depth qualitative interviews with 17 maternity
workers, 14 pregnant or postpartum women, four male partners and two
traditional birth attendants; as well as structured observations of 22 births; were
conducted at four health facilities. Participants reported that fears of HIV testing;
fears of involuntary disclosure of HIV status to others, including spouses; and
448
HIV/AIDS stigma are among the reasons that women avoid delivering in health
facilities. Maternity workers now have to take into account the HIV status of the
women they serve (as well as their own fears of becoming infected and
stigmatized) but do not seem to be adequately prepared to handle issues related
to consent, confidentiality and disclosure. Importantly, it appeared that women
of unknown HIV status during labor and delivery were likely to be targets of
stigma and discriminatory practices and that these women were not receiving
needed counseling services. The findings suggest that increasing infection
control precautions will not be enough to address the challenges faced by
maternity care providers in caring for women in high-HIV-prevalence settings.
consent, confidentiality and disclosure. Furthermore, this study points to the
necessity of paying more attention to the care of women of unknown HIV-
quality of maternity care, increase utilization and contribute to overall
improvements in maternal health, while also enhancing prevention of mother-to-
child-transmission and HIV care.
Preventing mother-to-child transmission of HIV in Western Kenya:

operational issues.
Author: Van't Hoog, A. H.; Mbori-Ngacha, D. A.; Marum, L. H.; Otieno, J. A.; Misore, A.
O.; Nganga, L. W., and Decock, K. M.
To improve uptake in a program to prevent mother-to-child HIV transmission
and describe lessons relevant for prevention of mother-to-child transmission
programs in resource-poor settings.
Methods:
Implementation of a pilot project that evaluates approaches to increase program
uptake at health facility level at New Nyanza Provincial General Hospital, a
public hospital in western Kenya, an area with high HIV prevalence. Client flow
was revised to integrate counseling, HIV testing, and dispensing of single-dose
nevirapine into routine antenatal services. The number of facilities providing
PMCT services was expanded to increase district-wide coverage. Main outcome
measures were uptake of counseling, HIV testing, nevirapine, and estimated
program impact.
449
Results:
Uptake of counseling and testing improved from 55 to 68% (P < 0.001),
nevirapine uptake from 57% to 70% (P < 0.001), and estimated program impact
from 15% to 23% (P = 0.03). Aggregate reports compare well with computer-
entered data.
Conclusion:
Addressing institutional factors can improve uptake, but expected program
impact remains low for several reasons, including relatively low efficacy of the
intervention and missed opportunities in the labor room
Evaluation of TB and HIV services prior to introducing TB-HIV activities

in two rural districts in western Kenya.
Author: Van't Hoog, A. H.; Onyango, J.; Agaya, J.; Akeche, G.; Odero, G.; Lodenyo, W.
and Marston, B. J.
Abstract: Setting:
Health facilities providing tuberculosis (TB) treatment in two districts in rural
western Kenya with a high TB and human immunodeficiency virus (HIV)
burden.
Objective:
To evaluate TB and HIV/acquired immune-deficiency syndrome (AIDS) services
at the facilities and identify barriers to providing quality diagnostic HIV testing
and counseling (DTC) and HIV treatment for TB patients in anticipation of the
introduction of TB-HIV collaborative services.
Methods:
We performed a standard interview with health workers responsible for TB care,
inspected the facilities and collected service delivery data. A self-administered
questionnaire on training attended was given to all health workers. Results were
shared with stakeholders and plans for implementation were developed.
Results:
Of the 59 facilities, 58 (98%) provided TB treatment, 19 (32%) offered sputum
microscopy and 24 (41%) HIV testing. Most facilities (72%) advised HIV testing
only if TB patients were suspected of having AIDS. Barriers identified included
unaccommodating TB clinic schedules and lack of space, which was an obstacle
to holding confidential discussions. The need to refer for HIV testing and/or HIV
care was a perceived barrier to recommending these services. Activities
implemented following the assessment aimed 1) to provide HIV testing and
cotrimoxazole prophylaxis at all TB treatment clinics, 2) to increase availability of
HIV treatment services, and 3) to address structural needs at each facility.
450
Conclusion:
This evaluation identified barriers to the implementation of HIV testing and care
services within facilities providing TB treatment.
Circulating and unique recombinant forms of HIV type 1 containing

subsubtype A2.
Author: Visawapoka, U.; Tovanabutra, S.; Currier, J. R.; Cox, J. H.; Mason, C. J.; Wasunna,
M.; Ponglikitmongkol, M.; Dowling, W. E.; Robb, M. L.; Birx, D. L., and
McCutchan, F. E.
Source: AIDS Res Hum Retroviruses. 2006 Jul; 22(7):695-702.
Abstract: HIV-1 strains containing subsubtype A2 are relatively rare in the pandemic but
have been repeatedly identified in Kenya, where candidate vaccines based in
part on subtype A, but not A2 strains, may be evaluated. Among the most recent
is CRF16_A2D, a circulating recombinant form (CRF) whose prototypes are
complete or partial HIV-1 sequences from Kenya, Korea, and Argentina. Using
samples from blood bank discards in Kenya and complete genome sequencing,
this report further documents CRF16_A2D and related recombinants and
identifies a second CRF, CRF21_A2D. The two A2-containing CRFs, and two
recombinants related to CRF16_A2D, share common structural elements but
appear to have been independently derived. Concerted selection may have
influenced the emergence and spread of certain A2-containing strains in Kenya.
The second complete subtype C sequence from Kenya is also reported here.
Monitoring of A2-containing recombinants and subtype C strains, both relatively
rare in Kenya, may be informative in the course of cohort development and
evaluation of candidate vaccines.
Improving the education response to HIV and AIDS: Lessons of partner

efforts in coordination, harmonisation, alignment, information sharing
and monitoring in Jamaica, Kenya, Thailand and Zambia.
Author: Visser-Valfrey M; Brown, C. R.; . = Abagi O; Buabuttra T, and Nalwamba C.
Abstract: This report documents the findings of a study on the quality and effectiveness of
collaboration among partners involved in the HIV and AIDS response in the
education sector. The study was commissioned by the United Nations Joint
Programme on HIV/AIDS (UNAIDS) Inter-Agency Task Team (IATT) on
Education which brings together UNAIDS Cosponsors, bilateral agencies, private
donors, and civil society organizations. The purpose of this study was to
document how external partners coordinate and harmonise their efforts at the
country level, to identify areas of overlap and significant gaps in country
responses, and to formulate recommendations for improving synergy and
alignment across IATT member agencies and other actors operating at the
451
country level. The case studies were conducted between March and May 2007 in
Jamaica, Kenya, Thailand and Zambia. These countries were selected to
represent geographical, epidemiological and socio-economic diversity and
because significant efforts have been undertaken insupport of education sector
responses to HIV and AIDS in these settings. The study was carried out by an
international consultant with the support of four local consultants. In each
country, an IATT member agency hosted the study, while the IATT Secretariat,
with the help of a working group of IATT members, undertook the overall
supervision of the study. Data for the study were collected through a
comprehensive documentation review and interviews with key stakeholders
from the education sector and the overall HIV and AIDS response. To ensure
maximum involvement of all parties, a draft country aide memoire was
produced after the field work, circulated to those consulted and finalised based
on the suggestions received. While every attempt was made to ensure that a
wide selection of stakeholders was consulted, the findings are limited by the
short duration of time in-country. The study is not a comprehensive mapping
exercise of country-level activity. Rather the findings reflect country stakeholder
perspectiveson engagements, progress and on-going challenges. (author's)
The impact of pre-exposure prophylaxis (PrEP) on HIV epidemics in

Africa and India: a simulation study.
Author: Vissers, D. C.; Voeten, H. A.; Nagelkerke, N. J.; Habbema, J. D., and de Vlas, S. J.
Pre-exposure prophylaxis (PrEP) is a promising new HIV prevention method,
especially for women. An urgent demand for implementation of PrEP is expected
at the moment efficacy has been demonstrated in clinical trials. We explored the
long-term impact of PrEP on HIV transmission in different HIV epidemics.
Methodology/principal findings:
We used a mathematical model that distinguishes the general population, sex
workers and their clients. PrEP scenarios varying in effectiveness, coverage and
target group were modeled in the epidemiological settings of Botswana, Nyanza
Province in Kenya, and Southern India. We also studied the effect of condom
addition or condom substitution during PrEP use. Main outcome was number of
HIV infections averted over ten years of PrEP use. PrEP strategies with high
effectiveness and high coverage can have a substantial impact in African settings.
In Southern India, by contrast, the number of averted HIV infections in different
PrEP scenarios would be much lower. The impact of PrEP may be strongly
diminished or even reversed by behavioral disinhibition, especially in scenarios
with low coverage and low effectiveness. However, additional condom use
during low coverage and low effective PrEP doubled the amount of averted HIV
infections.
452
Conclusions/significance:
The public health impact of PrEP can be substantial. However, this impact may
be diminished, or even reversed, by changes in risk behavior. Implementation of
PrEP strategies should therefore come on top of current condom campaigns, not
as a substitution.
Regular partners may contribute more to HIV transmission than clients.

Author: Voeten, H. A.; Egesah, O. B.; Varkevisser, C. M., and Habbema, J. D. Female sex
workers and unsafe sex in urban and rural Nyanza, Kenya:
Source: Trop Med Int Health. 2007 Feb; 12(2):174-82.
To compare the sexual behaviour of female sex workers in urban and rural areas
in Nyanza province in Kenya, and to compare their unsafe sex with clients and
with regular partners.
Methods:
In a cross-sectional study among 64 sex workers (32/32 in urban/rural areas),
sex workers kept a sexual diary for 14 days after being interviewed face-to-face.
Results:
Most sex workers were separated/divorced and had one or two regular partners,
who were mostly married to someone else. Sex workers in Kisumu town were
younger, had started sex work at an earlier age, and had more clients in the past
14 days than rural women (6.6 vs. 2.4). Both groups had an equal number of sex
contacts with regular partners (4.7). With clients, condom use was fairly frequent
(75%) but with regular partners, it was rather infrequent (<40%). For both urban
and rural areas, the mean number of sex acts in which no condom was used was
greater for regular partners (3.2 and 2.8 respectively) than for clients (1.9 and 1.0
respectively).
Conclusions:
Sex workers in urban and rural areas of Nyanza province practise more unsafe
sex with regular partners than with clients. Interventions for sex workers should
also focus on condom use in regular partnerships
453
Morbidity among HIV-1-infected mothers in Kenya: prevalence and

correlates of illness during 2-year postpartum follow-up.
Author: Walson, J. L.; Brown, E. R.; Otieno, P. A.; Mbori-Ngacha, D. A.; Wariua, G.;
Obimbo, E. M.; Bosire, R. K.; Farquhar, C.; Wamalwa, D., and John-Stewart, G. C.
Much of the burden of morbidity affecting women of childbearing age in sub-
Saharan Africa occurs in the context of HIV-1 infection. Understanding patterns
of illness and determinants of disease in HIV-1-infected mothers may guide
effective interventions to improve maternal health in this setting.
Methods:
We describe the incidence and cofactors of comorbidities affecting peripartum
and postpartum HIV-1-infected women in Kenya. Women were evaluated by
clinical examination and standardized questionnaires during pregnancy and for
up to 2 years after delivery.
Results:
Five hundred thirty-five women were enrolled in the cohort (median CD4 count
of 433 cells/mm) and accrued 7736 person-months of follow-up. During 1-year
follow-up, the incidence of upper respiratory tract infections was 161 per 100
person-years, incidence of pneumonia was 33 per 100 person-years, incidence of
tuberculosis (TB) was 11 per 100 person-years, and incidence of diarrhea was 63
per 100 person-years. Immunosuppression and HIV-1 RNA levels were
predictive for pneumonia, oral thrush, and TB but not for diarrhea; CD4 counts
<200 cells/mm(3) were associated with pneumonia (relative risk [RR] = 2.87, 95%
confidence interval [CI]: 1.71 to 4.83), TB (RR = 7.14, 95% CI: 2.93 to 17.40) and
thrush. The risk of diarrhea was significantly associated with crowding (RR =
1.86, 95% CI: 1.19 to 2.92) and breast-feeding (RR = 1.71, 95% CI: 1.19 to 2.44).
Less than 10% of women reported hospitalization during 2-year follow-up;
mortality risk in the cohort was 1.9% and 4.8% for 1 and 2 years, respectively.
Conclusions:
Mothers with HIV-1, although generally healthy, have substantial morbidity as a
result of common infections, some of which are predicted by immune status or
by socioeconomic factors. Enhanced attention to maternal health is increasingly
important as HIV-1-infected mothers transition from programs targeting the
prevention of mother-to-child transmission to HIV care clinics.
454
Albendazole treatment of HIV-1 and helminth co-infection: a

randomized, double-blind, placebo-controlled trial.
Author: Walson, J. L.; Otieno, P. A.; Mbuchi, M.; Richardson, B. A.; Lohman-Payne, B.;
Macharia, S. W.; Overbaugh, J.; Berkley, J.; Sanders, E. J.; Chung, M. H., and
John-Stewart, G. C.
Source: AIDS. 2008 Aug 20; 22(13):1601-9.
Several co-infections have been shown to impact the progression of HIV-1
infection. We sought to determine if treatment of helminth co-infection in HIV-1-
infected adults impacted markers of HIV-1 disease progression.
Design:
To date, there have been no randomized trials to examine the effects of soil-
transmitted helminth eradication on markers of HIV-1 progression.
Methods:
A randomized, double-blind, placebo-controlled trial of albendazole (400 mg
daily for 3 days) in antiretroviral-naive HIV-1-infected adults (CD4 cell count
>200 cells/microl) with soil-transmitted helminth infection was conducted at 10
sites in Kenya (Clinical Trials.gov NCT00130910). CD4 and plasma HIV-1 RNA
levels at 12 weeks following randomization were compared in the trial arms
using linear regression, adjusting for baseline values.
Results:
Of 1551 HIV-1-infected individuals screened for helminth infection, 299 were
helminth infected. Two hundred and thirty-four adults were enrolled and
underwent randomization and 208 individuals were included in intent-to-treat
analyses. Mean CD4 cell count was 557 cells/microl and mean plasma viral load
was 4.75 log10 copies/ml at enrollment. Albendazole therapy resulted in
significantly higher CD4 cell counts among individuals with Ascaris
lumbricoides infection after 12 weeks of follow-up (+109 cells/microl; 95%
confidence interval +38.9 to +179.0, P = 0.003) and a trend for 0.54 log10 lower
HIV-1 RNA levels (P = 0.09). These effects were not seen with treatment of other
species of soil-transmitted helminths.
Conclusion:
Treatment of A. lumbricoides with albendazole in HIV-1-coinfected adults
resulted in significantly increased CD4 cell counts during 3-month follow-up.
Given the high prevalence of A. lumbricoides infection worldwide, deworming
may be an important potential strategy to delay HIV-1 progression.
455
Early response to highly active antiretroviral therapy in HIV-1-infected

Kenyan children.
Author: Wamalwa, D. C.; Farquhar, C.; Obimbo, E. M.; Selig, S.; Mbori-Ngacha, D. A.;
Richardson, B. A.; Overbaugh, J.; Emery, S.; Wariua, G.; Gichuhi, C.; Bosire, R.,
and John-Stewart, G.
To describe the early response to World Health Organization (WHO)-
recommended nonnucleoside reverse transcriptase inhibitor (NNRTI)-based
first-line highly active antiretroviral therapy (HAART) in HIV-1-infected Kenyan
children unexposed to nevirapine. DESIGN: Observational prospective cohort.
Methods:
HIV-1 RNA level, CD4 lymphocyte count, weight for age z score, and height for
age z score were measured before the initiation of HAART and every 3 to 6
months thereafter. Children received no nutritional supplements.
Results:
Sixty-seven HIV-1-infected children were followed for a median of 9 months
between August 2004 and November 2005. Forty-seven (70%) used zidovudine,
lamivudine (3TC), and an NNRTI (nevirapine or efavirenz), whereas 25% used
stavudine (d4T), 3TC, and an NNRTI. Nevirapine was used as the NNRTI by 46
(69%) children, and individual antiretroviral drug formulations were used by 63
(94%), with only 4 (6%) using a fixed-dose combination of d4T, 3TC, and
nevirapine (Triomune; Cipla, Mumbai, India). In 52 children, the median height
for age z score and weight for age z score rose from -2.54 to -2.17 (P<0.001) and
from -2.30 to -1.67 (P=0.001), respectively, after 6 months of HAART.
Hospitalization rates were significantly reduced after 6 months of HAART (17%
vs. 58%; P<0.001). The median absolute CD4 count increased from 326 to 536
cells/microL (P<0.001), the median CD4 lymphocyte percentage rose from 5.8%
before treatment to 15.4% (P<0.001), and the median viral load fell from 5.9 to 2.2
log10 copies/mL after 6 months of HAART (P<0.001). Among 43 infants, 47%
and 67% achieved viral suppression to less than 100 copies/mL and 400
copies/mL, respectively, after 6 months of HAART.
Conclusion:
Good early clinical and virologic response to NNRTI-based HAART was
observed in HIV-1-infected Kenyan children with advanced HIV-1 disease.
456
HIV voluntary counseling and testing in Kenya.

