Attenuated tuberculin skin test responses associated with Mycobacterium intracellulare sputum colonization in an adolescent TB prevalence survey in Western Kenya.

INTRODUCTION: Exposure to Non-tuberculous Mycobacteria (NTM) varies regionally and may partly explain the disparate outcomes of BCG vaccination and tuberculosis (TB) susceptibility. METHODS: We examined NTM sputum colonization, associations with clinical characteristics, and tuberculin skin test (TST) responses in an adolescent TB prevalence survey. RESULTS: Among 5004 adolescents screened, 2281 (45.5 %) were evaluated further. TB and NTM prevalence rates were 0.3 % and 8.0 %, respectively. Among 418 NTM isolates, 103 were unidentifiable, and 315 (75 %) comprised 15 species, the most frequent being M. intracellulare (MAC) (108, 26 %), M. scrofulaceum (96, 23 %) and M. fortuitum (51, 12 %). "NTM colonized" adolescents had less frequent chronic cough and night sweats (adjusted odds ratio [aOR] 0.62, 95 % confidence interval [CI] 0.44-0.87and aOR 0.61, CI 0.42-0.89 respectively), and lower TST induration (median 11 mm (interquartile range [IQR] 0-16) vs 13 mm (IQR 6-17; p = 0.006)) when compared to "NTM not colonized" participants. MAC, but not M. scrofulaceum or M. fortuitum, was associated with decreased TST induration (median 7.5 mm (IQR 0-15) vs 13 mm (IQR 6-17) among "MAC colonized" vs "not colonized", p = 0.001). CONCLUSION: We observed high NTM prevalence rates with species-specific associations with TST induration, consistent with a model of species-dependent heterologous immunity among mycobacteria.

Towards pharmacogenomics-guided tuberculosis (TB) therapy: N-acetyltransferase-2 genotypes among TB-infected Kenyans of mixed ethnicity.

BACKGROUND: Though persons of African descent have one of the widest genetic variability, genetic polymorphisms of drug-metabolising enzymes such as N-Acetyltransferase-2 (NAT2) are understudied. This study aimed to identify prevalent NAT2 single nucleotide polymorphisms (SNPs) and infer their potential effects on enzyme function among Kenyan volunteers with tuberculosis (TB) infection. Genotypic distribution at each SNP and non-random association of alleles were evaluated by testing for Hardy-Weinberg Equilibrium (HWE) and Linkage Disequilibrium (LD). METHODS: We isolated genomic DNA from cryopreserved Peripheral Blood Mononuclear Cells of 79 volunteers. We amplified the protein-coding region of the NAT2 gene by polymerase chain reaction (PCR) and sequenced PCR products using the Sanger sequencing method. Sequencing reads were mapped and aligned to the NAT2 reference using the Geneious software (Auckland, New Zealand). Statistical analyses were performed using RStudio version 4.3.2 (2023.09.1 + 494). RESULTS: The most frequent haplotype was the wild type NAT2*4 (37%). Five genetic variants: 282C > T (NAT2*13), 341 T > C (NAT2*5), 803A > G (NAT2*12), 590G > A (NAT2*6) and 481C > T (NAT2*11) were observed with allele frequencies of 29%, 18%, 6%, 6%, and 4% respectively. According to the bimodal distribution of acetylation activity, the predicted phenotype was 76% rapid (mainly consisting of the wildtype NAT2*4 and the NAT2*13A variant). A higher proportion of rapid acetylators were female, 72% vs 28% male (p = 0.022, odds ratio [OR] 3.48, 95% confidence interval [CI] 1.21 to 10.48). All variants were in HWE. NAT2 341 T > C was in strong complete LD with the 590G > A variant (D' = 1.0, r2 = - 0.39) but not complete LD with the 282C > T variant (D' = 0.94, r2 = - 0.54). CONCLUSION: The rapid acetylation haplotypes predominated. Despite the LD observed, none of the SNPs could be termed tag SNP. This study adds to the genetic characterisation data of African populations at NAT2, which may be useful for developing relevant pharmacogenomic tools for TB therapy. To support optimised, pharmacogenomics-guided TB therapy, we recommend genotype-phenotype studies, including studies designed to explore gender-associated differences.

