HIV-1 protease inhibitor drug resistance in Kenyan antiretroviral treatment-naive and -experienced injection drug users and non-drug users.

BACKGROUND: Although injection drug use drives antiretroviral drug resistance, the prevalence of protease inhibitor (PI) resistance among Kenyan IDUs remains undetermined. We, therefore, explored PI resistance mutations and their association with viral load and CD4+ T cell counts in HIV-1 infected IDUs (ART-naive, n = 32; and -experienced, n = 47) and non-drug users (ART-naive, n = 21; and -experienced, n = 32) naive for PI treatment from coastal Kenya. RESULTS: Only IDUs harboured major PI resistance mutations consisting of L90M, M46I and D30 N among 3 (6.4 %) ART-experienced and 1 (3.1 %) -naive individuals. Minor PI mutations including A71T, G48E, G48R, I13V, K20I, K20R, L10I, L10V, L33F, L63P, T74S, V11I, and V32L were detected among the ART-experienced (36.2 vs. 46.9 %) and -naive (43.8 vs. 66.7 %) IDUs and non-drug users, respectively. All the four IDUs possessing major mutations had high viral load while three presented with CD4+ T cell counts of <500 cells/ml. Among the ART-naive non-drug users, CD4+ T cell counts were significantly lower in carriers of minor mutations compared to non-carriers (P < 0.05). CONCLUSION: Transmitted drug resistance may occur in IDUs underscoring the need for genotyping resistance before initiating PI treatment.

Clinical chemistry profiles in injection heroin users from Coastal Region, Kenya.

BACKGROUND: Although the co-burden of injection drug use and HIV is increasing in Africa, little is known about the laboratory markers of injection drug use and anti-retroviral treatment (ART) in Kenyan injection drug users. This study, therefore, aimed at determining the clinical chemistry profiles and identifying the key laboratory markers of HIV infection during ART in injection heroin users (IHUs). METHODS: Clinical chemistry measurements were performed on serum samples collected from HIV-1 infected ART-experienced (n = 22), naive (n = 16) and HIV-1 negative (n = 23) IHUs, and healthy controls (n = 15) from Mombasa, coastal Kenya. RESULTS: HIV uninfected IHUs had lower alanine aminotransferase (ALT) levels (P = 0.023) as ART-exposed IHUs exhibited lower albumin (P = 0.014) and higher AST to platelet index (APRI) (P < 0.0001). All IHUs presented with lower aspartate aminotransferase to ALT values (P = 0.001) and higher C-reactive protein (CRP) levels (P = 0.002). ART-naive IHUs had higher globulin levels (P = 0.013) while ART-experienced and naive IHUs had higher albumin to total protein (P < 0.0001) and albumin to globulin (P < 0.0001) values. In addition, CD4+ T cells correlated with ALT (ρ = -0.522, P = 0.011) and CRP (rho, ρ = 0.529, P = 0.011) in HIV negative and ART-experienced IHUs, respectively. HIV-1 viral load correlated with albumin to globulin index in ART-experienced (ρ = -0.468, P = 0.037) and naive (ρ = -0.554, P = 0.040) IHUs; and with albumin to total protein index (ρ = -0.554, P = 0.040) and globulin (ρ = 0.570, P = 0.033) in ART-naive IHUs. CONCLUSION: Absolute ALT, albumin, globulin, and CRP measurements in combination with APRI, AST to ALT, albumin to total protein and albumin to globulin indices may be useful laboratory markers for screening IHUs for initiating and monitoring treatment.

Effects of valacyclovir on markers of disease progression in postpartum women co-infected with HIV-1 and herpes simplex virus-2.

OBJECTIVE: Herpes simplex virus type 2 (HSV-2) suppression has been shown to reduce HIV-1 disease progression in non-pregnant women and men, but effects on pregnant and postpartum women have not been described. METHODS: We analyzed data from a cohort of Kenyan women participating in a randomized clinical trial of HSV-2 suppression. Pregnant HIV-1-seropositive, HSV-2-seropositive women who were not eligible for antiretroviral therapy (WHO stage 1-2, CD4>250 cells/µl) were randomized to either 500 mg valacyclovir or placebo twice daily from 34 weeks gestation through 12 months postpartum. Women received zidovudine and single-dose nevirapine for prevention of mother-to-child HIV-1 transmission. HIV-1 progression markers, including CD4 count and plasma HIV-1 RNA levels, were measured serially. Multivariate linear regression was used to compare progression markers between study arms. RESULTS: Of 148 women randomized, 136 (92%) completed 12 months of postpartum follow-up. While adjusted mean CD4 count at 12 months (565 cells/µl placebo arm, 638 cells/µl valacyclovir arm) increased from antenatal levels in both arms, the mean CD4 count increase was 73 cells/µl higher in the valacyclovir arm than placebo arm (p = 0.03). Mean increase in CD4 count was 154 cells/µl in the valacyclovir arm, almost double the increase of 78 cells/µl in the placebo arm. At 12 months, adjusted HIV-1 RNA levels in the placebo arm increased by 0.66 log(10) copies/ml from baseline, and increased by only 0.21 log(10) copies/ml in the valacyclovir arm (0.40 log(10) copies/ml difference, p = 0.001). CONCLUSION: Women randomized to valacyclovir suppressive therapy during pregnancy and postpartum had greater increases in CD4 counts and smaller increases in plasma HIV-1 RNA levels than women in the placebo arm. Valacyclovir suppression during pregnancy and breastfeeding may improve outcomes and delay antiretroviral therapy for HIV-1/HSV-2 co-infected women.