Author: Wambugu S; Tegang, S. P.; . = Namwebya JH, and Obiero W.
Source: 2001-05. Analysis of data.
Abstract: Kenya has witnessed an unparalleled upsurge in voluntary and counseling

(VCT) services since 2001. This increase was assisted by the USAID-funded
IMPACT (Implementing AIDS Prevention and Care) Project, which is managed
by Family Health International (FHI). IMPACT is a pioneer in VCT, and has
helped establish 217 of Kenya's 687 VCT sites. This paper investigates trends in
client utilization of VCT service between 2001 and 2005 within a sample of these
IMPACT-supported sites. The analysis sought to establish sociodemographic and
sexual behavior profiles of VCT clients and their HIV prevalence; correlate these
client profiles with the service delivery model Chosen; ascertain how clients
learned about VCT services and whether this information influenced them to
seek and use other interventions; investigate links, if any, between types of
referrals made and the sexual behavior profiles and serostatus of VCT clients;
establish whether mass communication campaigns and the availability of
antiretroviral therapy (ART) influenced clients to come to the sites. (excerpt)
HIV / AIDS and associated morbidity and mortality among hospitalised

children in Kilifi, Kenya.
Author: Wamsele J and Kisenge, R.
Source: Tanzania Health Research Bulletin. 2006 May; 8(2):90-94.
Abstract: This study was carried to determine the frequency of HIV/AIDS and associated
morbidity and mortality among children hospitalised in the paediatric ward at
the Kilifi District Hospital, Kenya. All 7519 children admitted between January
2004 and June 2005 were eligible for the study. Testing for HIV antibodies was
done using Determine and Unigold tests. Of the admitted children, 163 (2.2%)
had clinical features of AIDS. Sixty (36.8%) of the HIV-positive children were
below < 18 months and 103 (64.2%) were >/= 18 months old. There were 84
(51.5%) boys and 79 (49.5% girls). The median age was 2 years (range = 8 days to
11 years). The median duration of hospital stay for children with AIDS was 11
days (range 2 days to 6 weeks). The commonest causes of admission for children
with HIV/AIDS were malnutrition (40.8%) and pulmonary tuberculosis (20.9%).
Bacillus species were the most common isolates from the children blood samples
with malnutrition. The inpatient mortality of 20.9% was observed among HIV
positive children and malnutrition was a co-morbidity in 42.1% of those who
died. In conclusion, this study revealed that the prevalence of paediatric
HIV/AIDS in this area is high and appropriate interventions need to be taken to
contain the worsening situation. (author's)
457

Author: Waruru, A. K.; Nduati, R., and Tylleskar, T.
Source: BMC Med Inform Decis Mak. 2005; 5:24.
interviewing and explored its feasibility, usability, and acceptability in a PMTCT
program in Kenya.
Methods:
compare ability to use ACASI by education level.
Results:
Mean ages for intended time for breastfeeding as reported by ACASI were 11
months by ACASI and 19 months by FTF interviewing (p < 0.001). Introduction
of complementary foods at <or=3 months was reported more frequently by
respondents in ACASI compared to FTF interviews for 7 of 13 complementary
food items commonly utilized in the study area (p < 0.05). More respondents
reported use of unsuitable utensils for infant feeding in ACASI than in FTF
interviewing (p = 0.001). In other sensitive questions, 7% more respondents
reported unstable relationships with ACASI than when interviewed FTF (p =
0.039). Regardless of education level, respondents used ACASI similarly and
majority (65%) preferred it to FTF interviewing mainly due to enhanced usability
and privacy. Most respondents (79%) preferred ACASI to FTF for future
interviewing.
458
Conclusion:
education is low.
Power brokering, empowering, and educating: the role of home-based

care professionals in the reduction of HIV-related stigma in Kenya.
Author: Waterman, H.; Griffiths, J.; Gellard, L.; O'Keefe, C.; Olang, G.; Ayuyo, J.;
Obwanda, E.; Ogwethe, V., and Ondiege, J.
Source: Qual Health Res. 2007 Oct; 17(8):1028-39.
Abstract: In this article the authors report on how home-based care (HBC) professionals
reduce stigmatizing behavior in Kenya. This study was part of an action research
project that evaluated the introduction of HBC. HBC professionals coordinate the
delivery of HIV/AIDS services at a district level and educate community-based
health workers in HBC. Understanding how HBC professionals reduce stigma is
crucial to reduce, prevent, and treat HIV/AIDS. Fifty HBC professionals
participated in 27 focus group interviews over 18 months. Stigma featured
strongly when they discussed barriers to the introduction of HBC. Using
sociological theory, the authors organized the data into five themes: Power
broking and mobilization, Stigma as a social construction, Community and
structural interventions, Educating and training people, and Historical context.
The HBC professionals appear to operate at mostly individual and community
levels in their efforts to challenge stigma, and in spite of the difficulties they
appear to be having some impact.
Perceptions of children with HIV/AIDS from the USA and Kenya: self-
concept and emotional indicators.
Author: Waweru, S. M.; Reynolds, A., and Buckner, E. B.
Source: Pediatr Nurs. 2008 Mar-2008 Apr 30; 34(2):117-24.
Abstract: Perceptions of children's self-concept and associated emotional indicators were

assessed in two populations, United States and Kenya, in children living with
HIV/AIDS. Assessment of the self-concept mode of the Roy Adaptation Model
used both verbal and nonverbal strategies. The sample of children (N = 48), ages
7 to 12 years who were HIV-positive, was recruited from a family clinic that
cares for children with chronic illness in the United States (n = 6) and an
orphanage that provides for HIV-positive children in Kenya (n = 42). Self-
concept was measured using a modification of Piers-Harris Self-Concept Scale.
Emotional indicators were measured from Human Figure Drawings (HFD)
459
described by Koppitz (1968). All U.S. children were found to have an average
self-concept and one-third demonstrated significant emotional indicators. In
Kenya, 93% of the participants had an average self-concept and half were found
to have significant emotional indicators. HFD can be used with other screening
tools to perform a psychosocial assessment and screening for referral. This study
contributes to nursing science by introducing a model-based assessment with
cross-cultural applicability.
Initial outcomes of an emergency department rapid HIV testing program

in western Kenya.
Author: Waxman, M. J.; Kimaiyo, S.; Ongaro, N.; Wools-Kaloustian, K. K.; Flanigan, T. P.,
and Carter, E. J.
Source: AIDS Patient Care STDS. 2007 Dec; 21(12):981-6.
Abstract: This paper reports the initial operational outcomes of an emergency department-
based HIV testing program in a high-prevalence and resource-limited setting by
describing (1) the number and percentage of patients approached, tested, and
found to be HIV positive and (2) the linkage of care to the HIV clinic. A
retrospective log and chart review of the initial 5 months (January 2006 to April
2006) of the HIV testing program was performed. Patients were selected for HIV
testing by routine screening and by provider initiated referrals. Out of the 1371
patients who were approached for HIV testing, 1339 (97.7%) patients were tested
for HIV. Three hundred twelve (22.7%) of the patients tested were HIV positive.
Within a sample group of patients newly diagnosed with HIV in the department,
82% were compliant with their initial HIV clinic visit and 65% were compliant
with a 1-month follow-up visit. The implementation of an emergency
department-based HIV testing program in a high HIV prevalence and resource
poor country is feasible with a high percentage of patients accepting HIV testing
and a high percentage of positive patients presenting to follow-up care.
Establishment of rapid HIV testing in emergency departments can identify
significant numbers of HIV-positive patients who would otherwise remain
undiagnosed and provides an education opportunity for those patients who are
HIV negative.
Mapping of experiences of access to care, treatment and support - Kenya.

Author: Webi, E.
Abstract: Namibia, Kenya and Tanzania. The findings will contribute to advocacy for
increased political support and resources to address gendered barriers to care,
treatment and support. The project complements a mapping and database of civil
society organizations (CSOs) providing treatment by the French consortium -
SIDACTION. The research was carried out in Homabay (rural) and Kibera
community (urban) involving women and men living with HIV and AIDS (13th
460
December 2005 - 31st January 2006). Data was gathered through questionnaires
and focus group discussions (FGDs). Women who participated in the focus
group discussions were aged between 22 - 45 years old and in total 100 people
took part in the project, including questionnaire respondents. The service
providers in both sites were of varied age group (28-45 years) and both female
and male service providers participated in the focus group discussions. Results
from the mixed sex and service provider focus groups are presented here but the
main emphasis is onthe results from the women only focus groups. (excerpt)
Treating curable sexually transmitted infections to prevent HIV in

Africa: Still an effective control strategy?
Author: White, R. G.; . = Orroth KK; Glynn JR; Freeman EE, and Bakker R.
Source: JAIDS. Journal of Acquired Immune Deficiency Syndromes. 2008 Mar; 47(3):346-
353.
Abstract: Evidence regarding the effectiveness of sexually transmitted infection (STI)

treatment for HIV prevention in Africa is equivocal, leading some policy makers
to question whether it should continue to be promoted for HIV control. We
explore whether treating curable STIs remains a cost-effective HIV control
strategy in Africa. The model STDSIM was fitted to the characteristics of 4
populations in East and West Africa. Over the simulated HIV epidemics, the
population-attributable fractions (PAFs) of incident HIV attributable to STIs, the
impact of syndromic STI management on HIV incidence, and the cost per HIV
infection averted were evaluated and compared with an estimate of lifetime HIV
treatment costs (US $3500). Throughout the HIV epidemics in all cities, the total
PAF for all STIs remained high, with $50% of HIV transmission attributed to
STIs. The PAF for herpes simplex virus type 2 increased during the epidemics,
whereas the PAF for curable STIs and the relative impact of syndromic
management decreased. The models showed that the absolute impact of
syndromic management remains high in generalized epidemics, and it remained
cost-saving in 3 of the 4 populations in which the cost per HIV infection averted
ranged between US $321 and $1665. Curable STI interventions may remain cost-
saving in populations with generalized HIV epidemics, particularly in
populations with high-risk behaviors or low male circumcision rates. (author's)
Renal disease in an antiretroviral-naive HIV-infected outpatient

population in Western Kenya.
Author: Wools-Kaloustian K; Gupta, S. K.; . = Muloma E; Owino-Ong'or W, and Sidle J.
Source: Nephrology Dialysis Transplantation. 2007; 22(8):2208-2212.
461
Abstract: Several commonly used antiretrovirals (ARVs) require dose adjustments to

prevent toxicities in the presence of renal insufficiency. Because outpatient
human immunodeficiency virus (HIV)-infected indigenous African populations
have been published to date, it is not known if already scarce resources should be
allocated to detect renal dysfunction, in those without risk factors for kidney
disease, prior to initiation of increasingly available antiretrovirals in developing
countries. A cross-sectional study to determine the prevalence of and risk factors
for renal disease in a cohort of medically stable, HIV-infected, antiretroviral-
naive adults, without diabetes or hypertension, presenting to an HIV clinic in
western Kenya. Of 373 patients with complete data, renal insufficiency (CrCl < 60
ml/min) was identified in 43 (11.5%) [18 (4.8%) had a CrCl < 50 ml/min].
Despite high correlation coefficients between the threerenal function estimating
equations used, when compared to creatinine clearance as calculated by
Cockcroft-Gault, lower rates of moderate to severe renal insufficiency were
identified by the Modification of Diet in Renal Disease equations. Proteinuria,
defined as a urine dipstick protein of equal to or greater than 1+, was detected in
only 23 subjects (6.2%). Renal insufficiency is not uncommon, even in stable
patients without diabetes or hypertension. Conversely, proteinuria was
unexpectedly infrequent in this population. Utilizing resources to assess renal
function prior to initiation of antiretrovirals in order to identify those likely to
benefit from dosage adjustment is justified. (author's)no prospective studies of
the prevalence or risk factors for kidney disease in stable
Associations of sexual risk taking among Kenyan female sex workers

after enrollment in an HIV-1 prevention trial.
Author: Yadav, G.; Saskin, R.; Ngugi, E.; Kimani, J.; Keli, F.; Fonck, K.; Macdonald, K. S.;
Bwayo, J. J.; Temmerman, M.; Moses, S., and Kaul, R.
Female sex workers (FSWs) often lack the ability to negotiate safer sex and are at
high risk for HIV-1 infection and sexually transmitted infections (STIs).
Methods:
Seronegative FSWs were enrolled in an STI/HIV-1 prevention trial in Nairobi,
Kenya. Demographics and sexual risk taking were assessed every 3 months.
Predictors of reduced risk taking were defined using multivariate logistic
regression.
Results:
Four hundred sixty-six FSWs were enrolled and followed for just over 2 years
each. A spectrum of sex work was apparent: FSWs working in night clubs were
younger, charged more for sex, and used condoms more frequently; FSWs
working from home were older, charged less, and used condoms the least; and
those working in bars were intermediate. Increases in reported condom use
462
were most significant and sustained for FSWs working from home and charging
less for sex and were poorly maintained for bar-based FSWs. Self-reported lower
condom use, higher client numbers, and alcohol use were associated with higher
STI rates.
Conclusions:
Home-based FSWs and those charging less for sex used condoms the least at
baseline but showed the greatest and most sustained improvements over time.
Potential response heterogeneity in FSW subgroups should be considered in the
design of HIV-1 prevention programs.
Viability and effectiveness of large-scale HIV treatment initiatives in

sub-Saharan Africa: experience from western Kenya.
Author: Wools-Kaloustian, K.; Kimaiyo, S.; Diero, L.; Siika, A.; Sidle, J.; Yiannoutsos, C.
T.; Musick, B.; Einterz, R.; Fife, K. H., and Tierney, W. M.
Source: AIDS. 2006 Jan 2; 20(1):41-8.
To determine the clinical and immunological outcomes of a cohort of HIV-
infected patients receiving antiretroviral therapy.
Design:
Retrospective study of prospectively collected data from consecutively enrolled
adult HIV-infected patients in eight HIV clinics in western Kenya.
Methods:
CD4 cell counts, weight, mortality, loss to follow-up and adherence to
antiretroviral therapy were collected for the 2059 HIV-positive non-pregnant
adult patients treated with antiretroviral drugs between November 2001 and
February 2005.
Results:
Median duration of follow-up after initiation of antiretroviral therapy was 40
weeks (95% confidence interval, 38-43); 111 patients (5.4%) were documented as
deceased and 505 (24.5%) were lost to follow-up. Among 1766 (86%) evaluated
for adherence to their antiretroviral regimen, 78% reported perfect adherence at
every visit. Although patients with and without perfect adherence gained
weight, patients with less than perfect adherence gained 1.04 kg less weight than
those reporting perfect adherence (P = 0.059). CD4 cell counts increased by a
mean of 109 cells/microl during the first 6 weeks of therapy and increased more
slowly thereafter, resulting in overall CD4 cell count increases of 160, 225 and 297
cells/microl at 12, 24, and 36 months respectively. At 1 year, a mean increase of
170 cells/microl was seen among patients reporting perfect adherence compared
with 123 cells/microl among those reporting some missed doses (P < 0.001).
463
Conclusions:
Antiretroviral treatment of adult Kenyans in this cohort resulted in significant
and persistent clinical and immunological benefit. These findings document the
viability and effectiveness of large-scale HIV treatment initiatives in resource-
limited settings.
The long-term impacts of orphanhood on education attainment and land

inheritance among adults in rural Kenya.
Author: Yamano, T.
Abstract: The long-term economic impacts of the AIDS epidemic on orphans have been
major concerns in countries hit by the epidemic. Responding to these concerns,
previous studies have investigated the schooling of orphans. Yet, few studies
have investigated the impacts of orphan status into adulthood. Therefore, this
paper examines the education attainment and land inheritance of former
orphans, who have lost at least one parent before reaching 15, by using a survey
of 889 households in Kenya in 2004. In the survey, we have asked the ages of
household members when they lost their parents, if they have suffered such a
loss, and identified former orphans. Among individuals who started schooling
before the Free Education Program introduced in 1974, we find about a one year
lower educational attainment among former maternal orphans compared with
former non-orphans. We do not find a similar difference in education attainment
among the younger cohorts, who started schooling after 1974. Even the Cost-
Sharing Scheme introduced in 1988 does not seem to lower the educational
attainment of former orphans. On inherited land, we find no significant
difference between households headed by former orphans and non-orphans.
(author's)
Working-age adult mortality and primary school attendance in rural

