HIV testing experiences in Nairobi slums: the good, the bad and the ugly.

BACKGROUND: HIV testing is an integral component of HIV prevention, treatment and care and, therefore, is crucial in achieving UNAIDS 90-90-90 targets. HIV testing in Kenya follows both the voluntary counselling and testing (VCT) and provider initiated testing and counselling (PITC) models. However, little is known about the individual experiences of undergoing an HIV test in the two testing models. This study provides experiential evidence of undergoing an HIV test in a resource poor urban slum setting. METHODS: The study explored testing experiences and challenges faced in respect to ensuring the 3 Cs (consent, counselling and confidentiality), using in-depth interviews (N = 41) with HIV-infected men and women in two slum settlements of Nairobi City. The in-depth interview respondents were aged above 18 years with 56% being females. All interviews were audio-recorded, transcribed and then translated into English. The transcribed data were analysed using thematic analysis method. RESULTS: The respondent HIV-testing experiences were varied and greatly shaped by circumstances and motivation for HIV testing. The findings show both positive and negative experiences, with sporadic adherence to the 3Cs principle in both HIV testing models. Although some respondents were satisfied with the HIV testing process, a number of them raised a number of concerns, with instances of coercion and testing without consent being reported. CONCLUSION: The 3Cs (consent, counselling and confidentiality) principle must underlie HIV testing and counselling practices in order to achieve positive testing outcomes. The study concludes that adherence to the 3Cs during HIV testing contributes to both the individual and public health good - irrespective of whether testing is initiated by the individual or by the health provider.

Community influences on modern contraceptive use among young women in low and middle-income countries: a cross-sectional multi-country analysis.

BACKGROUND: Despite investment in family planning programs and education, unmet need for family planning remains high among young women (aged 15-24) in low and middle-income countries, increasing the risk for unwanted pregnancies and adverse social and reproductive health outcomes. There is a dearth of cross-national research that identifies the differential impact of community level factors among youth in low and middle-income countries (LMICs), which is imperative for the design of structural level interventions aimed at increasing family planning use. METHODS: Grounded in the socio-ecological framework, this paper utilizes Demographic and Health Survey (DHS) from 52 LMICs to examine the influence of community level reproductive, gender, fertility, literacy and economic indicators on modern contraceptive use among female youth. Analyses are conducted using multi-level logistic regressions with random community-level effects. RESULTS: Our findings highlight the positive influence of community level education attainment and negative influence of gender and fertility related norms on young women's contraceptive use. Additionally, increased exposure to mass media did not positively influence young women's uptake of modern contraceptive methods. CONCLUSIONS: Taken together, findings indicate that young women's contraceptive decision-making is greatly shaped by their social contexts. The commonalities and regional variations in community level influences provide support for both structural level interventions and tailored regional approaches to family planning interventions.

Ambivalence in pregnancy intentions: The effect of quality of care and context among a cohort of women attending family planning clinics in Kenya.

CONTEXT: Ambivalence in pregnancy intentions is well-documented in sub-Saharan African (SSA) settings and has been associated with inconsistent use of contraception, thereby exposing women using contraception to the possibility of unintended pregnancies. A better understanding of the potential role for client counseling interventions in enabling women to achieve their pregnancy intentions is essential for aiding program efforts to reduce unintended pregnancies. OBJECTIVE: To measure ambivalence in pregnancy intentions longitudinally and determine its association with the quality of care received, controlling for demographic, socio-economic and contextual factors among a cohort of family planning (FP) clients in Kenya. METHODS: This paper uses data drawn from a prospective cohort study of FP clients to investigate the relationship between the quality of care received during FP service delivery and the decisiveness of their pregnancy intentions over time. The study tests the hypothesis that higher quality of care enables women to be less ambivalent about their pregnancy intentions. Binary logistic regression with random effects and multinomial logistic regression were used to assess the predictive effect of the quality of care received by a woman on the decisiveness or ambivalence of her pregnancy intentions, and on any shifts in ambivalence over time, controlling for background characteristics. The study recruited 1,957 women aged 15-49 years attending twelve family planning clinics in four counties in Central Kenya; of these, 1,053 women were observed for four rounds of data collection over a period of 24 months and form the sample for analysis. FINDINGS: A substantial proportion (43%) of women expressed ambivalence about their intentions to become pregnant at some point during the study period, while over half (57%) remained unequivocal throughout the study. Almost one third of women (31%) shifted from being unequivocal to ambivalent and 12% shifted from ambivalence to being unequivocal. Women experiencing higher quality of care have lower odds of ever expressing ambivalence and higher odds of remaining unequivocal over time, net of other factors. Quality of care was not associated with a shift in ambivalence over time. CONCLUSION: FP programs offering higher quality of care are likely to support women to be more decisive in their pregnancy intentions. Improving the quality of care can contribute to reduced ambivalence and consequently reduced likelihood of unintended pregnancy among contraceptive users. This study provides further evidence of the benefits gained through providing high quality services. TRIAL REGISTRATION: ClinicalTrials.gov NCT01694862.

Contraceptive need and use among individuals with HIV/AIDS living in the slums of Nairobi, Kenya.