Valacyclovir suppressive therapy reduces plasma and breast milk HIV-1 RNA levels during pregnancy and postpartum: a randomized trial.

BACKGROUND: The effect of herpes simplex virus type 2 (HSV-2) suppression on human immunodeficiency virus type 1 (HIV-1) RNA in the context of prevention of mother-to-child transmission (PMTCT) interventions is unknown. METHODS: Between April 2008 and August 2010, we conducted a randomized, double-blind trial of twice daily 500 mg valacyclovir or placebo beginning at 34 weeks gestation in 148 HIV-1/HSV-2 coinfected pregnant Kenyan women ineligible for highly active antiretroviral therapy (CD4 > 250 cells/mm(3)). Women received zidovudine and single dose nevirapine for PMTCT and were followed until 12 months postpartum. RESULTS: Mean baseline plasma HIV-1 RNA was 3.88 log(10) copies/mL. Mean plasma HIV-1 was lower during pregnancy (-.56 log(10) copies/mL; 95% confidence interval [CI], -.77 to -.34) and after 6 weeks postpartum (-.51 log(10) copies/mL; 95% CI, -.73 to -.30) in the valacyclovir arm than the placebo arm. Valacyclovir reduced breast milk HIV-1 RNA detection at 6 and 14 weeks postpartum compared with placebo (30% lower, P = .04; 46% lower, P = .01, respectively), but not after 14 weeks. Cervical HIV-1 RNA detection was similar between arms (P = .91). CONCLUSIONS: Valacyclovir significantly decreased early breast milk and plasma HIV-1 RNA among women receiving PMTCT. CLINICAL TRIALS REGISTRATION: NCT00530777.

Drug use in a rural secondary school in Kenya.

Alcohol abuse and alcohol-related use problems among adolescents are highly prevalent and are a major concern worldwide. This study estimated the prevalence of drug abuse, knowledge about drug abuse and its effect on psychosocial well-being and induced behavioral problems among students of a public rural secondary school that admitted both girls and boys which offered both boarding and day school facilities. The students filled out a self-reporting substance use tool which measures the prevalence, frequency, and general patterns of substance use. Alcohol, tobacco, khat (catha edulis) and bhang (cannabis) were the most commonly reported substance of use, with user prevalence rates of 5.2%, 3.8%, 3.2%, and 1.7%, respectively. Tobacco use was initiated at 10 years, while cannabis, hard drugs, khat, and alcohol were initiated at 11, 12, 13, and 15 years of age, respectively. Among the students 71% were aware that their schoolmates were on drugs and it was known by 49.8%, 41.7%, 37.6%, 44.3%, and 32.4% of these students that using alcohol, tobacco, khat, cannabis, and hard drugs, respectively was a behavioral problem in the school. Three quarters of the students were aware that use of drugs was harmful to their health, with majority (78.6%) indicating that drug users need help to stop the drug use behavior. However most (73.6%) of the students suggested drug users in school should be punished. The drug use behavioral problems included school dropout, poor scholastic attainment, drunken driving, delinquency, and adolescence pregnancy which threaten the stability of the education system, family as an institution (family difficulties) and society at large. Therefore, teachers have an added burden of playing an active role in guidance and counselling the survivors of drug abuse, a pandemic facing teaching institutions apart from instilling knowledge.

Prevalence of substance abuse among patients in general medical facilities in Kenya.