Kenya.
Author: Yamano T and Jayne, T. S.
Source: Economic Development and Cultural Change. 2005; 53:619-653.
Abstract: The article is organized as follows. We first identify potential pathways by which
adult mortality may affect child school attendance and the timing of each
pathway. Second, we estimate reinterview models to assess the degree to which
sample attrition is a problem and use the inverse probabilities of being
reinterviewed as weights to control for attrition in the subsequent analyses.
Then, using household fixed effects to control for time-invariant unobservables,
we estimate the impacts of adult mortality on child school attendance in rural
Kenya after stratifying sampled households and their children by wealth and
gender. Kenya is one of the most heavily HIV-infected countries in the world:
464
13.5% of adults ages 15-49 were estimated to be living with HIV in June 2000.
(excerpt)
Payment for antiretroviral drugs is associated with a higher rate of

patients lost to follow-up than those offered free-of-charge therapy in
Nairobi, Kenya.
Author: Zachariah, R.; Van Engelgem, I.; Massaquoi, M.; Kocholla, L.; Manzi, M.; Suleh,
A.; Phillips, M., and Borgdorff, M.
Source: Trans R Soc Trop Med Hyg. 2008 Mar; 102(3):288-93.
Abstract: This retrospective analysis of routine programme data from Mbagathi District
Hospital, Nairobi, Kenya shows the difference in rates of loss to follow-up
between a cohort that paid 500 shillings/month (approximately US$7) for
antiretroviral drugs (ART) and one that received medication free of charge. A
total of 435 individuals (mean age 31.5 years, 65% female) was followed-up for
146 person-years: 265 were in the 'payment' cohort and 170 in the 'free' cohort.
The incidence rate for loss to follow-up per 100 person-years was 47.2 and 20.5,
respectively (adjusted hazard ratio 2.27, 95% CI 1.21-4.24, P=0.01). Overall risk
reduction attributed to offering ART free of charge was 56.6% (95% CI 20.0-76.5).
Five patients diluted their ART regimen to one tablet (instead of two tablets)
twice daily in order to reduce the monthly cost of medication by half. All these
patients were from the payment cohort. Payment for ART is associated with a
significantly higher rate of loss to follow-up, as some patients might be unable to
sustain payment over time. In resource-limited settings, ART should be offered
free of charge in order to promote treatment compliance and prevent the
emergence of drug resistance.
AIDS treatment and intrahousehold resource allocations: children's

nutrition and schooling in Kenya.
Author: Zivin, J. G.; . = Thirumurthy H, and Goldstein M.
Abstract: The provision of life-saving antiretroviral (ARV) treatment has emerged as a key
component of the global response to HIV/AIDS, but very little is known about
the impact of this intervention on the welfare of children in the households of
treated persons. We estimate the impact of ARV treatment on children's
schooling and nutrition outcomes using longitudinal household survey data
collected in collaboration with a treatment program in western Kenya. We find
that children's weekly hours of school attendance increase by 20 to 35 percent
within six months after treatment is initiated for the adult household member.
For boys in treatment households, these increases closely follow their reduced
market labor supply. Similarly, young children's short-term nutritional status-as
measured by their weight-for-height Z-score-also improves dramatically. These
465
results illustrate how the intrahousehold allocation of time and resources are
altered in response to significant health improvements. Since the improvements
in children's schooling and nutrition at these critical early ages will affect their
socio-economic outcomes in adulthood, the widespread provision of ARV
treatment is likely to generate significant long-run macroeconomic benefits.
(author's)
Challenges of care-givers in a HIV endemic area of central Kenya: a

gender based approach
Author: Kamau G., The People Daily Newspaper Ltd, Nairobi, Kenya.
Abstract: The HIV/AIDS scourge can be termed as one of the most serious human rights
issues of this century to be tackled with a gender-sensitive approach.
Constitutional and national protection of the rights of those infected and affected
by the scourge is lacking in most parts of the country.
This paper presents the statistics of the disease in Nairobi Kenya where 50
HIV/AIDS caregivers and health workers were interviewed. The results indicate
that women now constitute almost 60 percent of all infections with more than
200,000 women and girls infected. Most caregivers are women. They have to
grapple with the challenges of raising those living with the scourge, an
assignment that is tasking because they have little or no control over the family's
income. They expose themselves to infection by living intimately with the
infected .Thus; the real challenge is to make the disease a priority issue of the
women's movement countrywide.
With all the resources to combat the scourge in the country, women leaders are
needed at every level to unite and counter the spread of the virus.
Violence against them and exploitation through prostitution fuels the epidemic.
Women, especially those in rural areas, fear losing their homes and being
rejected by their families. There is need for a gendered response sensitive to the
needs and multiple vulnerabilities of women and young girls with HIV/AIDS
while recognizing and4lr.engthening their own agency.
It is imperative that prevention information, confidential counselling and testing,
treatment for sexually transmitted diseases and comprehensive drug and anti-
retroviral treatment be available to men and women equally.
Our findings show a need to adopt comprehensive gender-based programmes,

rather than piecemeal prevention projects to address this epidemic adequately.
Non-discrimination, legal protection and equal access to services are critical if
gender-based approach is to be an effective strategy.
Keywords: HIV/AIOS|WOMEN RIGHTS | VULNERABILITY | EQUALITY |

STRATEGY
466
Men who have sex with men (MSM) and HIV prevention and care in
Kenya.
Source: Parkinson A., Liverpool VCT & Care Kenya
Abstract: Background & Objectives:

This presentation will examine the experiences of Liverpool VCT in providing
prevention and care services to MSM in Kenya. As the only organization in East
Africa actively undertaking this work, LVCT has insights and experience that
other organizations may benefit from.
Findings/Lessons Learnt:
Specifically, this presentation will examine lessons learnt in the provision of
prevention and care services for MSM in Kenya, as well as presenting national
VCT data on MSM, prevalence rates and related challenges.
Conclusions/Recommendations:
The presentation will recommend increased access for MSM to VCT, care and RH
services as well as creating targeted interventions that are acceptable to MSM.
Keywords: MSM | HIV | SEXUALITY | RH RIGHTS | ACCESS TO CARE
Expanding and Integrating the Deaf HIV/ AIDS/STI Programme towards

Efficiency.
Author: Henderson K., Liverpool VCT & Care (LVCT) Kenya
The Deaf community numbers approximately 650,000 out of about 32,000,000
people in Kenya. It is most concentrated in the urbane regions and also spread
out in the rural areas in lesser but significant numbers. In the Deaf community,
access to education and services is more limited and employment either is lower
or reaps less per capita income than the rest of the population. With its own
linguistic culture based in Kenyan Sign Language, this community faces stigma
and poverty at a more alarming level than general.
As the mission of LVCT Kenya is to reduce the rate of HIV transmission in

Kenya, the organization aims to:
 Implement high quality voluntary counseling and testing (VCT) and care
services throughout Kenya
 Provide technical assistance and support to GoK and partners
 Develop research- and evidence-based practice to inform policy
Since October 2003, LVCT has trained 12 Deaf counselours and mobilizers and
established three Deaf VCT stand-alone sites in Kisumu, Mombasa, and Nairobi,
467
reinforced by monthly mobile VCT clinics in surrounding regions. After

counseling and testing, Deaf clients who test positive for HIV are referred to local
clinics that provide care and ART therapy. The objectives of the programme are
two-fold:
 To increase provision and quality of VCT and care services for Deaf clientele
 To increase provision and quality of VCT services for the adjacent hearing
population
In 2005, a coordinator position held by a Deaf professional was also established

to run the programme.
Findings/Lessons Learnt:
 Maintaining anonymity and confidentiality in Deaf community
 Mobilization of rural Deaf communities requires more support, consistency,
time, and creativity
 Data on Deaf clientele is lacking
 Limited Deaf involvement in professional development
 Quality of care of Deaf PLWHA decreases after VCT service
Conclusions and Recommendations

 Data collection of Deaf and physically challenged clientele needs to be
incorporated in national data system
 VCT & Care scale-up then must begin to reflect above data e.g. access ramps
& lifts, sign language fluency and sensitivity training among care providers
 Increase provision of Deaf counselors at rural stand alone sites near sizable
Deaf communities and trim down over-reliance on costly mobile VCT
activities
Keywords: DEAF, CULTURE, BARRIERS TO ACCESS, HIV/AIDS, SEXUAL HEALTH
468
The HIV Status and associated factors among clients attending the
Egerton University VCT centre in 2006.
Author: Dr. Douglas Kamau Ngotho, Faculty Of Health Sciences, Egerton University, P.O
Box 536.
Abstract: Summary:
The study covered the period between Jan 2nd and December 31st 2006. The
essence was to assess the HIV status and other related data of the clients who
were attended in that VCT centre that year. The details of all the clients were
documented and analyzed appropriately.
The results, conclusions and recommendations were there from extracted.
Objectives:
 To relate the demographic data to the HIV status
 To assess the purpose of attendance
 To assess the sexual practices
 To make some recommendations based on findings
Measures:
Of the 846 clients who attended the number and the attendant percentage of
those tested was documented. This was also done for those found to be
seropositive. The demographic data of all the clients and the infected ones was
analyzed and compared. The information on the services required and how the
clients knew of their existence was documented and analyzed. Sexual history
over the last twelve months and the use of the condom was analyzed as was
couple discordance and the referral pattern.
Results:
Of the 846 clients who attended, 715(84.5%) were tested and 36(5.0%) found to be
positive. Of these positive ones 25(69.4%) were females. The age-group most
affected was 29-32 years. Although the students constituted 54.7% of the total
population, they were the least affected. One the other hand the married
monogamous were the most affected (36.1% of the seropositive). Plan for the
future and the desire to know the serostatus were the key reasons for visiting the
clinic. Information from a relative or friends was the key motivation for the visit.
There was still a proposion of clients with multiple sexual partners yet condom
use was mstill low. No couple discordance was noted and the referral was done
appropriately.
Conclusion:
The seropositivity and its female to ratio are similar to the National one. The age
group distribution seems to peak at 29-32 years, decline rapidly thereafter and
then plateau at between 34 and 44 years before a final gentle drop. This pattern
would be expected. The students and the professionals had the lowest infection
rates. It is possible they could have been more sensitized but there was a
reasonable number of students who had not had sex and many also with one
469
sexual partner. Of the educated, those with secondary education had the highest
infection rate.
One would have expected the primary education level. Besides, those without
education had the lowest rate. However, those without a job had the highest rate.
The married monogamous comprised about 40% of those infected. It might help
to investigate this cohort. Most clients wanted to know their status with a future
in mind. Of concern are those with multiple sexual partners and yet condom use
is low. This should be an area for emphasis in awareness and practice.
Recommendations:
 Vigilance in our Universities on data collection, analysis and dissemination.
 Address the needs of the non-academic staff from whom the infected cases
were highest.
 Find out why married monogamous clients were most affected
 Continue information dissemination as catalyst for VCT attendance.
 Find out modes of enhancing condom use especially where multiple sexual
partners are concerned
Effectiveness Of Non-Nucleoside Reverse Transcriptase Inhibitor-

Containing Antiretroviral Therapy In Women Previously Exposed To A
Single Dose Of Nevirapine: A Multi-Country Cohort Study.
Author: James Kiarie5, John Ongech5,Paul J Weidle1, Jeffrey Stringer2, Michelle S
McConnell3, 4, Thanomsak Anekthananon6, Tavatchai Jariyasethpong7, Dara
Potter2, Winnie Mutsotso8, Craig B Borkowf1, Omotayo Bolu4.
Source: Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention
(CDC), Atlanta, GA, US. University of Alabama at Birmingham Centre for
Infectious Disease Research in Zambia, Lusaka. Thailand Ministry of Public
Health--US CDC Collaboration, Nonthaburi, Thailand Global AIDS Program,
NCHHSTP, CDC, Atlanta, GA, US. Kenyatta National Hospital/University of
Nairobi, Nairobi, Kenya Department of Social and Preventive Medicine, Siriraj
Hospital, Mahidol University, Bangkok, ThailandInfectious Diseases Unit,
Rajavithi Hospital, Bangkok, Thailand. CDC-Kenya, Nairobi, Kenya
Maternal-infant single-dose nevirapine (SDNVP) reduces perinatal HIV
transmission, but induces viral resistance to non-nucleoside reverse transcriptase
inhibitor (NNRTI) drugs in some women. Prior SDNVP exposure may
compromise future maternal treatment with NNRTI-based antiretroviral therapy
(ART).
Methods:
Between May ’05 and Jan ’07, we enrolled SDNVP-exposed and unexposed
women starting NNRTI-based ART in a prospective cohort study in Zambia,
Thailand, and Kenya. Women were frequency matched at entry by WHO stage
470
and CD4 cell count (CD4). We compared treatment failure (viral load [VL] >400
copies/ml, not on NNRTI, died) between exposure groups at 6 months after ART
initiation.
Results:
We studied 878 women (355 SDNVP-exposed, 523 unexposed). SDNVP-exposed
women were younger (29 vs 33 yrs, p<0.001), had a higher median CD4 (160 vs
139 cells/mm3 p=0.007), and lower median VL (97,300 vs 142,000 copies/ml,
p=0.02), but were of similar weight (51 vs 52 kg, p=0.4). At 6 months after ART
initiation, 186 (21%) women had failed (76 had VL >400 copies/ml, 51
discontinued the study, 48 died, and 11 had been changed to a protease
inhibitor). Women with exposure to SDNVP <6 months before NNRTI-based
ART initiation, with baseline CD4 0-49 cells/mm3, or VL >100,000 copies/ml had
poorer treatment responses (Table). Women exposed to SDNVP >12 months
before NNRTI-based ART did as well as unexposed women.
Baseline covariates N Multivariate odds ratio for CI95
treatment failure at 6 months
adjusted for age
Time since Unexposed 523 1.0
SDNVP <6 115 1.86 1.12-3.09
exposure 7-12 67 1.61 0.87-2.98
(months) >12 173 0.90 0.56-1.45
Country Thailand 217 1.0
Zambia 509 2.00 1.23-3.23
Kenya 152 1.47 0.81-2.65
CD4 >200 255 1.0
(cells/mm3) 50-199 479 1.42 0.91-2.21
0-49 144 3.21 1.88-5.49
VL <10,000 114 1.0
(copies/ml) 10,000-99,999 296 1.86 0.95-3.62
>100,000 462 2.25 1.17-4.29
Missing 6 .
WHO Stage I/II 416 1.0
III 358 1.42 0.95-2.10
IV 104 1.65 0.96-2.84
In a secondary analysis including only those still on NNRTI-based ART at 6

months, we found similar results.
Conclusions:
A high proportion (79%) of women in this cohort responded to 6 months of
NNRTI-based ART whether previously exposed to SDNVP or not. These data do
suggest an increased risk of treatment failure among women with recent SDNVP
exposure, but not with SDNVP exposure >12 months before initiation of NNRTI-
based ART.
Recommendations:
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Treatment with ART or perinatal HIV prevention strategies other than SDNVP
should be considered for pregnant women who are likely to initiate ART within
1 year after delivery.
Revised (2008 version) National Guidelines for Prevention of Mother-to-