OBJECTIVE: To understand contraceptive need and use among individuals with HIV/AIDS living in slums. METHODS: A sequential mixed-methods study was conducted in two slums in Nairobi, Kenya, from November 6th, 2009 to April 18th, 2010. Data were obtained by quantitative survey (n=513), qualitative in-depth interviews (n=41), and key informant interviews (n=14). RESULTS: In all, 250 (55.5%) participants used contraceptives. Condoms were the most frequently reported modern method (n=142; 60.4%), followed by injectables (n=55; 23.4%) and dual methods (n=38; 15.3%). Unmet need was reported by 151 (33.6%) individuals. Factors associated with contraceptive use were education, marital status, number of living children, discussion of contraception with a provider, and social support. Personal, conceptual, and structural barriers to contraceptive use were identified. CONCLUSIONS: Individuals with HIV/AIDS wished to limit their fertility but experienced high unmet need for contraception. Multi-level interventions, including educational campaigns and integration of HIV and family planning services, are required to overcome barriers.

Fertility desires among men and women living with HIV/AIDS in Nairobi slums: a mixed methods study.

OBJECTIVES: Fertility desires require new understanding in a context of expanding access to antiretroviral therapy for people living with HIV/AIDS in Sub-Saharan Africa. This paper studies the fertility desires and their rationales, of slum-dwelling Kenyan men and women living with HIV/AIDS who know their serostatus, but have different antiretroviral therapy treatment statuses. It addresses two research questions: How do people living with HIV/AIDS consider their future fertility? What factors contribute to an explanation of fertility desires among people living with HIV/AIDS. METHODS: A mixed methods study (survey [n = 513] and in-depth interviews [n = 41]) with adults living with HIV/AIDS living in Nairobi slums was conducted in 2010. Regression analyses assess independent relationships between fertility desires and socio-demographic factors. Analyses of in-depth interviews are used to interpret the statistical analyses of fertility desires. RESULTS: Our analyses show that fertility desires are complex and ambivalent, reflecting tensions between familial and societal pressures to have children versus pressures for HIV (re-)infection prevention. More than a third (34%) of men and women living with HIV expressed future fertility desires; however, this is significantly lower than in the general population. Factors independently associated with desiring a child among people living with HIV/AIDS were age, sex, number of surviving children, social support and household wealth of the respondent. DISCUSSION: Increasing access to ART is changing the context of future childbearing for people living with HIV/AIDS. Prevailing values mean that, for many people living with HIV/AIDS, having children is seen as necessary for a "normal" and healthy adult life. However, the social rewards of childbearing conflict with moral imperatives of HIV prevention, presenting dilemmas about the "proper" reproductive behaviour of people living with HIV/AIDS. The health policy and service delivery implications of these findings are explored.

Living with HIV postdiagnosis: a qualitative study of the experiences of Nairobi slum residents.

OBJECTIVES: To characterise the experiences of heterosexual men and women living with HIV postdiagnosis and explain these experiences in relation to their identity and sexuality. DESIGN: Qualitative study using in-depth interviews and a theoretically informed biographic disruption theory. SETTING: Interviews were conducted in two Nairobi slums (Kenya). PARTICIPANTS: 41 HIV-infected heterosexual men and women aged 18 years or older. RESULTS: People living with HIV have divergent experiences surrounding HIV diagnosis. Postdiagnosis, there are multiple phases of identity transition, including status (non-)disclosure, and attempts at identity repair and normalcy. For some people, this process involves a transition to a new self-identity, incorporating both HIV and antiretroviral treatment (ART) into their lives. For others, it involves a partial transition, with some aspects of their prediagnosis identity persisting, and for others it involves a rejection of HIV identity. Those people who were able to incorporate HIV/AIDS in their identity, without it being disruptive to their biography, were pursuing safer sexual and reproductive lives. By contrast, those people with a more continuous biography continued to reflect their prediagnosis identity and sexual behaviour. CONCLUSIONS: People living with HIV/AIDS (PLWHA) had to rework their sense of identity following diagnosis in the context of living in a slum setting. Men and women living with HIV in slums are poorly supported by health systems and services as they attempt to cope with a diagnosis of HIV. Given the availability of ART, health services and professionals need to support the rights of PLWHA to be sexually active if they want to and achieve their fertility goals, while minimising HIV transmission risk.

Beliefs and practices about antiretroviral medication: a study of poor urban Kenyans living with HIV/AIDS.

Interest in medication-taking as a social behaviour is growing. Drawing on qualitative data, this study interrogates beliefs and practices related to antiretroviral therapy (ART) use among urban poor Kenyan people living with HIV/AIDS (PLWHA). Responding PLWHA relied on a range of ingenious strategies to remember to take their medications but did not necessarily perceive compliance with medical instructions as key to treatment efficacy. They also believed that compliance can even hurt some patients. PLWHA relied on both compliance and non-compliance to seek social acceptance, maintain a reputation of being healthy, dispel rumours about one's status, and minimise economic vulnerability. Compliance was further used to mark gratitude to supportive caregivers and providers, and non-compliance to appraise the efficacy of other treatments which promise permanent cure. The medication-taking practices of poor Kenyan PLWHA reflect their struggles with deprived livelihoods and stigma.