Efficacy of assisted partner services for people who inject drugs in Kenya to identify partners living with HIV and hepatitis C virus infection: a prospective cohort study.

BACKGROUND: People who inject drugs are at increased risk of both HIV and hepatitis C virus (HCV) infections but face barriers to testing and engagement in care. Assisted partner services are effective in locating people with HIV but are understudied among people who inject drugs. We assessed whether assisted partner services could be used to find, test for HIV and HCV infections, and link to care the partners of people who inject drugs in Kenya. METHODS: In this prospective study at eight sites offering harm-reduction services in Kenya, we enrolled people aged 18 years or older who inject drugs and were living with HIV (index participants) between Feb 27, 2018, and Nov 1, 2021. Index participants provided information about their sexual and injecting partners (ie, anyone with whom they had had sexual intercourse or injected drugs in the previous 3 years), and then community-embedded peer educators located partners and referred them for enrolment in the study (partner participants). All participants underwent testing for HCV infection, and partner participants also underwent HIV testing. Index and partner participants with HIV but who were not on antiretroviral therapy (ART) were linked with treatment services, and those positive for HCV were linked to treatment with direct-acting antivirals. We calculated the number of index participants whom we needed to interview to identify partner participants with HIV and HCV infection. FINDINGS: We enrolled 989 people living with HIV who inject drugs, who mentioned 4705 sexual or injecting partners. Of these 4705 partners, we enrolled 4597 participants, corresponding to 3323 unique individuals. 597 (18%) partner participants had HIV, of whom 506 (85%) already knew their status. 358 (71%) of those who knew they were HIV positive were virally suppressed. 393 (12%) partner participants were HCV antibody positive, 213 (54%) of whom had viraemia and 104 (26%) of whom knew their antibody status. 1·66 (95% CI 1·53-1·80) index participants had to be interviewed to identify a partner with HIV, and 4·24 (3·75-4·85) had to be interviewed to find a partner living with HIV who was unaware of their HIV status, not on ART, or not virally suppressed. To find a partner seropositive for HCV who did not know their antibody status, 3·47 (3·11-3·91) index participants needed to be interviewed. Among the 331 index and partner participants living with HIV who were not on ART at enrolment, 238 (72%) were taking ART at 6-month follow-up. No adverse events were attributed to study procedures. INTERPRETATION: Use of assisted partner services among people with HIV who inject drugs was safe and identified partners with HIV and HCV infections. Assisted partner services was associated with increased uptake of ART for both index participants and partners. FUNDING: US National Institutes of Health.

Prevalence and correlates of violence among sexual and injecting partners of people who inject drugs living with HIV in Kenya: a cross-sectional study.

BACKGROUND: In Kenya, violence is common among people who inject drugs (PWID) living with HIV and their sexual and injecting partners and may lead to decreased uptake of HIV services, increased HIV risk behaviors, and increased HIV transmission. Violence is defined as any physical harm, threatened harm, or forced sexual acts inflicted on a person in the past year. Understanding the nature of violence and its correlates among PWID and their partners will inform population-specific public health interventions and policy recommendations. METHODS: This is a cross-sectional study nested in a prospective cohort study conducted in eight public health centers, methadone clinics, and needle syringe programs in Nairobi, Kilifi, and Mombasa counties in Kenya. 3,302 sexual and/or injecting partners of PWID living with HIV were recruited through assisted partner services and participated in the study. Prevalence and correlates of violence were identified using the Wald test and negative binomial regression. RESULTS: Out of 3302 study participants, 1439 (44%) had experienced violence within the past year. Physical violence was the most common form of violence experienced (35%), followed by being threatened (23%) or subjected to sexual violence (7%). In an adjusted analysis, female participants reported higher experiences of sexual violence (prevalence ratio [PR] = 2.46; 95% confidence interval [CI] 1.62, 3.74; p < 0.001) compared to male participants. In adjusted analysis, coastal residents had a higher experience of overall violence (PR = 1.48; 95% CI 1.27, 1.72; p < 0.001) than those living in Nairobi. This regional effect was relatively stronger among the female respondents (pinteraction = 0.025). Participants' sex modified the association between region and experiencing violence after adjusting potential confounding factors. CONCLUSIONS: The study reveals the prevalence of violence among PWID and identifies high-risk sub-groups, including women, specifically for sexual violence, and coastal residents. Tailored interventions addressing their unique needs are essential. A holistic approach that combines violence prevention and response, comprehensive harm reduction, healthcare access, and community support is crucial to address the complex issue of drug use and HIV burden among PWID in Kenya for improved health outcomes.

Occupational roles and risks of community-embedded peer educators providing HIV, hepatitis C and harm reduction services to persons who inject drugs in Nairobi, Kenya.