Child Transmission of HIV infection in Kenya: What is new?
Author: Dr. Boaz Otieno-Nyunya, Moi University School of Medicine, P.O. Box 30003,
Eldoret Tel: 0722-263752, 0733-703214. Email: akinyijael@yahoo.com
Author: Background:
Mother-to-child transmission (MTCT) is the most important source of HIV
infection in children. Most PMTCT programs in Kenya have relied on a single
dose nevirapine SDNVP) as the main prophylactic regime for (PMTCT), the
simplest regimen for settings where resources are constrained. WHO more
recently recommended newer and more efficacious regimens based on the
available scientific evidence and progmmatic experience. The revised(2008
version) National Guidelines for Prevention of Mother-to-Child Transmission of
HIV Infections in Kenya have incorporated these recommendation.
Objectives:
 Review the magnitude and trends of mother –to-child transmission in Kenya.
 Outline the components of the new national guidelines of PMTCT.
 Identify new issues and strategies in the PMTCT based on current evidence
and programmatic experience.
 Discuss service, research and pragmatic implications of the new
recommendations.
 Results:
 The new guidelines consist of the following ten chapters:
 Background
 Antenatal care and prevention of MTCT of HIV
 Intrapartum care
 Use of ARVs in pregnancy in treatment and prevention of mother-to-child
transmission of HIV infection.
 Immediate post natal and neonatal care.
 Late post natal care and family planning
 HIV diagnosis in children
 Feeding infants and young children born to HIV infected mothers
 Care and follow up of children of HIV infected mothers
 Monitoring and evaluation pf the PMTCT services.
Key Recommendations In The Revised Guidelines:

 All HIV pregnant women in the need of treatment should receive ART
 First line regimen for pregnant women in need of treatment is AZT+3TC
+NVP
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 In women for whom ART is not indicated, AZT should be given from 28
weeks of pregnancy plus SDNVP and 3TC at the onset of labour with a 7 day
tail of AZT plus 3TC to reduce the risk of NVP resistance; and the infant
SDNVP soon after birth plus AZT for 7 days.
 Alternative prophylactic regimens include AZT from 28 weeks plus SDNVP
for women and SDNVP and 7 days AZT for infant.
 Infants born HIV-positive women who had not received any ARVs should be
given SDNVP at birth plus AZT for 4 weeks.
 In programs (such as AMPATH) triple drug prophylaxis has been used since
2003. Experience gained shows that this is a feasible and effective option.
Interruption in MTCT of less than 5% has been achieved using this regimen
AZT+3TC +NLF/RJV (kaletra)
Conclusion:
Achieving global as well as local targets of PMTCT is feasible if we can increase
access to integrated and comprehensive programmes for preventing HIV
infection in infants and young children. The 4 pronged PMTCT approach must
be adopted with focus on all the four prongs.
Development Of A Human Vaginal Spermicide And Microbicide

(Unipron) To Prevent Pregnancy And Transmission Of HIV/AIDS
(Safety Studies).
Author: Obiero, J.A., Mburu, N., Mwaura, B., Waititu, K., Mulei, I., Farah, I., Mwethera,
P.G
Source: Institute of Primate Research, P.O. Box 24481, Karen, Nairobi. Kenya
Abstract: Summary:
Identification and characterization of bacterial species before and after UniPron
administration, toxicity effect of UniPron on vaginal mucosa and body organs
(liver and kidney).
Objectives:
To characterize the normal vaginal microbial flora during follicular, luteal and
menstrual stages in the baboon.
 To determine the effect of UniPron on normal vaginal microbial flora in the
baboon.
 To evaluate the effect of UniPron on the vaginal epithelium.
 Determine the effect of UniPron on liver and kidney functions.
Measures:
Investigation of safety of UniPron using a baboon model.
RESULTS:
Lactobacilli, the predominant bacteria in the normal vagina of humans was not
affected by administration of UniPron. There were no visible lesions/irritation
on vagina mucosa and liver and kidney function tests were normal.
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Conclusion:
UniPron did not cause any negative side effects and therefore safe to use in the
baboon model.
Recommendations:
These studies can be extended to humans.
Effects Of HIV/AIDS On Maternity Care Providers On Labor & Delivery

Wards In Kisumu, Kenya.
Author: Janet M. Turan, *Elizabeth A. Bukusi, Craig R. Cohen, John Sande, Suellen Miller
Source: Center for Microbiology Research, KEMRI, Box 19464, Post Code 00202, Nairobi
Honorary Lecturer,Department of Obstetrics and Gynecology,University of
Nairobi, email: ebukusi@csrtkenya.org
To explore the impact of HIV/AIDS on maternity care providers (MCPs) in labor
and delivery in a high HIV prevalence setting in sub-Saharan Africa.
Design:
Qualitative one-on-one in-depth interviews and observations of care provision.
Setting:
Four health facilities providing labor and delivery services (a provincial hospital,
a district hospital, a health center, and a small private maternity hospital) in
Kisumu, Nyanza Province, Kenya.
Participants:
18 MCPs, including 14 nurse/midwives, 2 clinical officers, and 2 ob/gyn
specialists.
Results:
The HIV/AIDS epidemic has had numerous adverse effects, and a few positive
effects, on MCPs in this setting. Adverse effects include reductions in the
number of health care providers, increased workload, burnout, reduced
availability of services in small health facilities when workers are absent due to
attending HIV/AIDS training programs, difficulties with confidentiality and
unwanted disclosure, and MCPs’ fears of becoming HIV infected and resultant
stigma and discrimination. Positive effects include improved infection control
procedures on maternity wards and enhanced MCP knowledge and skills.
Conclusion/ Recommendations:
A multi-faceted package including policy, infrastructure, and training
interventions is needed to support MCPs in these settings and ensure that they
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are able to perform their critical roles in maternal healthcare and prevention of
HIV/AIDS transmission.
HIV/AIDS And Maternity Care In Kenya: How Fears Of Stigma And

Discrimination Affect Uptake And Provision Of Labor And Delivery
Services.
Author: Janet M. Turan, Suellen Miller, *Elizabeth A. Bukusi, John Sande, Craig R. Cohen
Source: Center for Microbiology Research, KEMRI, Box 19464, Post Code 00202, Nairobi
Honorary Lecturer,Department of Obstetrics and Gynecology,University of
Nairobi, email: ebukusi@csrtkenya.org
Abstract: Background;
Although policies and programs exist to promote safe motherhood in sub-
Saharan Africa, maternal health has not improved, and may be deteriorating in
on maternity care.
Methods:
We conducted a study in Kisumu, Kenya to explore how fears related to
HIV/AIDS affect women’s uptake and health workers’ provision of labor and
delivery services. In-depth qualitative interviews with 17 maternity workers, 14
pregnant or postpartum women, 4 male partners, and 2 traditional birth
attendants; as well as structured observations of 22 births; were conducted at
four health facilities.
Results:
Participants reported that fears of HIV testing; fears of involuntary disclosure of
HIV status to others, including spouses; and HIV/AIDS stigma are among the
reasons that women avoid delivering in health facilities. Maternity workers now
have to take into account the HIV status of the women they serve (as well as their
own fears of becoming infected and stigmatized), but do not seem to be
adequately prepared to handle issues related to consent, confidentiality, and
disclosure. Importantly, it appeared that women of unknown HIV status during
labor and delivery were likely to be targets of stigma and discriminatory
practices, and that these women were not receiving needed counseling services.
The findings suggest that increasing infection control precautions will not be
enough to address the challenges faced by maternity care providers in caring for
women in high HIV prevalence settings.
Conclusions and Recommendations:

consent, confidentiality, and disclosure. Furthermore, this study points to the
necessity of paying more attention to the care of women of unknown HIV
475
quality of maternity care, increase utilization, and contribute to overall

improvements in maternal health, while also enhancing PMTCT and HIV care.
Sexual practice among pregnant women in relation to knowledge of HIV

serostatus at Kenyatta National Hospital and Pumwani Maternity
Hospital.
Author: Dr. Dan Okoro, Dr. Machoki J. M’Imunya, Dr. Wanyoike Gichuhi.
The prevalence HIV infection among pregnant women is varied from one region
to another. Sexual behavior among HIV positive patients seems not to change
especially in the settings of non-disclosure and emergence of antiretroviral
therapy. This imparts negatively on PMTCT strategies. Public health strategies
have emphasized partner notification and interventions to reduce sexual risk
among HIV positive individuals.
The study aimed to compare the sexual practice patterns among HIV positive
and HIV negative pregnant women in relation to HIV status disclosure.
Study design:
Prospective cohort study between February 2007 and July 2007. Participants were
followed up for four weeks.
Setting:
This was a cohort study of 110 HIV positive and 110 HIV negative pregnant
women followed up in antenatal clinics of Kenyatta National Hospital, a referral
and teaching hospital and Pumwani Maternity hospital, the largest single
obstetric unit in the country. Their sexual behaviour was stratified by HIV status
and HIV status disclosure over the period of follow up.
Broad objective:
To compare sexual practices of HIV positive and HIV negative pregnant women
attending antenatal clinics at the Kenyatta National Hospital and Pumwani
Maternity hospital.
Specific objectives:
 To compare sexual frequency and desire of the HIV infected pregnant
women against those who are HIV negative.
 To compare the rates of disclosure of HIV serostatus between HIV positive
and negative pregnant mothers.
 To determine the effect of HIV status on frequency of condom use.
Main Outcome Measures:

Change in Sexual desire, condom use, disclosure of HIV status to sexual partner,
serodiscordance, effect of couple counseling.
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Results:
A total of 220 pregnant mothers who were enrolled in this study of whom 110
were HIV positive and 110 were HIV negative. Most of the participants (75%)
were tested for HIV during the index antenatal clinic. The HIV positive pregnant
women had earlier sexual debut compared to their negative counterparts
(p=0.002). Disclosure rate among the HIV positive was 84.5% compared to 96.4%
among the HIV negative clients (p=0.005). Frequency of sex and change of sexual
desire was not affected by the HIV status at baseline (p=0.076) but significantly
different in the follow up between the two groups (p=0.000). About 50% of the
HIV negative women did not know the HIV status of their spouses. Two-thirds
(67%) of the HIV positive women were either not using condoms or doing so
inconsistently. Couple counseling improved condom use among HIV positive
couple (OR=1.25).
Conclusion:
The HIV status and its disclosure determine change of sexual desire. Couple
communication (status disclosure) improves condom use and it should be
emphasized in PMCT interventions. Motivating messages should be designed to
improve safe sexual practice among the HIV positive and negative in order to
prevent more new infections.
Effectiveness Of A Comprehensive PMTCT Program.

Author: Ong’ech J O , Kiarie J N , Gachoki A W, Govedi F, Mutsotso W, Mbori-Ngacha D.
Source: Kenyatta National Hospital, University of Nairobi department of Obstetric and

Gynecology, and Pediatrics, Pumwani Maternity Hospital, CDC Kenya
Background:
Although theoretical efficacy of PMTCT interventions has been established in
randomized clinical trials it is important to determine actual transmission rates
in program settings. In Kenyatta National Hospital we evaluated the uptake of
antiretrovirals, elective caesarean section, replacement feeding and contraception
for PMTCT. Program effectiveness was determined by DNA PCR testing of
infants.
PMTCT antiretroviral regimens are short course AZT with nevirapine, HIVNET
012, HAART for mothers requiring treatment and 1 week AZT and single dose
nevirapine to all HIV exposed babies within 72hours of delivery. Other
interventions include elective caesarian section, support with replacement
feeding for mothers who opt not to breastfeed, and post-pregnancy care and
contraception
Methods:
Service delivery data that is reported to National AIDS and STI Control Program
(NASCOP) on monthly was summarized. The PCR test results were obtained
477
from program records. Data entry and analysis was done using SPSS version
11.5.
Results:
Of 933 HIV positive women 910 (97%) received ARVs for PMTCT, 570 (61%)
opted for replacement feeding and 330 (35%) were delivered by elective
caesarian section, and 215 (23%) are on family planning methods.
Among women who received ARVs for PMTCT 269 (30%) received short course
AZT with nevirapine, 377(41%) received HIVNET 012, 89 (10%) received HAART
and for 175 (19%) mothers only the infants received post exposure prophylaxis.
The median age of the 68 tested infants was 3.5 months (range 1-12 months), 14
(21%) tested HIV positive. There were no significant differences in transmission
rates by mode of delivery (15% for caesarean section vs 23% for vaginal delivery
P=0.4), mode of infant feeding (21% for replacement feeding vs 38% for breast
feeding P=0.3) and the maternal PMTCT regimen (16% for AZT/NVP vs 14% for
HAART vs 29% for HIVNET 012 P=29%).
Conclusion:
The uptake of PMTCT antiretrovirals and replacement feeding are high while
that of caesarean section and contraception are low. HIVNET 012 and infant PEP
account for 60% of the antiretroviral interventions due to late presentation of
women. The observed transmission rates with antiretrovirals, caesarean section
and replacement feeding are higher than would be expected from the theoretical
efficacy of these interventions.
Kenya HIV/AIDS Service Provision Assessment Survey 2004.