A cross-sectional survey on the effectiveness of public health campaigns for changing knowledge, attitudes, and practices in Kenyan informal settlements during the COVID-19 pandemic.

We performed two cross-sectional surveys across three informal settlements in Kenya (within Kisii county, Nairobi, and Nakuru county) to study the effectiveness of public health interventions during the COVID-19 pandemic. A total of 720 participants were surveyed from 120 randomly selected geographical locations (240 participants/settlement/survey), and a coordinated health promotion campaign was delivered between the two surveys by trained staff. Information relating to knowledge, attitudes, and practices (KAP) were collected by trained field workers using a validated questionnaire. The main outcomes showed improvements in: (i) mask-wearing (% of participants 'Always' using their mask increased from 71 to 74%, and the percentage using their masks 'Sometimes' decreased from 15% to 6%; p<0.001); (ii) practices related to face mask usage (% of subjects covering the mouth and nose increased from 91 to 95%, and those covering only part of their face decreased from around 2.5% to <1%; p<0.001). Significant improvements were also seen in the attitudes and expectations relating to mask wearing, and in the understanding of government directives. Over 50% of subjects in the post-campaign survey reported that social distancing was not possible in their communities and fears associated with COVID-19 testing were resistant to change (unchanged at 10%). Access to COVID-19 testing facilities was limited, leaving a large proportion of people unable to test. As willingness to take a COVID-19 test did not change between surveys (69 vs 70%; p = 0.57), despite increased availability, we recommend that policy level interventions are needed, aimed at mitigating adverse consequences of a positive test. Improvements of KAPs in the more crowded urban environment (Nairobi) were less than at settlements in rural or semi-urban settings (Nakuru and Kisii). We conclude that coordinated public health campaigns are effective in facilitating the change of KAPs amongst people living amidst challenging socio-economic conditions in informal settlements.

Over-prescription of short-acting ß2-agonists remains a serious health concern in Kenya: results from the SABINA III study.

BACKGROUND: Despite a high asthma burden in Kenya, insights into asthma management practices, including prescription of short-acting ß2-agonists (SABAs), are lacking. Therefore, this study describes patient demographics, disease characteristics, and asthma treatment patterns in the Kenyan cohort of the SABA use IN Asthma (SABINA) III study. METHODS: Patients with asthma (aged ≥ 12 years) with medical records containing data for ≥ 12 months prior to the study visit from 19 sites across Kenya were included in this cross-sectional study and classified by investigator-defined asthma severity (guided by the 2017 Global Initiative for Asthma [GINA] recommendations) and practice type (primary/specialist care). Data on severe exacerbation history, prescribed asthma treatments, and over-the-counter (OTC) SABA purchases in the 12 months before the study visit and asthma symptom control at the time of the study visit were collated using electronic case report forms. All analyses were descriptive in nature. RESULTS: Overall, 405 patients were analyzed (mean age, 44.4 years; female, 68.9%), of whom 54.8% and 45.2% were enrolled by primary care clinicians and specialists, respectively. Most patients were classified with mild asthma (76.0%, GINA treatment steps 1-2) and were overweight or obese (57.0%). Only 19.5% of patients reported full healthcare reimbursement, with 59% receiving no healthcare reimbursement. The mean asthma duration of patients was 13.5 years. Asthma was partly controlled/uncontrolled in 78.0% of patients, with 61.5% experiencing ≥ 1 severe exacerbation in the preceding 12 months. Crucially, 71.9% of patients were prescribed ≥ 3 SABA canisters, defined as over-prescription; 34.8% were prescribed ≥ 10 SABA canisters. Additionally, 38.8% of patients purchased SABA OTC, of whom 66.2% purchased ≥ 3 SABA canisters. Among patients with both SABA purchases and prescriptions, 95.5% and 57.1% had prescriptions for ≥ 3 and ≥ 10 SABA canisters, respectively. Inhaled corticosteroids (ICS), ICS with a long-acting ß2-agonist fixed-dose combination, and oral corticosteroid bursts were prescribed to 58.8%, 24.7%, and 22.7% of patients, respectively. CONCLUSIONS: SABA over-prescription occurred in almost three-quarters of patients, with over one-third of patients purchasing SABA OTC. Therefore, SABA over-prescription is a major public health concern in Kenya, underscoring an urgent need to align clinical practices with latest evidence-based recommendations.