Alcoholism and other substance abuse continue to be a problem among younger and older populations. The prevalence of substance abuse has only been studied among outpatients and in limited samples of inpatients in Kenya. This study therefore aimed to establish patterns of substance abuse in patients admitted in general medical facilities in Kenya. The Alcohol Use Disorders Identification Test (AUDIT) and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) were used to measure the prevalence of substance abuse among patients in 10 medical facilities in Kenya. Data were collected over a 4-week period in November 2005. The overall alcohol user rate using the two instruments was 25.1% and 25.5%, respectively. All the patients who used alcohol exhibited pathological use, which bordered from harmful use to dependence. Apart from alcohol, other abused substances included tobacco, cannabis, cocaine, amphetamines/khat, and sedatives. The clinicians' pick rate for substance use in general hospitals was negligible. These findings suggest the need for specific enquiry for substance abuse in patients in general medical facilities.

Patterns of drug abuse in public secondary schools in Kenya.

The objective of this study was to establish the association between substance abuse and the sociodemographic characteristics of secondary school students. All the students of 17 randomly stratified public secondary schools in Nairobi were required to complete self-administered sociodemographic and the School Toolkit questionnaires in a cross-sectional descriptive survey. Nearly all (96.6%; 1252/1296) the students, comprising more males (62.5%) than females, completed all the items on the questionnaires. Their mean age was 17 years. Alcohol and cigarette use were common and began as early as before age 11. No significant correlation was found between fathers' education and substance abuse. Mothers' education had a significant but negative correlation. There were increased rates of substance abuse compared to past surveys. Campaigns against drug use should include those aged 11 years and should focus on education on the dangers of alcohol and tobacco use, as these are gateways to use of other drugs.

Psychosocial and health aspects of drug use by students in public secondary schools in Nairobi, Kenya.

The objective of this study was to evaluate the influence of family, psychosocial, health, demographic, and behavioral characteristics on regular drug use. All the students of 17 randomly stratified public secondary schools in Nairobi were required to complete self-administered sociodemographic and the Drug Use Screening Inventory-Revised (DUSI-R) questionnaires in a cross-sectional descriptive study. All the 1328 students, of whom 58.9% were male, responded to all the questions, giving a response rate of 100%. The mean age of the respondents was 16 years and 78.1% were in boarding school. One third (33.9%) scored positively for substance abuse. Significant correlations were found between several domains of substance abuse and school, class, mode of school attendance, age, and gender. Students abusing drugs have multiple comorbidity of medical, psychological, and social pathologies. There are evidence-based intervention entry points for drug abuse that go beyond mere impartation on knowledge about the harmful effects of drugs.

The prevalence of mental disorders in adults in different level general medical facilities in Kenya: a cross-sectional study.

BACKGROUND: The possibility that a significant proportion of the patients attending a general health facility may have a mental disorder means that psychiatric conditions must be recognised and managed appropriately. This study sought to determine the prevalence of common psychiatric disorders in adult (aged 18 years and over) inpatients and outpatients seen in public, private and faith-based general hospitals, health centres and specialised clinics and units of general hospitals. METHODS: This was a descriptive cross-sectional study conducted in 10 health facilities. All the patients in psychiatric wards and clinics were excluded. Stratified and systematic sampling methods were used. Informed consent was obtained from all study participants. Data were collected over a 4-week period in November 2005 using various psychiatric instruments for adults. Descriptive statistics were generated using SPSS V. 11.5. RESULTS: A total of 2,770 male and female inpatients and outpatients participated in the study. In all, 42% of the subjects had symptoms of mild and severe depression. Only 114 (4.1%) subjects had a file or working diagnosis of a psychiatric condition, which included bipolar mood disorder, schizophrenia, psychosis and depression. CONCLUSION: The 4.1% clinician detection rate for mental disorders means that most psychiatric disorders in general medical facilities remain undiagnosed and thus, unmanaged. This calls for improved diagnostic practices in general medical facilities in Kenya and in other similar countries.

Clinical epidemiology in patients admitted at Mathari Psychiatric Hospital, Nairobi, Kenya.