Author: Muga R, Ndavi PM, Kizito PL, Buluma R, LumumbaV, Ametepi P, Fronczak N,
and Alfredo F.
It is estimated that 2.2 million people in Kenya have been infected while 1.5
million have already died from HIV/AIDS, leaving behind approximately
140,000 infants and children living with the virus. The President’s Emergency
Funds for AIDS Relief (PEPFAR), working with the U.S. Government is
committed to working with international, national and local leaders worldwide
to promote integrated prevention, treatment, and care programs to combat the
disease
Objective:
Kenya Service Provision Assessment Survey (KSPA) 2004 on HIV/AIDS
determined the capacity of the formal health sector in Kenya to provide both
basic and advanced level HIV/AIDS services, availability of record keeping
systems for monitoring HIV/AIDS care and support as well youth friendly
services. These indicators summarize the PEPFAR indicators.
478
Methodology:
Data were collected from 440 facilities including hospitals, health centers,
maternities, clinics, dispensaries and VCT centers. Facilities managed by the
government, non-governmental organizations (NGOs), private-for-profit, and
faith based organizations (FBOs) were included in the survey.
Outcome measures:
In order to address these aspects, HIV/AIDS related services that were assessed
included counseling and testing (CT), care and support services (CSS),
antiretroviral (ARV) therapy (ART), post-exposure prophylaxis (PEP),
prevention of mother-to-child transmission (PMTCT), and youth friendly
services.
Results:
Counseling and testing (CT), care and support services (CSS), antiretroviral
(ARV) therapy (ART), post-exposure prophylaxis (PEP), prevention of mother-
to-child transmission (PMTCT), and youth friendly services were available in 37,
68, 7, 8, 24, and 5 percent, respectively of all facilities in Kenya. HIV testing
services, were more commonly found in Nairobi (77 percent of all facilities) and
least in Nyanza and North Eastern provinces (19 and 135 percent respectively.
Assessment of record keeping revealed that 77, 96 and 50 percent of all facilities
nationally had records of test results and clients receiving results for all eligible
service sites and a written informed consent policy in all sites offering voluntary
counseling and testing respectively.
Facilities that provide care and support services for HIV/AIDS clients also offer
basic level care related to TB, STIs, OIs and malaria in Kenya. TB services, DOTS
programme, and malaria medicines were available in 54, 33 and 99 percent,
respectively, of all facilities offering CSS. Availability of drugs for treatment of
various STIs ranged from 75% for gonorrhea to over 90 % for syphilis, chlamydia
and trichomoniasis. Treatment for OIs was offered in 63 percent of facilities
providing CSS for HIV/AIDS clients.
Advanced care and support services including antiretroviral therapy (ART),

facility with identified home based care service site (17% Gov., 25% NGO, 15%
private-for-profit, and 23% FBO) and access to post exposure prophylaxis (PEP)
and PMTCT are available in less than 30% of facilities nationally: all management
authorities are performing poorly on this score.
Efforts must be made to increase the provision of HIV/AIDS related services

irrespective of the facility type and management authority. There is need to
address the inequities in provision of HIV/AIDS related services in Kenya.
Youth friendly services need special attention.
Impact of Intrapartum and Postpartum HIV Counseling and Testing at

Pumwani Maternity Hospital.
479
Author: Govedi Fridah, Ong’ech John O, Kiarie James, Gachoki Agnes, Mutsotso W,
Mbori-Ngacha Dorothy
Source: University of Nairobi1, Kenyatta National Hospital 2 Pumwani maternity

Hospital, CDC Kenya.
Introduction:
Pumwani Maternity Hospital is the largest maternity hospital in the country
conducting 24,000 deliveries per year. It is a low cost public hospital with 256
nurses, 6 obstetricians, 2 pediatricians and 18 medical officers.
Background:
A survey in 2003 showed that most women presenting in labour did not know
their HIV status. PMTCT services offered in PMH include, HIV counseling and
testing (ante-natal, intrapartum and postpartum), counseling and support of
infant feeding options, post pregnancy care of HIV infected women (providing
continuing counseling, medical care and contraception), Training of service
providers, program supervision to improve quality of services and renovation of
service delivery points.
Methods:
Service delivery data submitted to NASCOP were analyzed to assess the impact
of Intrapartum and Postpartum testing.
Results:
Ninety nine percent of women counseled accepted testing, intrapartum and
immediate postpartum counseling and testing accounted for 89% of women
tested. Prevalence of HIV among tested women reduced from 21% in 2004 to
13% in 2005, while uptake of antiretrovirals among HIV positive women
increased from 49% in 2004 to 89% in 2005. About 52% of HIV positive women
opted to formula feed and 23% initiated effective contraception during follow-up
post pregnancy.
Conclusion:
Intrapartum and Postpartum counseling and testing have been introduced
successfully in PMH and reach a high number of women and their children.
Uptake of intervention is high inspite most mothers being tested intrapartum
and postpartum however contraception uptake remains a challenge.
Assessing Reproductive Health Clinics For Art Provision In Kenya: A

Case Study Of Family Planning Association Of Kenya.
Author: Joachim Osur, Wilfred Ochan; Alejandra Trossero; Andrew Maranga; Dan
Murokora
Source: FPAK/IPPFRO/IPPFCO, Box 30581-00100, Nairobi
480
The urgency to achieve universal access to ART is forcing health systems to find
innovative ways of integrating HIV care into the existing established service
delivery points. On the other hand, reproductive health clinics have suffered
serious set backs since the advent of HIV as more attention went to HIV care
parallel programming. It is now becoming quite clear that better results could be
achieved in both of the two areas through integration of services. It is not
however known how prepared SRH clinics are to be able to offer HIV care. The
entry points to HIV care presented by SRH clinics also need evaluation to
establish the advantages that they present.
Objectives:
To assess site preparedness to initiate, manage and sustain ARV treatment in
SRH clinics. To find out the possibility of ART roll out through SRH clinics using
SRH services as entry points.
Methodology:
This was a cross sectional study. A modified DELIVER ARV Site Preparedness
Assessment Tool was used. It covered the 6 ART Domains of Leadership &
Model of Care; Services and Clinical Care; Monitoring & Evaluation; Human
Resource Capacity; Laboratory Capacity and Drug Management & Procurement.
Key informant and group interviews were conducted with clinic managers,
service providers, laboratory staff, PLWAs and staffs from Ministry of Health.
ARV policies, plans and reports and research and accreditation tools were
reviewed. Observations were done on status of facilities, equipment and supplies
level.
Results:
The SRH clinics were found to have the leadership, infrastructural and technical
capacities for initiation of ART using the national ARV protocols. Established
VCT, management of opportunistic infections, MCH and family planning would
act as entry points for ART patient recruitment. However, SRH needs of positive
community were not adequately addressed. Links with positive community
existed in only two clinics, but were not formalized and there was a reported
barrier associated with stigma & discrimination. Similarly, strategic partnerships
with other service and care providers had not been institutionalized. Data
collection tools needed to be updated to include ARV and HIV/AIDS services.
Laboratory had enough capacity in terms of personnel and facilities for basic
tests in ART programme. However, there was need for pharmaco-vigilance to
monitor adverse drug events. The logistics & dispensing systems were adequate
in handling antiretroviral drugs.
Conclusions:
With minimal improvements, SRH clinics offer a great opportunity for HIV care.
The country could gain a major mileage in increasing access to ART by using
these clinics.
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Recommendations:
SRH clinics, both privately owned, NGO owned and government owned should
integrate ART treatment into their services. The clinics would need to be assessed
for this service and identified gaps sealed. A pharmaco-vigilance programme
should be a component of this service.
It would also be necessary for the clinics to build stronger networks with PLWAs
and to recruit them as paid counselors, treatment educators, community
mobilizers, etc. for pursuit of the GIPA/MIPA principle.
Antenatal Hiv/Aids Counselling And Testing At The Pgh, Nakuru - A

Retrospective Study (1st October 2002 To 31st December 2004).
Author: Dr. Douglas Kamau Ngotho, Egerton University, P. O. Box 536, Njoro.
Antenatal counseling for HIV/AIDS at the PGH, Nakuru was started on 1st
October 2002. This was important because of the role played by vertical
transmission in this pandemic. The desire to know the progress and value of this
clinic motivated the undertaking of the study.
Objective:
To assess the degree of seropositivity among mothers attending the antenatal
clinic at PGH, Nakuru.
Design:
Retrospective study.
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Methodology:
All the available data of clients attending the antenatal clinic at the PGH Nakuru
between 1st October 2002 and 31st December 2004 was analysed for various
parameters.
Results:
Over the stated period 7829 clients attended the antenatal clinic and were
counselled. Out of this member 5933 clients were tested and 523 (8.8%) found to
be positive.
The mean age of the mean age of the attendees was 21.8 year and the range 14-57
years. The age group with the highest attendance was 21-25 years. Of the entire
positive cases 39.8% belonged to this age group. However, the highest
proportionate percentage of positive cases was that above 35years (11.4%).
The mean gestational age at first visit was 31.2 weeks and the range 5 - 40 weeks.
The highest attendance was at 28-32 weeks and highest prevalence of
seropositivity was at 13-17 weeks.
The majority of the attended were para 1-2. This group also had the highest
number of positive cases (239, 45.7%). The highest prevalence was among those
with a parity of 3-4 (15.3%).
Although the majority of the mothers were married and also had the highest
number of positive cases (486, 92.9%) the positivity rate was higher among the
single than the married clients, 10.7% and 8.7% respectively.
Conclusion:
A significant number of mothers were infected during pregnancy and therefore
had a high chance of giving birth to infected babies.
Recommendation:
Since the rate of vertical transmission can be reduced by counseling and testing
and also the use of the anti-retroviral therapy, the establishment of facilities for
PMTCT countrywide should be given high priority
Optimising and scaling up Prevention of Mother to Child Transmission

of HIV in Western Kenya: the Academic Model for the Prevention and
Treatment of HIV/AIDS (AMPATH) Programme Experience.
Author: B. Otieno- Nyunya, Moi University School of Medicine, P.O Box 3003, Eldoret,
Kenya. Email: nyunya@mtrh.org.
The primary objective of the AMPATH PMTCT programme is aligned to the
global as well as the national objective to prevent HIV transmission of HIV from
infected mothers to their infants, with a target of 20% by year end of year 3 and
40% by end of year 5 having been set for the MTRH programme
Outcome measures:
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Description of programme planning, implementation, programme processes

including training and management. Counselling and testing uptake, maternal
HIV-seroprevalence, proportion of patients with tracer cards filled for location of
defaulters, counseling for and type of infant feeding, ARV prophylaxis and
treatment. Infant seroprevalence
Results:
More than 14,700 pregnant women have been counselled and tested for HIV
between March 2002 and December 2005 while 1,131 HIV positive women have
been enrolled into the pMTCT programme and into HAART follow-up
programme alongside other patients being followed up in the AMPATH HIV
treatment programme. Currently there are 20,128 HIV-Positive patients, 13,372
or approximately two-thirds of who are women, are on follow up. Of the total
9,721 patients who are currently receiving ARVs in the AMPATH programme,
8,871 (91.2%) are on HIV treatment including 576 children while 860 (8.8%) of the
patients are pregnant women on prophylaxis for total pMTCT. Several trainings
were organised to build capacity of health care providers, and to continue
supplementary training to replace health workers lost through transfers and
internal brain drain. Ongoing training proved invaluable to keep abreast with
the rapid changes in the health care system. It was necessary during the course of
the four years to make modifications in the structure of the programme including
introducing onsite testing and modifying patient flow. It was also necessary to
introduce performance improvement initiatives in order to optimise programme
uptake.
Conclusions and lessons learned:

Many changes in programme structure, policies regarding testing and
antiretroviral drug regimes for prophylaxis as well as changes in practices on
infant feeding were necessary to accommodate the changing resource
environment new evidence and changing international and national as well as
local experience and thinking.
It is possible to achieve ‘90%, 90%, 90%’ regarding PMTC counselling; testing
and enrolment into HIV care through aggressive opt-out testing, as well as
integration of PMTC services to other reproductive health care services. Stigma
and silence are still major challenges hindering uptake of essential PMTC
interventions. Comprehensive services synergize different components.
Replacement infant feeding is difficult but possible to achieve through individual
counselling, community counselling, male involvement and subsidized or free
formula supplies.
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Effectiveness of the program for Prevention of Mother to Child

Transmission of HIV in Nyanza province, Kenya.
Authors: Kizito M Lubano , Terese Delvaux
Source: Institution 1.Kenya Medical Research Institute, Institute of Tropical Medicine,

Antwerp, Belgium.
Abstract: Purpose:
 To determine the effectiveness of PMTCT program in Nyanza province.
 To compare the effectiveness of PMTCT program of Nyanza province with
programs from other areas.
Methods:
Operational analysis of Antenatal care activities using adapted Piot's Model, and
comparative Analysis using standardized PMTCT indicator.
Results:
During the 1st quarter of 2003, out of 9871 first-visit pregnant women, 7770 (78%)
were counselled, and 5439 (70%) were tested; 1577 (29%) were HIV positive, 398
mothers (25%) took Nevirapine, with a possible 55 cases of perinatal HIV
averted.
Conclusions:
 Therefore, the effectiveness of the program was 14 %
 The effectiveness is very low, but comparable to similar programs elsewhere.
 Recommendations for Nevirapine should be considered in light of home

deliveries without antenatal care and knowledge of serostatus.
Recommendations:
 1 There IS need to address primary prevention in this community with avery,
high background prevalence.
 2. There is need to integrate family planning with prevention efforts to
prevent unwanted pregnancies in HIV positive women
 3. There is need to focus on the youth (10-24 year-olds) especially the girls
who are disproportionately affected
 4. There is need to strengthen postpartum continuum of care to support the
women and their families.
485
Feaslbllity and willingnes for community level Promotion and

Distribution of condoms for Dual Protection among youth in urban
slums in Kenya and Tanzania.
Author: E. M. Teri & E. Taban
Source: Family Health International Nairobi, Kenya. Consultant
One of the most pressing challenges for health providers in sub-Saharan Africa is
how to supply male condoms, and promote their correct and consistent use at
the community level for dual protection against unwanted pregnancy and
STI/HIV-AIDS. In spite of condom distribution and promotion efforts, male
condom use remains low in countries such as Kenya and Tanzania. Hence, HIV
infection and unwanted pregnancy rates continue to escalate. Little is known
about the feasibility of supplying condoms through outlets other than health
facilities, CBD programs and pharmacies and/or whether people in slum settings
are willing to promote, distribute, or use condoms, if they are provided free of
cost.
Objective:
To identify potential structures and resources at community level that can be
utilized to support condom promotion for dual protection and provide baseline
data to inform a design of a Reproductive Health Initiative (RHI) on dual
protection. The study aimed to answer the following questions: What are
community groups and leaders attitudes towards condom use and willingness to
promote or provide condoms for dual protection to community members,
especially young people? What community structures and resources in urban
slum settings could be used to support community level condom promotion for
dual protection.
Methods:
The study was conducted in Nairobi (Kabiro and Kangemi), Mombasa
(MIongwe) in Kenya and Arusha (Unga Limited). Tanzania. Convenience
samples of retail shops, hair beauty salons /barbershops video show rooms, bars,
guesthouses and nightclubs were selected. A total of 143 establishments were
selected and semi-structured interviews were conducted. Over 83 structured
Interviews were conducted with male and female groups of youth, community
adults and community leaders. Thirty-two focus group discussions were held
with women and men community groups. Epi-lnfo computer program was used
for data entry and analysis.
Results:
Community group leaders know what condoms are and over 9O% could identify
condoms when shown in packets of three. Overall, 84% of the respondents knew
the reasons for which condoms are used (to prevent unwanted pregnancy - 95%),
to prevent STI, HIV and AIDS - 84%). About 87% of community group leaders
support the use of condoms for prevention of pregnancy and ST1, HIV and AIDS
486
and about 90% of them would be willing to distribute Information materials for
dual protection. About 85% of community leaders would be wiling to show
videos to the youth and about 85% of women and 74% of men would be willing
to promote condom use in their communities. Nearly 80% of potential condom
outlets (such as bars, guest houses. kiosks and shops) would be willing to make
condoms available in their establishments.
Conclusion:
It is feasible to use non conventional condom outlets and community structures
to promote and distribute male condoms in communities for prevention of
unwanted pregnancy and STI, HIVandAIDS. Community based projects could
work with these community structures to mitigate the problems of unwanted
pregnancy and STI, HIV and AIDS because of their wider reach in the
community
Service providers' attitudes towards condom promotion: Preliminary

findings from a follow-up study of a Female Condom Community
Intervention Trial.
Authors: Cathy Toroitich-Ruto. PhD, Lorie Broomhall, PhD, Paul Kuria, Evaline Kibunch,
George Dzombo, Michael Welsh
Source: FHI Nairobi, FHI NC
The Female Condom Community Intervention Trial (FCCIT) study was
conducted on tea, coffee and flower plantations in central and western Kenya
between 1998 -1999. It was designed to determine whether the introduction and
promotion of female condoms (FCs) would successfully Increase overall condom
use and reduce the incidence of STI. Findings from the FCCIT indicated that
although the rate of male and female condom use increased substantially, the STI
prevalence showed no significant decrease. Some of the questions this study was
designed to investigate are: What factors may account for differences between
reported levels of condom use and incidence of STI among FCCIT study
participants?; what factors are hindering providers from promoting female and
male condoms to FP Clients?; and what accounts for differences between the
level of condom promotion among clinic staff and outreach staff (depot holders)?
These data discrepancies provided the basis for further investigation.
Objective:
This presentation will investigate the factors influencing the promotion or lack of
it among clinic staff and depot holders in order to explain variations in condom
distribution.
Methods:
Qualitative methods were used to explore factors influencing condom use to
provide a contextual understanding of sexual activity, the meanings of those
487
relationships, and especially in negotiation for condom use. Timed clinic

observations, participant observations, structured In-depth interviews and focus
group discussions were conducted. Estate managers, villagers elders {key
Informants}, private practitioners, untrained health providers, clinicians, depot
holders and plantation workers were interviewed in 2 major tea estates that
participated in the FCCIT.
Results:
Preliminary findings show that the low performing sites promoted and
distributed less condoms because some clinicians felt that promoting condoms
was morally wrong. This explains the lack of initiative in providing condoms
even when they know that a client needs condoms. Another explanation for low
condom distribution was that some clinicians might have also given up on clients
who frequently go back to the clinic for treatment of STIs and therefore did not
see reason to provide condoms. Some providers were not motivated to promote
and distribute condoms; probably because they felt that they were too busy
treating clients.
Conclusion:
Obtaining more ethnographic information would increase our knowledge about
the individual, social, and cultural factors influencing condom rejection and
acceptance and can be used to develop strategies to improve condom promotion
at service delivery points (SDPs) throughout Kenya and Eastern and southern
Africa.
Factors hindering the promotion of Condoms by STI Service Providers in