Second-Line Switch to Dolutegravir for Treatment of HIV Infection.

BACKGROUND: Data to inform the switch from a ritonavir-boosted protease inhibitor (PI) to dolutegravir in patients living with human immunodeficiency virus (HIV) infection who do not have genotype information and who have viral suppression with second-line therapy containing a ritonavir-boosted PI have been limited. METHODS: In a prospective, multicenter, open-label trial conducted at four sites in Kenya, we randomly assigned, in a 1:1 ratio, previously treated patients without genotype information who had viral suppression while receiving treatment containing a ritonavir-boosted PI to either switch to dolutegravir or continue the current regimen. The primary end point was a plasma HIV type 1 RNA level of at least 50 copies per milliliter at week 48, assessed on the basis of the Food and Drug Administration snapshot algorithm. The noninferiority margin for the between-group difference in the percentage of participants who met the primary end point was 4 percentage points. Safety up to week 48 was assessed. RESULTS: A total of 795 participants were enrolled, with 398 assigned to switch to dolutegravir and 397 assigned to continue taking their ritonavir-boosted PI; 791 participants (397 in the dolutegravir group and 394 in the ritonavir-boosted PI group) were included in the intention-to-treat exposed population. At week 48, a total of 20 participants (5.0%) in the dolutegravir group and 20 (5.1%) in the ritonavir-boosted PI group met the primary end point (difference, -0.04 percentage points; 95% confidence interval, -3.1 to 3.0), a result that met the criterion for noninferiority. No mutations conferring resistance to dolutegravir or the ritonavir-boosted PI were detected at the time of treatment failure. The incidence of treatment-related grade 3 or 4 adverse events was similar in the dolutegravir group and the ritonavir-boosted PI group (5.7% and 6.9%, respectively). CONCLUSIONS: In previously treated patients with viral suppression for whom there were no data regarding the presence of drug-resistance mutations, dolutegravir treatment was noninferior to a regimen containing a ritonavir-boosted PI when the patients were switched from a ritonavir-boosted PI-based regimen. (Funded by ViiV Healthcare; 2SD ClinicalTrials.gov number, NCT04229290.).

Prevalence and predictors of tuberculosis infection among people living with HIV in a high tuberculosis burden context.

BACKGROUND: Tuberculosis (TB) disease is the leading cause of mortality among people living with HIV (PLHIV). Interferon-gamma release assays (IGRAs) are approved for TB infection ascertainment. However, current IGRA data on the prevalence of TB infection in the context of near-universal access to antiretroviral therapy (ART) and TB preventive therapy (TPT) are lacking. We estimated the prevalence and determinants of TB infection among PLHIV within a high TB and HIV burden context. METHODS: This cross-sectional study included data from adult PLHIV age ≥18 years in whom QuantiFERON-TB Gold Plus (QFT-Plus) assay, an IGRA, was performed. TB infection was defined as a positive or indeterminate QFT-Plus test. Participants with TB and those who had previously used TPT were excluded. Regression analysis was performed to identify independent predictors of TB infection. RESULTS: Of 121 PLHIV with QFT-Plus test results, females were 74.4% (90/121), and the mean age was 38.4 (SD 10.8) years. Overall, 47.9% (58/121) were classified as TB infection (QFT-Plus test positive and indeterminate results were 39.7% (48/121) and 8.3% (10/121), respectively). Being obese/overweight (body mass index ≥25 kg/m2; p=0.013, adjusted OR (aOR) 2.90, 95% CI 1.25 to 6.74) and ART usage for >3 years (p=0.013, aOR 3.99, 95% CI 1.55 to 10.28) were independently associated with TB infection. CONCLUSION: There was a high TB infection prevalence among PLHIV. A longer period of ART and obesity were independently associated with TB infection. The relationship between obesity/overweight and TB infection may be related to ART use and immune reconstitution and requires further investigation. Given the known benefit of test-directed TPT among PLHIV never exposed to TPT, its clinical and cost implications for low and middle-income countries should be explored further.

