Impact of the COVID-19 pandemic on obstetrical care at a tertiary care facility in Mombasa, Kenya: Time-series analyses and staff perspectives.

The COVID-19 pandemic caused disruption in healthcare delivery due to reductions in both health facility capacity and care-seeking behavior. For women experiencing obstetric complications, access to comprehensive emergency obstetric care is critical for maternal and child health. In Kenya, pandemic-related restrictions began in March 2020 and were compounded by a healthcare worker strike in December 2020. We examined medical record data at Coast General Teaching and Referral Hospital, a large public hospital, and conducted staff interviews to understand how healthcare disruptions impacted care delivery and perinatal outcomes. Routinely collected data from all mother-baby dyads admitted to the Labor and Delivery Ward from January 2019 through March 2021 were included in interrupted time-series analyses. Outcomes included number of admissions and proportion of deliveries that resulted in caesarean sections and adverse birth outcomes. Interviews were conducted with nurses and medical officers to understand how the pandemic impacted clinical care. Pre-pandemic, the ward averaged 810 admissions/month, compared to 492 admissions/month post-pandemic (average monthly decrease: 24.9 admissions; 95% CI: -48.0, -1.8). The proportion of stillbirths increased 0.3% per month during the pandemic compared to the pre-pandemic period (95% CI: 0.1, 0.4). No significant differences were seen in the proportion of other adverse obstetrical outcomes. Interview results suggested that pandemic-related disruptions included reduced access to surgical theaters and protective equipment, and absence of COVID-19 guidelines. While these disruptions were perceived as impacting care for high-risk pregnancies, providers believed that overall quality of care did not diminish during the pandemic. However, they expressed concern about a likely increase in at-home births. In conclusion, while the pandemic had minimal adverse impact on hospital-based obstetrical outcomes, it reduced the number of patients able to access care. Emergency preparedness guidelines and public health messaging promoting timely obstetrical care are needed to ensure continuation of services during future healthcare disruptions.

Safer sexual behaviors after 12 months of antiretroviral treatment in Mombasa, Kenya: a prospective cohort.

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.

Short- and long-term efficacy of modified directly observed antiretroviral treatment in Mombasa, Kenya: a randomized trial.

OBJECTIVES: 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. CONCLUSIONS: M-DOT increased adherence, most notably among depressed participants.

Efficacy of highly active antiretroviral therapy in HIV-1 infected children in Kenya.

OBJECTIVE: 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.