Kenya.
Author: J.Liku, R.Okowa, O.Habil, Z.Omungo, L.Broohall
Source: Family Health International (FHI). Nairobi, Kenya, FH1, RTP, NC
With a total population of about 30 million, over 2 million Kenyan adults and
children are estimated to be living with HIV. Though nationwide the Infection
rate is 14%, in some areas it is even higher. In Nyanza province on Kenya's,
western border, the adult HIV prevalence is estimated at 30%-40%. Despite the
alarming reality of HIV In Kenya, condom use -known to be the only effective
way to avoid HIV and other STls among the sexually active - continues to be low.
488
Objective:
This study sought to identify, document and explain factors that Influence
condom promotion by various categories of STl service providers in order to
provide the Ministry of Health with information for interventions to improve
condom counseling and distribution.
Methods:
The study was conducted in an urban (Kisumu) and a rural site (Siaya) In
Kenya's Nyanza province. A purposive stratified sample of sites and providers
from both the formal and informal health sectors were selected for intensive
investigation and STI patients were interviewed individually. Qualitative
methods such as in-depth interviews and focus group discussions and structured
observations were used to collect data between May 2001 and March 2002. Ten
focus group discussions and 143 in- depth interviews were conducted.
Results:
Preliminary findings indicate that the mean age of STI patients who participated
in structured I observations was 25 years, 52% were male and 48% tamale. There
was little or no condom promotion by STI providers in government and
municipal facilities. Patients were hardly asked about their risky behavior and
providers steered away from discussions on or demonstration of condom use.
Pharmacy attendants, unlicensed health providers and traditional healers did not
provide any counseling on condoms at all. However, community based
distribution agents educated clients on condoms and STIs, provided condoms
and made referrals to the formal sector. Providers in the formal sector reported
that they were too busy to counsel STl patients in general and specifically, about
condoms. The content of condom counseling was inconsistent and varied greatly
and many providers said they had not been trained to educate clients on STls
and prevention strategies. Patients raised the issue of lack of confidentiality and
privacy, lack of free STI drugs led to a decline in the number of patients visiting
public facilities. As a result a shift to the informal sector {herbalists. unlicensed
providers) was noted while other patients resorted to self-medication.
Conclusion:
To be more effective, Interventions must address factors that affect providers’
promotion and provision of condoms and those that push STI patients towards
the Informal health sector
Teachers and HIV/AIDS: Conversations With Educators In Kenya.

Author: Karungari Kiragu
Source: Population Council, Nairobi
489
It is increasingly feared that teachers are at greater risk for HIV than other
professionals of similar education in sub-Saharan Africa. Some factors cited as
elevating their risk include their frequent postings and transfers, their
comparatively higher and steadier income especially in rural areas (despite the
low salaries), and their access to power especially with young female students.
Even if teachers were not at higher risk than anyone else, their role in a country's
development makes them a special group that deserves unique attention.
Significant deaths and illnesses among teachers can erode gains made in
educating a labor force, and thereby reverse hard-won economic and
developmental achievements. Little is known about what teachers themselves
feel about HIV/AIDS, and how they are coping with it in the classrooms and in
the schools. Even less is known about the needs of teachers Vis a Vis HIV/AIDS
at home and in their personal lives.
Methods:
In order to learn what teachers think about HIV/AIDS and how they are coping
with it at home and at school, informal conversations were held with teachers in
41 primary and secondary schools in two districts in Kenya. A total of 74 teachers
evenly split between males and females were involved. The sample also included
school principals. Data were collected in March 2002.
Results:
Teachers feel they are inadequately informed about HIV/AIDS. Unless they are
teaching an HIV-related subject such as family life education, most teachers
report that they do not have any unique way of getting HIV/AIDS information
when compared to the rest of the population. Teachers also feel at elevated risk
of the infection, because they are often requested to deal with emergencies
among students that could expose them to bodily fluids. Some teachers also
acknowledge that they are at higher risk as a result of the nature of their jobs,
higher income, and access to potential sex partners. While a handful know
teachers living with HIV, most say they would feel uncomfortable interacting too
closely with such a person, especially sharing cups and other utensils. Teachers
also say they are afraid of getting tested for HIV, since going for a test
acknowledges "self suspicion", in the words of one. As community leaders, they
feel VCT is an admission of previous wrongs.
Conclusions:
The assumption that teachers are adequately informed about HIV/ AIDS may be
mistaken. Programs should address the unique needs of teachers and help them
cope with HIV/AIDS both at school and at home. Such programs should address
the heavy stigma attached to PLHA, as well as the fear teachers have in getting
tested for HIV.
490
Formative Research on a Sex Worker Peer Education program in

Mombasa, Kenya.
Authors: Cathy Toroitich-Ruto**. Sarah Thomsen*, Michael stalker*, Peter Mwarogo**,
Ndugga Maggwa Baker**
Source: Family Health International (FHI), Nairobi.
The government of Kenya has declared HIV/AIDS a national disaster and is
committed to continuing its spread and attenuating its impact. One of the
strategies identified to achieve this goal is condom promotion. Particularly
among those population groups that are at the greatest risk of' contracting HIV
and other sexually transmitted Infections (STIs), such as sex workers (SWs). The
female condom has not been introduced in Kenya's national contraceptive
method mix. Since it is a female initiated dual protection method. 1t has been
hypothesized that it would fill the gap in protection against STIs among high-
risk populations in Kenya. The current FHI/IMPACT SW project in Mombasa
provides an opportunity to explore the potential for strengthening a peer
education program by introducing the female condom.
Objectives:
To provide information on how the current FHI/IMPACT STl reduction project
in Mombasa can be modified to achieve maximum public health benefit by 1)
determining the feasibility of introducing the female condom to the current peer
education programme; 2) assessing the current SW peer education program; and
3) determining the best way to address men in a female condom intervention
with SWs.
Methods:
Several data collection procedures were used, including participant observation,
in-depth interviews, and focus group discussions. Participant observations were
conducted in the places where sex workers and their clients hang out, such as
bars, discos, traditional brew dens, and guesthouses. In depth Interviews were
carried out with 20 SWs and 20 partners of SWS to determine the best way of
incorporating them in the program. Finally, after receiving an introduction to the
female condom and an opportunity to try them for three weeks, focus group
discussions were held with approximately 50 SW peer educators regarding their
perspectives on the method.
Results and Conclusions:

Preliminary findings show that there are opportunities for increased male
condom promotion among sex workers and their partners In Mombasa. It also
appears to be feasible to introduce the female condom in this population. These
results will be validated by a cross sectional survey to be conducted in this
population In October. If there is evidence of a condom gap a follow-up
intervention study will be designed to empirically test the value of adding the
female condom to the condom distribution system. Findings from this formative
491
research will help to inform the design of that study and will bring a broader
context of the cultural and economic context of sexual networking among the sex
workers .Further findings will be presented at this conference.
Sexual privacy as a critical challenge to Behaviour Change among the

Nairobi Urban Poor.
Author: Mary Amuyunzu-Nyamongo and Monica Magadi
Abstract: Aim:
HIV prevalence in, Kenya is higher in urban areas (16-17%) compared to rural
areas (11-12%). Even in urban areas, the poor tend to suffer a higher burden of
the condition (National AIDS Control Council 2000). To mitigate the spread and
impact of HIV/AIDS, behavior change proponents promote three main strategies
namely abstinence, mutual faithfulness to one partner and condom use. Further,
in recognition of women's vulnerability to sexual exploitation their
empowerment to negotiate safe sex has been adopted as an important strategy.
However, for these strategies to succeed there must be an enabling environment
that includes access to condoms, access to health services and sexual privacy.
This paper examines the implications of lack of sexual privacy on the sexual lives
of slum dwellers in Nairobi.
Methods:
The data come from a qualitative study that was conducted in four slum areas of
Nairobi namely Kibera, Majengo, Kahawa North and Embakasi in January 1999.
The main purpose of the study was to assess sexual networking patterns of
informal settlements in relation to the people's knowledge on HIV/AIDS and the
perceived incidence. Forty focus group discussions. (FGDs) were conducted with
groups of both single and married men and women in the age categories 13-17,
18-24, 25-49 and 50+. Also involved were community leaders and service
providers. The data were transcribed verbatim and analyzed using NUDIST.
Results:
The FGD participants recognized privacy during sex as a big problem mainly
because most of the households have single-roomed sleeping arrangements. The
coping strategies adopted by parents include "waiting for children to fall asleep,
turning the lights off, using curtain materials to separate the sleeping places,
playing loud music, postponing sexual activity or sending the other children
away". The young people on the other hand have sex at "friend's houses, in the
grass/bush, in the toilets/bathrooms, along walls and dark alleys and in
abandoned, collapsed or incomplete housing structures". Lack of privacy
compromises the ability of the residents to implement safe sex practices,
especially use of condoms and abstinence. Sexual activity takes place in the
shortest time possible and with minimal noise, which essential makes the use of
condoms impracticable. In addition, women are constrained in negotiating safe
sex especially if there are children and other kin in the same room. It is also
492
difficult for abstinence to be effective among the youth due to early initiation to
sexual activity.
Conclusion:
Lack of privacy during sex could be a contributing factor to low condom use and
low levels of abstinence among the youth in urban poor areas. Lack of sexual
privacy also poses numerous negative psychological and social consequences
including embarrassment to parents and children, frustrated sex lives, lack of
quality sex, lack of respect between children and their neighbors, and early
socialization of children into sex. These factors could also partly explain the
linkage between poverty and HIV infection in poor urban areas
Using VCT Statistics from Kenya in Understanding the Association

between Gender and HIV.
Author: Otwombe, K. N.; Ndindi, P.; Ajema, C.; Wanyungu, J.
Source: WHO Regional Office for Africa, Library, Brazzaville, Congo Journal Title
SAHARA Journal of Social Aspects of HIV/AIDS/Journal des Aspects Sociaux
du VIH/SIDA
Abstract: This paper demonstrates the importance of utilising official statistics from the
voluntary counselling and testing centres (VCT) to determine the association
between gender and HIV infection rates in Kenya.The study design adopted was
a record based survey of data collected from VCT sites in Kenya between the
second quarter of 2001 and the second quarter of 2004. Of those who were tested,
significantly more females tested positive (P0.0001) and had twice as high a
chance of being infected by HIV (Odds ratio 2.27 with CI 2.23 to 2.31) than
males.We conclude that VCT statistics may lead to better planning of services
and gender sensitive interventions if utilised well.
Language: English
HIV/AIDS and associated morbidity and mortality among hospitalised

children in Kilifi, Kenya.
Source: WHO Regional Office for Africa, Library, Brazzaville, Congo
Author: Wamsele, J.; Kisenge, R.
Abstract: This study was carried to determine the frequency of HIV/AIDS and associated
morbidity and mortality among children hospitalised in the paediatric ward at
the Kilifi District Hospital, Kenya. All 7519 children admitted between January
2004 and June 2005 were eligible for the study. Testing for HIV antibodies was
493
done using Determine and Unigold tests. Of the admitted children, 163 (2.2) had
clinical features of AIDS. Sixty (36.8) of the HIV-positive children were below 18
months and 103 (64.2) were ¡Y 18 months old. There were 84 (51.5) boys and 79
(49.5girls). The median age was 2 years (range
Language: English
AIDS in Kenya: Trends, Interventions and Impact.

Source: WHO Country Office Representative, Kenya
Author: Ministry of Health
Abstract: The book talks about HIV and AIDS in Kenya what has been achieved between
1992 and 2002. It has enabled the MOH to document and disseminate valuable
information and data on the prevailing HIV/AIDS situation in the country, its
current projected impact, the interventions being mounted against the pandemic,
and their resultant effect.
Language: English

Source: Bioline International, Journal Title African Health Sciences
Author: Ochieng, Washingtone; Ogoyi, Dorington; Mulaa, Francis J.; Ogola, Simon;
Musoke, Rachel; Otsyula, Moses G.
children in Africa.
Methods:
Results:
494
Asymptomatic and symptomatic disease had, respectively, a rise in median HIV-

1 RNA load from 1,195 to 132,543 and from 42,962 to 1,109,281 copies/ml in
children below 6 years.The increase in viral load was 10-fold higher for
had initial median CD4+ T-lymphocyte counts of 647 (22) cells/µL, declining to
378 (20) while those above 6 years had initial values of below 335 (15) but which
increased to 428 (17). Median viral load correlated significantly with median
CD4+ T-lymphocyte percentage in children above 6 years (p=0.026) but not
below.
Conclusions:
replicating virus. Interventions aimed at boosting the naïve immune system may
AIDS in Kenya: background projections, impact, interventions.