Over-prescription of short-acting ß2-agonists is associated with poor asthma outcomes: results from the African cohort of the SABINA III study.

BACKGROUND: The extent of short-acting ß2-agonist (SABA) overuse in Africa remains poorly documented. As part of the SABA use IN Asthma (SABINA) III study, we assessed SABA prescriptions/clinical outcomes in 3 African countries. METHODS: Data on disease characteristics/asthma treatments were collected from patients (≥12 years) using electronic case report forms. Patients were classified by investigator-defined asthma severity (guided by the 2017 Global Initiative for Asthma) and practice type (primary/specialist care). Multivariable regression models analyzed associations between SABA prescriptions and outcomes. RESULTS: Data from 1778 patients (mean age, 43.7 years) were analyzed. Most patients were female (62.4%) and had moderate-to-severe asthma (63.3%), with 57.1 and 42.9% of patients treated in specialist and primary care, respectively. Asthma was partly controlled/uncontrolled in 66.2% of patients, with 57.9% experiencing ≥1 severe exacerbation in the previous 12 months. Overall, 46.5% of patients were prescribed ≥3 SABA canisters in the preceding 12 months (over-prescription); 26.2% were prescribed ≥10 canisters. SABAs were purchased over-the-counter by 32.6% of patients, of whom 79.3% had received SABA prescriptions; 71.9% and 40.1% for ≥3 and ≥10 canisters, respectively. Higher SABA prescriptions (vs. 1-2 canisters) were associated with increased incidence rate of severe exacerbations and lower odds of having at least partly controlled asthma (except 3-5 canisters). CONCLUSIONS: Findings from this African cohort of the SABINA III study indicate that SABA over-prescription and SABA over-the-counter purchase are common and associated with poor asthma-related outcomes. This highlights the need for healthcare providers/policymakers to align clinical practices with the latest treatment recommendations.

A technical review of face mask wearing in preventing respiratory COVID-19 transmission.

Since the outbreak of the COVID-19 pandemic, most countries have recommended their citizens to adopt social distance, hand hygiene, and face mask wearing. However, wearing face masks has not been well adopted by many citizens. While the reasons are complex, there is a general perception that the evidence to support face mask wearing is lacking, especially for the general public in a community setting. Face mask wearing can block or filter airborne virus-carrying particles through the working of colloid and interface science. This paper assesses current knowledge behind the design and functioning of face masks by reviewing the selection of materials, mask specifications, relevant laboratory tests, and respiratory virus transmission trials, with an overview of future development of reusable masks for the general public. This review highlights the effectiveness of face mask wearing in the prevention of COVID-19 infection.

Factors associated with the timely uptake of initial HIV virologic test among HIV-exposed infants attending clinics within a faith-based HIV program in Kenya; a cross-sectional study.