BACKGROUND: Knowledge of types and co-morbidities of disorders seen in any facility is useful for clinical practice and planning for services. AIM: To study the pattern of co-morbidities of and correlations between psychiatric disorders in in-patients of Mathari Hospital, the premier psychiatric hospital in Kenya. STUDY DESIGN: Cross-sectional. METHODS: All the patients who were admitted at Mathari Hospital in June 2004 and were well enough to participate in the study were approached for informed consent. Trained psychiatric charge nurses interviewed them using the Structured Clinical Interview for DSM-IV Axis I disorders Clinical Version (SCID-I). Information on their socio-demographic profiles and hospital diagnoses was extracted from their clinical notes using a structured format. RESULTS: Six hundred and ninety-one patients participated in the study. Sixty-three percent were male. More than three quarters (78%) of the patients were aged between 21 and 45 years. More than half (59.5%) of the males and slightly less than half (49.4%) of the females were single. All the patients were predominantly of the Christian faith. Over 85% were dependents of another family member and the remainder were heads of households who supported their own families. Schizophrenia, bipolar I disorder, psychosis, substance use disorder and schizo-affective disorder were the most common hospital and differential diagnoses. Of the anxiety disorders, only three patients were under treatment for post-traumatic stress disorder (PTSD). Nearly a quarter (24.6%) of the patients were currently admitted for a similar previous diagnosis. Schizophrenia was the most frequent DSM-IV (Diagnostic and Statistical Manual of Mental Disorders-fourth edition) diagnosis (51%), followed by bipolar I disorder (42.3%), substance use disorder (34.4%) and major depressive illness (24.6%). Suicidal features were common in the depressive group, with 14.7% of this group reporting a suicidal attempt. All DSM-IV anxiety disorders, including obsessive-compulsive disorders, were highly prevalent although, with the exception of three cases of PTSD, none of these anxiety disorders were diagnosed clinically. Traumatic events were reported in 33.3% of the patients. These were multiple and mainly violent events. Despite the multiplicity of these events, only 7.4% of the patients had a PTSD diagnosis in a previous admission while 4% were currently diagnosed with PTSD. The number of DSM-IV diagnoses was more than the total number of patients, suggesting co-morbidity, which was confirmed by significant 2-tailed correlation tests. CONCLUSION: DSM-IV substance use disorders, major psychiatric disorders and anxiety disorders were prevalent and co-morbid. However, anxiety disorders were hardly diagnosed and therefore not managed. Suicidal symptoms were common. These results call for more inclusive clinical diagnostic practice. Standardized clinical practice using a diagnostic tool on routine basis will go a long way in ensuring that no DSM-IV diagnosis is missed. This will improve clinical management of patients and documentation.

Attitudes toward psychiatry: a survey of medical students at the University of Nairobi, Kenya.

OBJECTIVES: The authors aim to determine the attitudes of University of Nairobi, Kenya, medical students toward psychiatry. METHODS: The study design was cross-sectional. Self-administered sociodemographic and the Attitudes Toward Psychiatry-30 items (ATP-30) questionnaires were distributed sequentially to every third medical student in his or her lecture theater before or immediately after the lectures. Analysis was done using SPSS version 11.5 and the results are presented in tables. RESULTS: Nearly 75% of the students had overall favorable attitudes toward psychiatry but only 14.3% considered psychiatry as a potential career choice. Sixty-six percent reported that they would not choose psychiatry as a career while the remaining 19.7% were not decided. CONCLUSIONS: There is dissonance between positive attitudes toward psychiatry and the choice of psychiatry as a potential career. Therefore, there is a need to bridge the gap by addressing the various factors that potentially account for this dissonance.

The prevalence of anxiety and depression symptoms and syndromes in Kenyan children and adolescents.

BACKGROUND: Community studies on children and adolescents in Western settings suggest prevalence rates of anxiety and depressive symptoms that require intervention. AIM: To establish equivalent prevalence rates in a Kenyan (developing country) situation Method: Self-administered questionnaires for socio-demographic data, three Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV)-based instruments for anxiety symptoms and syndromes in children, one instrument for depression and one culture sensitive instrument for depression and anxiety were administered in three different sets to 3 775 randomly sampled students drawn from a stratified sample of 34.7% of all public secondary schools in Nairobi, Kenya. RESULTS: The prevalence rates of anxiety and depression symptoms and syndromes varied widely depending on sex and age and also on the emphasis of the different instruments used, and also according to the cut-off points for the various syndromes and instruments. Clinical diagnostic scores for depression were recorded in 43.7% of all the students. Using the cut-off points for the Multidimensional Anxiety Scale for Children (MASC), anxiety was recorded in 12.9% of all students. Nearly half (40.7%) of the respondents who completed the Short Leyton Obsessional Inventory for Children and Adolescents had positive scores for obsessive disorder, 81.1% were positive for compulsive disorder and an average of 69.1% had positive scores for both obsessive and compulsive disorders combined. Amongst those who completed the Ndetei-Othieno-Kathuku (NOK) scale for Depression and Anxiety, 49.3% had positive scores for moderate to severe anxiety with or without depression. The Screen for Child Anxiety Related Disorders - Revised (SCARED-R) yielded high levels (50-100%) for the different syndromes, with obsessive-compulsive disorder at 99.3%, just below separation anxiety and school phobia at 100%. Suicidal thoughts and plans were prevalent at 4.9-5.5%. CONCLUSION: Anxiety and depression were found at prevalence rates no less than is found in the West. This calls for appropriate clinical practices and policies.