Source: Kenya Medical Research Institute, Kenya.
Author: Kenya, Ministry of Health, National AIDS Control Programme; National Council
for Population and Development.
Abstract: The booklet provides information about the AIDS epidemic in Kenya in terms of
background projections; impact; and interventions. Future projections of AIDS
infection are given as well as the social and economic impacts of AIDS and what
needs to be done to prevent the spread of AIDS.
Language: English

Hospital, Kenya.
Source: WHO Regional Office for Africa, Library, Brazzaville, Congo
Author: Moth, I.; Ayayo, A.; Kaseje, D.
services at Nyanza Provincial Hospital in Kenya. A cross-sectional exploratory
collect primary and secondary data. The study population was 133 clients
registered for PMTCT services. The study revealed that 52.4 of clients received
495

intervention, 96 waited for more than 90 minutes, and 89 took less than 10
information divulged during counselling. In addition, 80 of clients did not
present for follow-up counselling irrespective of HIV status, and 95 did not
HIV result (31.5), enrollment (53.6), and delivery (80.7). Reasons for dropout
included fear of positive HIV result, chronic illness, stigma and discrimination,
unsupportive spouse and inability to pay for the services.
Language: English
Integrating HIV voluntary counselling and testing services into

reproductive health settings.
Source: United Nations Population Fund
Author: Myaya, M.
Abstract: This guide aims to provide sexual and reproductive health (SRH) programme
planners, managers, and providers with the information necessary to integrate
voluntary counselling and testing (VCT) for HIV/AIDS within their services.
VCT has been shown to be an effective strategy to facilitate behaviour change for
HIV prevention. It offers an entry point for early care and support for those
infected with HIV and prevention of mother to child transmission. VCT also
plays a role in reducing stigma and discrimination. The cost of establishing VCT
services within existing SRH settings is lower than establishing them in
freestanding sites. In particular, the guide considers integration within the
context of family planning (FP) service provision. FP and VCT service provision
have similar aims of reaching sexually active people and promoting safe and
healthy sexuality, including the prevention of HIV, sexually transmitted
infections (STIs), and unwanted pregnancy. FP settings offer specific
opportunities for reaching women with VCT. (excerpt)
Language: English
Keywords: REPRODUCTIVE HEALTH SERVICES| HIV | DELIVERY HEALTH CARE |

INTEGRATED | HEALTH PLANNING GUIDELINES
Integrating STI and MCH / FP services.

Author: Population Council. Africa Operations Research and Technical Assistance Project
496
Source: Population Council, Africa Operations Research and Technical Assistance Project
Abstract: This operations research brief summarizes research carried out under the Africa
OR/TA Project 11 from 1995-1999 including situation analysis of programs to
provide STI, HIV/AIDS services and MCH and FP services using an integrated
approach and subsequent intervention studies to test ways of improving the
existing approaches.
Language: English
Personal digital assistants for HIV treatment adherence, safer sex

behavior support, and provider training in resource-constrained settings.
Author: Kurth, A. E.; Curioso, W. H.; Ngugi, E.; McClelland, L.; Segura, P.; Cabello, R.,
and Berry, D. L.
Source: AMIA Annu Symp Proc. 2007; 1018.
Abstract: We developed a Web-based application delivered on PDAs (Colecta-PALM in

Peru, Pambazuko-PALM in Kenya), to collect data from HIV patients and to
facilitate HIV provider training. Colecta-PALM provides tailored feedback
(behavioral messaging) based on risk assessment responses for HIV patients.
Pambazuko-PALM collects patient risk assessment data, and delivers counseling
protocol training and evaluation to nurses involved in HIV care
SIECUS PEPFAR country profiles: focusing in on prevention and youth.

Kenya.
Abstract: The HIV/AIDS-prevalence rate nationally is 6.7%, with rates as high as 35% in
some surveyed communities. That translates to 1.2 million Kenyan adults living
with HIV/AIDS, and women ages 15-49 represent over half of those infected.
The epidemic is generalized -- no longer confined to specific "high risk groups"
but experienced by the people as whole. The primary mode of transmission is
heterosexual intercourse, which accounts for 90% of new cases. In Kenya, as
throughout Africa, poverty exacerbates the crisis by diminishing access to
information, testing, treatment, and care on all levels. Poverty also constrains
individuals' choices about sexual behavior and makes them more vulnerable to
infection, especially those who are additionally marginalized or disempowered
such as women and young people. For example, in one study in Kenya, 6.7% of
sexually active women and 15.4% of sexually active men reported exchanging
sex for money or other gifts in the year prior to the survey. In fact, the highest
rates of transactional sex are among young people with 13.5% of young women
ages 15-19 and 20.9% of young men ages 20-24 reporting having engaged in this
practice
497
High Mycoplasma genitalium organism burden is associated with

shedding of HIV-1 DNA from the cervix.
Author: Manhart, L. E.; Mostad, S. B.; Baeten, J. M.; Astete, S. G.; Mandaliya, K., and
Totten, P. A.
Abstract: We assessed the relationship between infection with Mycoplasma genitalium, an

emerging sexually transmitted pathogen, and cervical shedding of human
immunodeficiency virus (HIV)-1 DNA among 303 HIV-1-positive Kenyan
women. HIV-1 shedding was detected by qualitative polymerase chain reaction
(PCR) in 154 women (51%); M. genitalium was detected by qualitative PCR in 52
(17%), and organism burden was determined by quantitative PCR. Women with
high M. genitalium organism burdens (more than the median of 3195
genomes/mL) were 3-fold more likely to shed HIV-1 DNA than were M.
genitalium-negative women (adjusted OR, 2.9 [95% confidence interval, 1.1-7.6]),
yet this did not appear to be mediated by traditional measures of cervical
inflammation (elevated polymorphonuclear leukocyte count
Epidemiology of human papillomavirus infection among fishermen

along Lake Victoria Shore in the Kisumu District, Kenya.
Author: Ng'ayo, M. O.; Bukusi, E.; Rowhani-Rahbar, A.; Koutsky, L. A.; Feng, Q.; Kwena,
Z. A., and Holmes, K. K.
Source: Sex Transm Infect. 2008 Feb; 84(1):62-6.
The epidemiology of human papillomavirus (HPV) infection in men in Kenya is
largely uncharacterized. We set out to determine the prevalence and
determinants of HPV infection among sexually active fishermen along Lake
Victoria in the Kisumu district of Kenya.
498
Methods:
Genital swabs were obtained from 250 consenting fishermen from 18 beaches
and a detailed sociodemographic questionnaire was administered. HPV
positivity was determined by polymerase chain reaction amplification and
detected by dot blot hybridisation with generic HPV and beta-globin probes.
HPV positive samples were genotyped using the Roche Linear array assay.
Results:
Overall, 144 (57.6%) fishermen had detectable HPV DNA, 106 (42.4%) were
infected with oncogenic HPV types, with HPV-16 being the most frequent type
(12.4%). Among HPV positive men, 105 (72.9%) were infected with more than
one HPV type and 20 (13.9%) were infected with more than six different types.
HIV seropositive men (PR 1.49, 95% CI 1.19 to 1.86) and those divorced or
separated (PR 1.62, 95% CI 1.13 to 2.33) were more likely to be infected with
HPV. HIV infection (PR 1.22, 95% CI 1.01 to 1.47) was the only factor
independently associated with infection with multiple types of HPV.
Conclusion:
The prevalence of oncogenic HPV infection is high among this population and is
associated with HIV serostatus and marital status. This community could benefit
from enhanced sexually transmitted infection and HIV prevention interventions.
Morbidity in the first year postpartum among HIV-infected women in

Kenya.
Author: Chersich MF; Luchters SM; Yard E; Othigo JM; Kley N
Source: International Journal of Gynecology and Obstetrics. 2008 Jan;100(1):45-51.
Abstract: The objective was to assess the effects of HIV infection on morbidity and the
needs of infected women for services in the first year postpartum. A cross-
sectional study with 500 women attending a child-health clinic in Mombasa,
Kenya. Postpartum duration was a median of 3.3 months (interquartile range,
1.9-6.1 months). The 54 HIV-infected women had a lower income and less
financial support than the uninfected women, and they were more likely to
experience fever, dyspnea, and dysuria, and to have genital warts (odds ratio
[OR], 9.6; 95% confidence interval [CI], 2.6-35.6; P less than 0.001), candidiasis
(OR, 2.9; 95% CI, 1.2-6.8; P=0.012), and bacterial vaginosis (OR, 1.8; 95% CI, 0.95-
3.3; P=0.066). Six (nearly 15%) of the HIV-infected women had low- or high-
grade squamous intraepithelial lesions, and 21 (42%) had an unmet need for
contraception. More than half of all women were anemic, and normocytic anemia
was predominant among the HIV infected. Compared with uninfected women,
morbidity was increased for HIV-infected women during the year following
delivery. This period could be used to offer these, and all-women, family
planning services, cervical cancer screening, and treatment for anemia and
499
reproductive tract infections. (author's)
Language: English

POSTPARTUM WOMEN | PERSONS LIVING WITH HIV/AIDS |
MORBIDITY | ANEMIA | POSTPARTUM PROGRAMS | DEVELOPING
RESEARCH METHODOLOGY | PUERPERIUM | REPRODUCTION | HIV
INFECTIONS | VIRAL DISEASES | DISEASES | FAMILY PLANNING
PROGRAMS | FAMILY PLANNING
Confronting the "sugar daddy" stereotype: age and economic

asymmetries and risky sexual behavior in urban Kenya.
Author: Luke N
Abstract: Context:
"Sugar daddy" relationships, which are characterized by large age and economic
asymmetries between partners, are believed to be a major factor in the spread of
HIV in Sub-Saharan Africa. Information is needed about sugar daddy
partnerships-and about age and economic symmetries more generally-to
determine how common they are and whether they are related to unsafe sexual
behavior.
Methods:
The sample comprised 1,052 men and aged 21-45 who were surveyed in Kisumu,
Kenya, in 2001. Data on these men and their 1,614 recent nonmarital partnerships
were analyzed to calculate the prevalence of sugar daddies and sugar daddy
relationships, as well as a range of age and economic disparities within
nonmarital partnerships. Logistic regression models were constructed to assess
relationships between condom use at last sexual intercourse and various
measures of age and economic asymmetry.
Results:
The mean age difference between nonmarital sexual partners was 5.5 years, and
47% of men's female partners were adolescents. Fourteen percent of partnerships
involved an age difference of at least 10 years, and 23% involved more than the
mean amount of male-to-female material assistance. Men who reported at least
one partnership with both these characteristics were defined as sugar daddies
and made up 5% of the sample; sugar daddy relationships accounted for 4% of
partnerships. Sugar daddy partnerships and the largest age and economic
asymmetries were constructed were associated with decreased odds of condom
use.
500
Conclusions:
Although sugar daddy relationships are not as pervasive as generally assumed,
age and economic asymmetries in nonmarital partnerships are relatively
common. All these types of asymmetries are associated with nonuse of condoms.
Increasing women's power within asymmetric sexual relationships could
improve their ability to negotiate safer sexual behaviors, such as condom use.
(author's)
Language: English
Keywords: KENYA | RESEARCH REPORT | SAMPLING STUDIES | SUGAR

DADDIES | SEXUAL PARTNERS | URBAN POPULATION | PREVALENCE
| CONDOM USE | AGE FACTORS | PARTNER COMMUNICATION |
POWER | SAFER SEX | DEVELOPING COUNTRIES | AFRICA, EASTERN
| AFRICA, SUB SAHARAN | AFRICA | STUDIES | RESEARCH
METHODOLOGY | SEX BEHAVIOR | BEHAVIOR | POPULATION
MEASUREMENT | RISK REDUCTION BEHAVIOR | INTERPERSONAL
RELATIONS | POLITICAL FACTORS
Human papillomavirus detection by penile site in young men from

Kenya.
Author: Smith JS; Moses S; Hudgens MG; Agot K; Franceschi S
Abstract: Limited data are available on whether sampling from the penile shaft or urethra
increases detection of penile HPV infection in men beyond that found in the
glans and coronal sulcus. Within a randomized clinical trial, a validation study of
penile sampling was conducted in Kisumu, Kenya. Young men (18-24 years)
were invited to provide penile exfoliated cells using prewetted Dacron swabs to
determine the best site for HPV detection. beta-Globin gene PCR and HPV DNA
type GP5+/6+ PCR status were ascertained from 3 anatomical sites. A total of 98
young HIV-seronegative, uncircumcised men participated. Penile HPV
prevalence varied by anatomical site: 50% in penile exfoliated cells from the
glans, coronal sulcus, and inner foreskin tissue; 43% in the shaft and external
foreskin tissue; and 18% in the urethra (P less than 0.0001). For each anatomical
site, over 87% of samples were beta-globin positive. Beyond that found in the
glans/coronal sulcus, urethral sampling resulted in no increase in HPV positivity
andshaft sampling resulted in an additional 7.3% of overall HPV positivity. The
prevalence of high-risk HPV positivity varied by anatomical site: 39% in
glans/coronal sulcus, 31% in shaft, and 13% in the urethra (P less than 0.0001).
HPV 16 was the most common type identified. Penile HPV prevalence was
approximately 50% among young men in Kisumu, Kenya. Urethral sampling for
HPV detection in men added no sensitivity for HPV detection over that found
501
from sampling the glans/coronal sulcus and penile shaft. These data will help
inform studies on HPV transmission dynamics, and on the efficacy of HPV
prophylactic vaccines on penile HPV carri Language: English
Keywords: KENYA | RESEARCH REPORT | CLINICAL TRIALS | MEN | HPV |

PREVALENCE | TRANSMISSION | GENITALIA, MALE | RISK FACTORS
SAHARAN | AFRICA | CLINICAL RESEARCH | RESEARCH
METHODOLOGY | DEMOGRAPHIC FACTORS | POPULATION | VIRAL
DISEASES | DISEASES | MEASUREMENT | INFECTIONS | GENITALIA |
UROGENITAL SYSTEM | PHYSIOLOGY | BIOLOGY
High Mycoplasma genitalium organism burden is associated with

shedding of HIV-1 DNA from the cervix.
Author: Manhart, L. E.; Mostad, S. B.; Baeten, J. M.; Astete, S. G.; Mandaliya, K., and
Totten, P. A.
Abstract: We assessed the relationship between infection with Mycoplasma genitalium, an

emerging sexually transmitted pathogen, and cervical shedding of human
immunodeficiency virus (HIV)-1 DNA among 303 HIV-1-positive Kenyan
women. HIV-1 shedding was detected by qualitative polymerase chain reaction
(PCR) in 154 women (51%); M. genitalium was detected by qualitative PCR in 52
(17%), and organism burden was determined by quantitative PCR. Women with
high M. genitalium organism burdens (more than the median of 3195
genomes/mL) were 3-fold more likely to shed HIV-1 DNA than were M.
genitalium-negative women (adjusted OR, 2.9 [95% confidence interval, 1.1-7.6]),
yet this did not appear to be mediated by traditional measures of cervical
inflammation (elevated polymorphonuclear leukocyte count
502
Epidemiology of human papillomavirus infection among fishermen

along Lake Victoria Shore in the Kisumu District, Kenya.
Author: Ng'ayo, M. O.; Bukusi, E.; Rowhani-Rahbar, A.; Koutsky, L. A.; Feng, Q.; Kwena,
Z. A., and Holmes, K. K.
Source: Sex Transm Infect. 2008 Feb; 84(1):62-6.
The epidemiology of human papillomavirus (HPV) infection in men in Kenya is
largely uncharacterized. We set out to determine the prevalence and
determinants of HPV infection among sexually active fishermen along Lake
Victoria in the Kisumu district of Kenya.
Methods:
Genital swabs were obtained from 250 consenting fishermen from 18 beaches
and a detailed sociodemographic questionnaire was administered. HPV
positivity was determined by polymerase chain reaction amplification and
detected by dot blot hybridisation with generic HPV and beta-globin probes.
HPV positive samples were genotyped using the Roche Linear array assay.
Results:
Overall, 144 (57.6%) fishermen had detectable HPV DNA, 106 (42.4%) were
infected with oncogenic HPV types, with HPV-16 being the most frequent type
(12.4%). Among HPV positive men, 105 (72.9%) were infected with more than
one HPV type and 20 (13.9%) were infected with more than six different types.
HIV seropositive men (PR 1.49, 95% CI 1.19 to 1.86) and those divorced or
separated (PR 1.62, 95% CI 1.13 to 2.33) were more likely to be infected with
HPV. HIV infection (PR 1.22, 95% CI 1.01 to 1.47) was the only factor
independently associated with infection with multiple types of HPV.
Conclusion:
The prevalence of oncogenic HPV infection is high among this population and is
associated with HIV serostatus and marital status. This community could benefit
from enhanced sexually transmitted infection and HIV prevention interventions.
HIV / AIDS and home-based health care. International Journal for Equity
in Health.
Author: Opiyo, P. A.; . = Yamano T, and Jayne TS.
Source: 2008 Mar 18; 7:8.
Abstract: This paper highlights the socio-economic impacts of HIV/AIDS on women. It