BACKGROUND: Early infant diagnosis (EID) of HIV, followed by effective care including antiretroviral therapy (ART), reduces infant mortality by 76% and HIV progression by 75%. In 2015, 50% of 1.2 million HIV-exposed infants (HEI) in 21 priority countries received a virologic test within the recommended 2 months of birth. We sought to identify factors associated with timely uptake of virologic EID among HEI and gain insight into missed opportunities. METHODS: This was a cross-sectional study that used de-identified data from electronic medical records of 54 health facilities within the Christian Health Association of Kenya (CHAK) HIV Project database. All HEI who had their first HIV virologic test done between January 2015 and December 2017 were included in the study and categorized as either having the test within or after 8 weeks of birth. Multivariate linear mixed effects regression model was used to determine factors associated with uptake of the first HIV EID polymerase chain reaction (PCR). Predictor variables studied include sex, birth weight, the entry point into care, provision of ART prophylaxis for the infant, maternal ART at time of EID, mode of delivery, and place of delivery. RESULTS: We included 2020 HEI of whom 1018 (50.4%) were female. A majority, 1596 (79.0%) had their first HIV PCR within 2 months of birth at a median age of 6.4 weeks (interquartile range 6-7.4). Overall, HIV positivity rate at initial test among this cohort was 1.2%. Delayed HIV PCR testing for EID was more likely to yield a positive result [adjusted odds ratio (aOR) = 1.29 (95% confidence interval (CI) 1.09-1.52) p = 0.003]. Infants of mothers not on ART at the time of HIV PCR test and infants who had not received prophylaxis to prevent vertical HIV transmission had significant increased odds of a delayed initial test [aOR = 1.27 (95% CI = 1.18-1.37) p = < 0.0001] and [aOR = 1.43 (95% CI 1.27-1.61) p = < 0.001] respectively. CONCLUSION: An initial HIV PCR test done after 8 weeks of birth is likely to yield a positive result. Barriers to accessing ART for treatment among HIV-infected pregnant and breastfeeding women, and prophylaxis for the HEI were associated with delayed EID. In order to ensure timely EID, programs need to incorporate both facility and community strategy interventions to ensure all pregnant women seek antenatal care and deliver within health facilities.

Preconception Care Uptake and Immediate Outcomes among Discordant Couples Accessing Routine HIV Care in Kenya.

INTRODUCTION: A large proportion of new HIV infections occur within discordant partnerships making discordance a significant contributor to new HIV infections in Africa. Despite the role of preconception care for HIV discordant couples, there is little data on fertility desire and preconception care uptake. This study aimed at documenting fertility desire (desire to conceive), determining the uptake of preconception care, identifying HIV prevention strategies used during preconception care, and determining immediate conception outcomes among HIV discordant couples in Kenya. METHODS: We retrospectively extracted electronic medical record data on discordant couples at an HIV care discordant couples' clinic. We included data on couples who expressed a desire to conceive and were offered preconception care and followed up for 29 months. We collected data on sociodemographic characteristics, preconception prevention methods, and associated outcomes. RESULTS: Among couples, with male HIV-positive partners, there was a twofold likelihood of accepting preconception services (OR = 2.3, CI 95% (1, 1, 5.0)). A shorter discordant union was independently associated with the uptake of preconception services (OR = 0.92, CI 95% (0.86, 0.98)). The most used prevention intervention (38.5%) among discordant couples was a combination of pre-exposure prophylaxis (PrEP) by the uninfected partner, alongside HAART by the partner living with HIV. Pregnancy rates did not significantly (p = 0.06) differ among those who took up preconception care versus those who did not. HIV-negative partners of couples who declined preconception care had a significantly (p = 0.04) higher attrition from clinic follow-up. One confirmed seroconversion occurred; an HIV incidence rate of 0.19 per 100 person-years. CONCLUSION: The study demonstrates the feasibility of implementing safe and effective preconception servicesas part of routine HIV care for discordant couples living in low resource settings. The provision and the utilisation of safer conception services may be hindered by the poor retention to follow-up and care of HIV-negative partners. This challenge may impede the expected benefits of preconception care as an HIV prevention intervention.

Burden of prehypertension among adults in Kenya: a retrospective analysis of findings from the Healthy Heart Africa (HHA) Programme.