BACKGROUND: In Kenya, harm reduction organizations have adopted evidence-based peer educator (PE) programs, where former people who inject drugs (PWID) serve as community health liaisons to engage PWID in HIV, HCV and harm reduction services. While PEs play an integral role in healthcare delivery, little data exists on their roles, risks and experiences working with PWID, which may be used to inform local harm reduction policy. METHODS: PE's from two harm reduction sites in Nairobi were randomly and purposively selected to participate in semi-structured in-depth interviews. Thematic analysis was conducted to characterize the expected versus actual roles that PEs employ while serving PWID, personal motivation and/or challenges and occupational health risks. Data was analyzed using Atlas.ti software. RESULTS: Twenty PEs participated in the study. On average, PEs were 37 years of age, with 3 years of service. Female representation was 30%. Expected responsibilities included locating clients, establishing rapport, educating and escorting clients to addiction care facilities. Additional roles included attending to clients outside of work hours, escorting clients to medical appointments and facilitating patient-provider discussions. Occupational health risks included harassment by police and drug dealers, needle sticks, and close proximity to drug use environments that could prompt drug relapse. Despite these challenges and risks, PEs are motivated by their personal experiences of overcoming addiction with help from harm reduction programs. CONCLUSIONS/RECOMMENDATIONS: PEs play a vital role in HIV, HCV and harm reduction service delivery in Kenya, often exceeding their job descriptions by offering additional support to PWID. Recommendations include (1) advocating for PEs to provide patient navigation services, (2) promoting the use of post-exposure prophylaxis (PEP), (3) providing occupational mental health services to prevent drug relapse, and (4) collaborating with law enforcement to address harassment, with the ultimate goal of reducing HIV and HCV incidence among PWID.

Participation in methadone programs improves antiretroviral uptake and HIV viral suppression among people who inject drugs in Kenya.

BACKGROUND: HIV prevalence among people who inject drugs (PWID) in Kenya is estimated to be 18% compared to 4.5% in the general population. Studies from high-income countries have demonstrated that methadone use is associated with increased uptake of antiretroviral therapy (ART) and higher rates of viral suppression among PWID with HIV. However, it is unclear whether methadone use has the same effect among African PWID living with HIV. METHODS: We performed a cross-sectional study to evaluate associations between methadone program participation and ART uptake and viral suppression (HIV RNA viral load <1000 copies/ml) among PWID with HIV in Kenya. Participants were recruited from needle and syringe programs and methadone clinics, interviewed on site, and samples were obtained and assayed for HIV viral loads. Univariate and multiple logistic regression were used to determine associations. RESULTS: Among 679 participants, median age was 37 years, 48% were female, and 24% were in a methadone program. We observed higher proportions of ART use (96% vs. 87%, p = 0.001) and HIV viral suppression (78% vs. 65%, p = 0.012) among PWID on methadone compared to those not on methadone treatment. PWID who were not participating in a methadone program were 3-fold more likely to be off ART and approximately twice as likely to be viremic compared to those in methadone programs (adjusted odds ratio [aOR] = 3.35, 95% confidence interval [CI]: 1.35-8.35 and aOR = 1.90, 95% CI: 1.03-3.52, respectively). CONCLUSIONS: In this study, Kenyan PWID living with HIV participating in a methadone treatment program were more likely to be on ART and to have achieved viral suppression. Scale-up of methadone programs may have a positive impact on HIV epidemic control for this key population.

Barriers and facilitators of HIV and hepatitis C care among people who inject drugs in Nairobi, Kenya: a qualitative study with peer educators.

BACKGROUND: In Kenya, people who inject drugs (PWID) are disproportionately affected by HIV and hepatitis C (HCV) epidemics, including HIV-HCV coinfections; however, few have assessed factors affecting their access to and engagement in care through the lens of community-embedded, peer educators. This qualitative study leverages the personal and professional experiences of peer educators to help identify HIV and HCV barriers and facilitators to care among PWID in Nairobi, including resource recommendations to improve service uptake. METHODS: We recruited peer educators from two harm reduction facilities in Nairobi, Kenya, using random and purposive sampling techniques. Semi-structured interviews explored circumstances surrounding HIV and HCV service access, prevention education and resource recommendations. A thematic analysis was conducted using the Modified Social Ecological Model (MSEM) as an underlying framework, with illustrative quotes highlighting emergent themes. RESULTS: Twenty peer educators participated, including six women, with 2-months to 6-years of harm reduction service. Barriers to HIV and HCV care were organized by (a) individual-level themes including the competing needs of addiction and misinterpreted symptoms; (b) social network-level themes including social isolation and drug dealer interactions; (c) community-level themes including transportation, mental and rural healthcare services, and limited HCV resources; and (d) policy-level themes including nonintegrated health services, clinical administration, and law enforcement. Stigma, an overarching barrier, was highlighted throughout the MSEM. Facilitators to HIV and HCV care were comprised of (a) individual-level themes including concurrent care, personal reflections, and religious beliefs; (b) social network-level themes including community recommendations, navigation services, family commitment, and employer support; (c) community-level themes including quality services, peer support, and outreach; and (d) policy-level themes including integrated health services and medicalized approaches within law enforcement. Participant resource recommendations include (i) additional medical, social and ancillary support services, (ii) national strategies to address stigma and violence and (iii) HCV prevention education. CONCLUSIONS: Peer educators provided intimate knowledge of PWID barriers and facilitators to HIV and HCV care, described at each level of the MSEM, and should be given careful consideration when developing future initiatives. Recommendations emphasized policy and community-level interventions including educational campaigns and program suggestions to supplement existing HIV and HCV services.