argues that the socio-cultural beliefs that value the male and female lives
differently lead to differential access to health care services. The position of
503
women is exacerbated by their low financial base especially in the rural

community where their main source of livelihood, agricultural production does
not pay much. But even their active involvement in agricultural production or
any other income ventures is hindered when they have to give care to the sick
and bedridden friends and relatives. This in itself is a threat to household food
security. The paper proposes that gender sensitive policies and programming of
intervention at community level would lessen the burden on women who bear
the brunt of AIDS as caregivers and livelihood generators at household level.
Improvement of medical facilities and quality of services at local dispensaries is
seen as feasible since they are in the rural areas. Other interventions shouldtarget
freeing women's and girls' time for education and involvement in income
generating ventures. Two separate data sets from Western Kenya, one being
quantitative and another qualitative data have been used. (author's)
Equity, empowerment and choice: from theory to practice in public

health.
Author: Ratna, J. and Rifkin, S.
Source: J Health Psychol. 2007 May; 12(3):517-30.
Abstract: The purpose of this article is to illustrate how a framework that links equity and
empowerment to improved health outcomes for those who live in poverty can be
a useful tool for planning and managing health programmes. Using the work of
Amartya Sen, Susan Rifkin has developed a framework described in the acronym
CHOICE. The article applies the framework to two case studies from Kenya
seeking to reduce the disease burdens of malaria and HIV/AIDS. The article
examines how the process of pursuing equity and empowerment either supports
the positive health outcomes identified as objectives and/or strengthens these
outcomes.
A prospective study assessing the effects of introducing the female

condom in a sex worker population in Mombasa, Kenya.
Author: Thomsen, S. C.; Ombidi, W.; Toroitich-Ruto, C.; Wong, E. L.; Tucker, H. O.;
Homan, R.; Kingola, N., and Luchters, S.
To assess the impact and costs of adding female condoms to a male condom
promotion and distribution peer education programme for sex workers in
Mombasa, Kenya.
Design: A 12 month, prospective study of 210 female sex workers.
504
Methods:
We interviewed participants about their sexual behaviour every 2 months for a
total of seven times and introduced female condoms after the third interview. We
also collected cost data and calculated the cost and cost effectiveness of adding
the female condom component to the existing programme.
Results:
Introduction of the female condom in an HIV/AIDS prevention project targeting
sex workers led to small, but significant, increases in consistent condom use with
all sexual partners. However, there was a high degree of substitution of the
female condom for male condoms. The cost per additional consistent condom
user at a programme level is estimated to be 2160 dollars (1169 pounds sterling,
1711 euros) (95% CI: 1338 to 11 179).
Conclusions:
The female condom has some potential for reducing unprotected sex among sex
workers. However, given its high cost, and the marginal improvements seen
here, governments should limit promotion of the female condom in populations
that are already successfully using the male condom. More research is needed to
identify effective methods of encouraging sex workers to practise safer sex with
their boyfriends
Men who have sex with men and their HIV epidemics in Africa
[editorial].
Source: AIDS. 2007 Jun; 21(10):1361-1362.
Abstract: In this issue of the Journal, Geibel et al. report a capture-recapture study to
estimate the number of men who have sex with men (MSM) who sell sex in
Mombasa, Kenya. The authors surveyed 77 venues and estimated the number of
MSM selling sex at these venues to be 739. Like almost any other capture-
recapture study, this estimate is subject to a number of methodological
limitations (captures may not have been totally random and independent,
relatively high refusal rates, etc.), which affect its accuracy and precision. Be this
as it may, the importance of this study does not so much pertain to the accuracy
of the estimate, but more to the fact that the investigators were able to identify
and enroll hundreds of MSM selling sex in the African country of Kenya. This
number also indicates that there must be a fairly large population of male clients
willing to pay for the sexual services of these MSM, as well as a larger
community of other MSM, since most MSM do not sell sex. Indeed, an earlier
snowball-survey conducted in Nairobi in 2004 enrolled 500 MSM in a needs-
assessment within 2 months. (excerpt
The Spiritual Economy of Sexuality and Development in Africa
505
Source: Kamaara E., Department of Religion, Moi University, Eldoret - Kenya
Abstract: Background information:

HIV/AIDS is the single major threat to human life and to economic development
in Africa; the medical and economic impacts of HIV/AIDS are immense and
complex. The response to stop and control HIV/AIDS has yielded many useful
strategies and yet many mistakes and missed opportunities. Among
the later is the continued association of HIV/AIDS with medical departments
than with all departments.
Of specific concern to the proposed study is the continued reluctance to associate
HIV/AIDS control with factors of religion and spirituality. While positive living
has been identified and prescribed for PLWHAs little research has been done to
explain this in the context of religion and spirituality. Moreover no research has
been done to empirically investigate the actual impact of religion and spirituality
on healing and health for PLWHAs and consequently, on economics. This paper
is part of a bigger project towards addressing this knowledge gap.
Goal and objectives:

The goal of the proposed paper is to illustrate the need to integrate religion and
spirituality into HIV/AIDS prevention and treatment for reduced health
expenditure. The specific objectives include:
 To develop a Religio-Spiritual Health and Healing Measure for People
Living with HIV/AIDS (Reshem+) to empirically investigate the impact
of religion and spirituality on healing and health for PLWHAs.
 To explain positive living with HIV/AIDS in the context of religion and
spirituality.
 To indicate the relationship between religio-spiritual healing and health
and economic development in Africa.
Methodology:
Basically, qualitative and quantitative methods of data collection and analysis
will be used to collect data necessary for the development of a Reshem+. After an
empirical measure is produced the relationship between spiritual healing and
health and economic development will theoretically be propounded.
Expected Findings:
The expected findings of the research are:
Religion and spirituality is empirically related to Sexual healing and health for
people living HIV/AIDS Religio-spiritual health and Sexual healing is positively
related to economic development
506
Conclusion/lesson:
These findings will indicate one basic conclusion/lesson: the need to develop
religio spiritual therapy for reduced health expenditure.
Keywords: RELIGION | SPIRITUALITY | SEXUALITY | HEALTH | ECONOMICS
ABCs for HIV prevention in Kenya: messages, beliefs, and barriers.

Research summary.
Author: Pulerwitz J; Lillie T; Apicella L; McCauley A; Nelson T
Source: Research Summary;USAID Development Experience Clearinghouse DocID
Abstract: A great deal of attention has been focused recently on the promotion of the
"ABCs" of HIV prevention--being abstinent or delaying sex, remaining faithful to
one sexual partner or reducing the number of sexual partners, and consistently
using condoms during sex. Yet even as programs that focus on the ABCs to
prevent sexual HIV transmission are rolled out, questions remain about how
well different groups in varied cultural contexts actually understand the terms,
as well as how best to address challenges to adopting the ABC behaviors. The
Horizons Program and FHI/IMPACT developed a collaborative research study
in 2004 to explore how adults and youth in Kenya define and perceive the ABC
terms and behaviors. Additional objectives of the study were to identify attitudes
and norms around the ABC behaviors that influence perceptions of them, and
the role of important actors in transmitting messages about them. Findings
highlight potential challenges in promoting each of the ABC behaviors, as well as
some positive elements that can be built upon when developing programs.
(excerpt)
Language: English
Keywords: KENYA | RESEARCH REPORT | KAP SURVEYS | ADULTS |

ADOLESCENTS | HIV PREVENTION | BELIEFS | ABSTINENCE, BE
FAITHFUL, CONDOM USE | ATTITUDE | PERCEPTION | SEX
BEHAVIOR | RISK BEHAVIOR | AFRICA, EASTERN | AFRICA, SUB
SAHARAN | AFRICA | DEVELOPING COUNTRIES | SURVEYS |
SAMPLING STUDIES | STUDIES | RESEARCH METHODOLOGY | AGE
FACTORS | POPULATION | YOUTH | HIV INFECTIONS | VIRAL
DISEASES | DISEASES | CULTURE | SOCIOCULTURAL FACTORS |
BEHAVIOR | PSYCHOLOGICAL FACTORS
507
Comparison of HIV prevalence estimates from antenatal care

surveillance and population-based surveys in sub-Saharan Africa.
Author: Montana LS; Mishra V; Hong R
To compare HIV seroprevalence estimates obtained from antenatal care (ANC)
sentinel surveillance surveys in Ethiopia, Kenya, Malawi, Tanzania and Uganda
with those from population-based demographic and health surveys (DHS) and
AIDS indicator surveys (AIS).
Methods:
Geographical information system methods were used to map ANC surveillance
sites and DHS/AIS survey clusters within a 15-km radius of the ANC sites.
National DHS/AIS HIV prevalence estimates for women and men were
compared with national prevalence estimates from ANC surveillance. DHS/AIS
HIV prevalence estimates for women and men residing within 15 km of ANC
sites were compared with those from ANC surveillance. For women, these
comparisons were also stratified by current pregnancy status, experience of
recent childbirth and receiving ANC for the last birth.
Results:
In four of the five countries, national DHS/AIS estimates of HIV prevalence were
lower than the ANC surveillance estimates. Comparing women and men in the
catchment areas of the ANC sites, the DHS/AIS estimates were similar to ANC
surveillance estimates. DHS/AIS estimates for men residing in the catchment
areas of ANC sites were much lower than ANC surveillance estimates for
women in all cases. ANC estimates were higher for younger women than
DHS/AIS estimates for women in ANC catchment areas, but lower at older ages.
In all cases, urban prevalence was higher than rural prevalence but there were no
consistent patterns by education.
Conclusions:
ANC surveillance surveys tend to overestimate HIV prevalence compared to
prevalence among women in the general population in DHS/AIS surveys.
However, the ANC and DHS/AIS estimates are similar when restricted to
women and men, or to women only, residing in catchment areas of ANC sites.
Patterns by age and urban/rural residence suggest possible bias in the ANC
estimates.
Language: English
Keywords: ETHIOPIA | KENYA | MALAWI | TANZANIA | UGANDA | AFRICA, SUB

SAHARAN | RESEARCH REPORT | HIV INFECTIONS | PREVALENCE |
DEMOGRAPHIC AND HEALTH SURVEYS | DATA COLLECTION |
ANTENATAL CARE | EPIDEMIOLOGIC METHODS | PREGNANCY
COMPLICATIONS | RURAL POPULATION | URBAN POPULATION |
ESTIMATION TECHNICS | DEVELOPING COUNTRIES | AFRICA,
EASTERN | AFRICA | AFRICA, SOUTHERN | VIRAL DISEASES |
508
DISEASES | MEASUREMENT | RESEARCH METHODOLOGY |

DEMOGRAPHIC SURVEYS | POPULATION DYNAMICS |
DEMOGRAPHIC FACTORS | POPULATION | MATERNAL HEALTH
SERVICES | MATERNAL-CHILD HEALTH SERVICES | PRIMARY
HEALTH CARE | HEALTH SERVICES | DELIVERY OF HEALTH CARE |
HEALTH | POPULATION CHARACTERISTICS
509

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STIs, HIV and AIDS: 2005 - 2008

Source: International Journal of STD and AIDS. 2008 Jan;19(1):42-46.

Keywords: KENYA | RESEARCH REPORT | SURVEYS | MOTHERS | INFANT |

Document Number: 324667

Morbidity in the first year postpartum among HIV-infected women in

Author: Chersich MF; Luchters SM; Yard E; Othigo JM; Kley N

Source: International Journal of Gynecology and Obstetrics. 2008 Jan;100(1):45-51.

Keywords: KENYA | RESEARCH REPORT | CROSS SECTIONAL ANALYSIS |

Document Number: 323762

HIV, hepatitis B and hepatitis C coinfection in Kenya.

Author: Harania RS; Karuru J; Nelson M; Stebbing J

Source: AIDS. 2008 Jun 19;22(10):1221-1222.

Keywords: KENYA | RESEARCH REPORT | CLINICAL RESEARCH |

Document Number: 308638

HIV-neutralizing immunoglobulin A and HIV-specific proliferation are

Author: Hirbod T; Kaul R; Reichard C; Kimani J; Ngugi E

Source: AIDS. 2008 Mar 30;22(6):727-735.

Abstract: HIV-neutralizing immunoglobulin A (IgA) and HIV-specific cellular immunity

Keywords: KENYA | RESEARCH REPORT | PROSPECTIVE STUDIES | SEX

Document Number: 325533

Engendering health sector responses to sexual violence and HIV in

Author: Kilonzo N; Taegtmeyer M; Molyneux C; Kibaru J; Kimonji V

Source: AIDS Care. 2008 Feb;20(2):188-190.

Keywords: KENYA | RESEARCH REPORT | QUALITATIVE RESEARCH |

Document Number: 324185

Reduced rates of HIV acquisition during unprotected sex by Kenyan

Author: Kimani J; Kaul R; Nagelkerke NJ; Luo M; MacDonald KS

Source: AIDS. 2008 Jan 2;22(1):131-137.

and/or be causally related to future reductions in population prevalence.

Keywords: KENYA | RESEARCH REPORT | EPIDEMIOLOGIC METHODS | COHORT

Document Number: 322747

Provider characteristics among staff providing care to sexually

Author: Kwena Z; Sharma A; Wamae N; Muga C; Bukusi E

Source: Sexually Transmitted Diseases. 2008 May;35(5):480-483.

Abstract: The objectives were to evaluate the characteristics of providers in management of

Keywords: KENYA | RESEARCH REPORT | CROSS SECTIONAL ANALYSIS |

Document Number: 326476

Associations of human leukocyte antigen DRB with resistance or

Author: Lacap PA; Huntington JD; Luo M; Nagelkerke NJ; Bielawny T

Keywords: KENYA | RESEARCH REPORT | GENETIC TECHNICS | SEX WORKERS |

Document Number: 327151

Early effects of antiretroviral therapy on work performance: Preliminary

Author: Larson BA; Fox MP; Rosen S; Bii M; Sigei C

Source: AIDS, 2008 Jan 30;22(3):421-425.

final month before initiating ART. After 12 months on ART, we conservatively

Keywords: KENYA | RESEARCH REPORT | COHORT ANALYSIS | AGRICULTURAL

Document Number: 308615

HIV-1 persists in breast milk cells despite antiretroviral treatment to

Source: AIDS. 2008 Jul;22(12):1475-1485.

Abstract: The effects of short-course antiretrovirals given to reduce mother-to-child

RNA levels were modestly suppressed in HAART versus ZDV/sdNVP during

Keywords: KENYA | RESEARCH REPORT | CLINICAL RESEARCH | MOTHERS |

Document Number: 327563

Economic status, informal exchange, and sexual risk in Kisumu, Kenya.

Source: Economic Development and Cultural Change. 2008 Jan;56(2):375-396.

Keywords: KENYA | RESEARCH REPORT | SURVEYS | MEN | INCOME | SEX

Document Number: 314018

A prospective study of risk factors for bacterial vaginosis in HIV-1-

Source: Sexually Transmitted Diseases. 2008 Jun;35(6):617-623.

Keywords: KENYA | RESEARCH REPORT | PROSPECTIVE STUDIES | SEX

DEPO-PROVERA | DEVELOPING COUNTRIES | AFRICA, EASTERN |

Document Number: 327423

An outcome assessment of an ABC-based HIV peer education intervention among Kenyan

Author: Miller AN; Mutungi M; Facchini E; Barasa B; Ondieki W

STI's HIV and AIDS

STI's HIV and AIDS