BACKGROUND: Hypertension is the leading risk factor for mortality globally. African countries, including Kenya, have a high and rising prevalence of hypertension. Prehypertension is associated with an increased risk of progression to overt hypertension and a higher risk of cardiovascular disease and mortality. Despite this, little is documented on the prevalence and distribution of prehypertension in sub-Saharan Africa. This study sought to estimate the overall burden of prehypertension in Kenyan adults enrolled in a large hypertension control programme, Healthy Heart Africa. The distribution and determinants of prehypertension in the sample were explored as secondary objectives. METHODS: This was a post hoc analysis of cross-sectional data obtained from population-level blood pressure (BP) screening of adults aged ≥18 years in the community and ambulatory care facilities in 17/47 sub-national administrative units in Kenya. All participants with a complete record for systolic and diastolic BP were included. Descriptive analyses were performed for sociodemographic characteristics. Pearson's chi-square test was used to assess differences in categorical variables. Multivariate logistic regression analysis was performed to identify factors independently associated with prehypertension. RESULTS: Of 5,985,185 participant records that were included in the analysis, 34% were men (mean age: 45 [SD 2.9] years). The majority (63%) lived in rural Kenya. The prevalence of prehypertension was 54.5% and that of hypertension was 20.8%. Characteristics that were independently associated with prehypertension (adjusted odds ratio [95% CI]) included male sex (1.23 [±0.0023], p <  0.001 for all age groups > 25 years) and rural residence (1.60 [±0.023], p <  0.001). CONCLUSIONS: Approximately one in every two Kenyan adults has prehypertension. This calls for urgent development and roll-out of a national BP screening and control programme. It also provides a strong basis for the formulation of multisectoral national policies that will ensure implementation of evidence-based, low-cost public health interventions geared towards primary prevention of hypertension, especially in population groups that are traditionally considered at low risk, such as young adults and rural residents.

Trends, treatment outcomes, and determinants for attrition among adult patients in care at a large tertiary HIV clinic in Nairobi, Kenya: a 2004-2015 retrospective cohort study.

BACKGROUND: Understanding trends in patient profiles and identifying predictors for adverse outcomes are key to improving the effectiveness of HIV care and treatment programs. Previous work in Kenya has documented findings from a rural setting. This paper describes trends in demographic and clinical characteristics of antiretroviral therapy (ART) treatment cohorts at a large urban, referral HIV clinic and explores treatment outcomes and factors associated with attrition during 12 years of follow-up. METHODS: This was a retrospective cohort analysis of HIV-infected adults who started ART between January 1, 2004, and September 30, 2015. ART-experienced patients and those with missing data were excluded. The Cochran-Armitage test was used to determine trends in baseline characteristics over time. Cox proportional hazards models were used to determine the effect of baseline characteristics on attrition. RESULTS: ART uptake among older adolescents (15-19 years), youth, and young adults increased over time (p=0.0001). Independent predictors for attrition included (adjusted hazard ratio [95% CI]) male sex: 1.30 (1.16-1.45), p=0.0001; age: 15-19 years: 1.83 (1.26-2.66), p=0.0014; 20-24 years: 1.93 (1.52-2.44), p=0.0001; and 25-29 years: 1.31 (1.11-1.54), p=0.0012; marital status - single: 1.27 (1.11-1.44), p=0.0005; and divorced/separated: 1.56 (1.30-1.87), p=0.0001; urban residence: 1.40 (1.20-1.64), p=0.0001; entry into HIV care following hospitalization: 1.31 (1.10-1.57), p=0.0026, or transfer from another facility: 1.60 (1.26-2.04), p=0.0001; initiation of ART more than 12 months after the date of HIV diagnosis: 1.36 (1.19-1.55), p=0.0001, and history of a current or past opportunistic infection (OI): 1.15 (1.02-1.30), p=0.0284. CONCLUSION: Although ART uptake among adolescents and young people increased over time, this group was at increased risk for attrition. Single marital status, urban residence, history of hospitalization or OI, and delayed initiation of ART also predicted attrition. This calls for focused evidence-informed strategies to address attrition and improve outcomes.

Quality of sleep and risk for obstructive sleep apnoea in ambulant individuals with type 2 diabetes mellitus at a tertiary referral hospital in Kenya: a cross-sectional, comparative study.

BACKGROUND: Sleep disorders are common and associated with multiple metabolic and psychological derangements. Obstructive sleep apnoea (OSA) is among the most common sleep disorders and an inter-relationship between OSA, insulin resistance, obesity, type 2 diabetes (T2DM) and cardiovascular diseases has been established. Prevalence of sleep disorders in Kenyans, particularly in individuals with T2DM is unknown. We thus aimed to determine prevalence of poor quality of sleep (QOS) and high risk for OSA, among persons with T2DM and determine their associations with socio-demographic and anthropometric variables. METHODS: Utilising a Cross- Sectional Descriptive design, QOS and risk for OSA were determined in a randomly selected sample of patients with T2DM (cases) and an age and sex matched comparison group. The validated Pittsburgh Sleep Quality Index (PSQI) and Berlin Questionnaire (BQ) were used to measure QOS and risk for OSA respectively. Associations between poor QOS, high risk for OSA, and socio-demographic and anthropometric variables in cases were evaluated. RESULTS: From 245 randomly selected persons with T2DM attending outpatient clinics, aged over 18 years, 22 were excluded due to ineligibility thus 223 were included in the analysis; 53.8% were females, mean age was 56.8 (SD 12.2) years and mean BMI was 28.8 kg/m2 (SD 4.4). Among them, 119 (53%, CI 95% 46.5-60.2) had poor QOS and 99 (44% CI 95% 37.8-50.9) were at high risk for OSA. Among 112 individuals in comparison group, 33 (29.5%, CI 95% 20.9-38.3) had poor QOS and 9 (8%, CI 95% 3.3-13.4) had high risk for OSA. Cases had a significantly higher probability for poor QOS [OR 2.76 (95% CI 1.7-4.4))] and high risk for OSA [OR 9.1 (95% CI 4.4-19.0)]. Higher waist circumference was independently associated with a high risk for OSA in cases. CONCLUSIONS: We demonstrate a high burden of sleep disturbances in patients with T2DM. Our findings may have implications for clinicians to screen for sleep disorders when assessing patients with T2DM and warranting further attention by practitioners and researches in this field.

Trends in clinical characteristics and outcomes of Pre-ART care at a large HIV clinic in Nairobi, Kenya: a retrospective cohort study.

BACKGROUND: The success of antiretroviral therapy in resource-scarce settings is an illustration that complex healthcare interventions can be successfully delivered even in fragile health systems. Documenting the success factors in the scale-up of HIV care and treatment in resource constrained settings will enable health systems to prepare for changing population health needs. This study describes changing demographic and clinical characteristics of adult pre-ART cohorts, and identifies predictors of pre-ART attrition at a large urban HIV clinic in Nairobi, Kenya. METHODS: We conducted a retrospective cohort analysis of data on HIV infected adults (≥15 years) enrolling in pre-ART care between January 2004 and September 2015. Attrition (loss to program) was defined as those who died or were lost to follow-up (having no contact with the facility for at least 6 months). We used Kaplan-Meier survival analysis to determine time to event for the different modes of transition, and Cox proportional hazards models to determine predictors of pre-ART attrition. RESULTS: Over the 12 years of observation, there were increases in the proportions of young people (age 15 to 24 years); and patients presenting with early disease (by WHO clinical stage and higher median CD4 cell counts), p = 0.0001 for trend. Independent predictors of attrition included: aHR (95% CI): male gender 1.98 (1.69-2.33), p = 0.0001; age 20-24 years 1.80 (1.37-2.37), p = 0.0001), or 25-34 years 1.22 (1.01-1.47), p = 0.0364; marital status single 1.55 (1.29-1.86), p = 0.0001) or divorced 1.41(1.02-1.95), p = 0.0370; urban residency 1.83 (1.40-2.38), p = 0.0001; CD4 count of 0-100 cells/µl 1.63 (1.003-2.658), p = 0.0486 or CD4 count >500 cells/µl 2.14(1.46-3.14), p = 0.0001. CONCLUSIONS: In order to optimize the impact of HIV prevention, care and treatment in resource scarce settings, there is an urgent need to implement prevention and treatment interventions targeting young people and patients entering care with severe immunosuppression (CD4 cell counts <100 cells/µl). Additionally, care and treatment programmes should strengthen inter-facility referrals and linkages to improve care coordination and prevent leakages in the HIV care continuum.