Integration of HIV and reproductive health services in public sector facilities: analysis of client flow data over time in Kenya.

INTRODUCTION: Integration of HIV/AIDS with reproductive health (RH) services can increase the uptake and efficiency of services, but gaps in knowledge remain about the practice of integration, particularly how provision can be expanded and performance enhanced. We assessed the extent and nature of service integration in public sector facilities in four districts in Kenya. METHODS: Between 2009 and 2012, client flow assessments were conducted at six time points in 24 government facilities, purposively selected as intervention or comparison sites. A total of 25 539 visits were tracked: 15 270 in districts where 6 of 12 facilities received an intervention to strengthen HIV service integration with family planning (FP); and 10 266 visits in districts where half the facilities received an HIV-postnatal care intervention in 2009-2010. We tracked the proportion of all visits in which: (1) an HIV service (testing, counselling or treatment) was received together with an RH service (FP counselling or provision, antenatal care, or postnatal care); (2) the client received HIV counselling. RESULTS: Levels of integrated HIV-RH services and HIV counselling were generally low across facilities and time points. An initial boost in integration was observed in most intervention sites, driven by integration of HIV services with FP counselling and provision, and declined after the first follow-up. Integration at most sites was driven by temporary rises in HIV counselling. The most consistent combination of HIV services was with antenatal care; the least common was with postnatal care. CONCLUSIONS: These client flow data demonstrated a short-term boost in integration, after an initial intervention with FP services providing an opportunity to expand integration. Integration was not sustained over time highlighting the need for ongoing support. There are multiple opportunities for integrating service delivery, particularly within antenatal, FP and HIV counselling services, but a need for sustained systems and health worker support over time. TRIAL REGISTRATION NUMBER: NCT01694862.

Understanding HIV risks among adolescent girls and young women in informal settlements of Nairobi, Kenya: Lessons for DREAMS.

INTRODUCTION: High incidence of HIV infection among adolescent girls and young women (AGYW) has been attributed to the numerous and often layered vulnerabilities that they encounter including violence against women, unfavourable power relations that are worsened by age-disparate sexual relations, and limited access to sexual and reproductive health information and services. For AGYW living in urban informal settlements (slums), these vulnerabilities are compounded by pervasive poverty, fragmented social networks, and limited access to social services including health and education. In this paper, we assess sexual risk behaviours and their correlates among AGYW in two slum settlements in Nairobi, Kenya, prior to the implementation of interventions under the Determined Resilient Empowered AIDS-free Mentored and Safe (DREAMS) Partnership. METHODS: We drew on secondary data from the Transition to Adulthood study, the most recent representative study on adolescent sexual behaviour in the two settlements. The study was nested within the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). Data were collected in 2009 from 1,390 AGYW aged 12-23 years. We estimated the proportions of AGYW reporting ever tested for HIV, condom use, multiple sexual partners and age-disparate sex by socio-demographic characteristics. "High risk" sexual behaviour was defined as a composite of these four variables and age at first sex. Multivariable regression analyses were performed to identify factors associated with risk behaviours. RESULTS: Fifty-one percent of AGYW reported that they had ever tested for HIV and received results of their last test, with the proportion rising steeply by age (from 15% to 84% among those <15 years and 20-23 years, respectively). Of 578 AGYW who were sexually active in the 12 months preceding the survey, 26% reported using a condom at last sex, 4% had more than one sexual partner, and 26% had sex with men who were at least 5 years older or younger. All girls aged below 15 years who had sex (n = 9) had not used condoms at last sex. The likelihood of engaging in "high risk" sexual risk behaviour was higher among older AGYW (19-23 years), those in marital unions, of Luo ethnicity, out of school, living alone or with a friend (versus parents), living with spouse (versus parents), and those whose friends engaged in risky/anti-social behaviours. In contrast, Muslim faith, co-residence with both parents, and belonging to an organised social group were associated with lower odds of risky sexual behaviours. CONCLUSION: Our study findings suggest that multifaceted approaches addressing the educational and social mediators of AGYW's vulnerability and that also reach the people with whom AGYW live and interact, are needed to reduce the rapid onset of sexual risk during the adolescent years. There is a particular need to reach the youngest adolescent girls in poor urban settings, among whom condom use and awareness of HIV status is rare.

Reaching young women who sell sex: Methods and results of social mapping to describe and identify young women for DREAMS impact evaluation in Zimbabwe.

Young women (aged 15-24) who exchange sex for money or other support are among the highest risk groups for HIV acquisition, particularly in high prevalence settings. To prepare for introduction and evaluation of the DREAMS programme in Zimbabwe, which provides biomedical and social interventions to reduce adolescent girls' and young women's HIV vulnerability, we conducted a rapid needs assessment in 6 towns using a "social mapping" approach. In each site, we talked to adult sex workers and other key informants to identify locations where young women sell sex, followed by direct observation, group discussions and interviews. We collected data on socio-demographic characteristics of young women who sell sex, the structure and organisation of their sexual exchanges, interactions with each other and adult sex workers, and engagement with health services. Over a two-week period, we developed a "social map" for each study site, identifying similarities and differences across contexts and their implications for programming and research. Similarities include the concentration of younger women in street-based venues in town centres, their conflict with older sex workers due to competition for clients and acceptance of lower payments, and reluctance to attend existing services. Key differences were found in the 4 university towns included in our sample, where female students participate in diverse forms of sexual exchange but do not identify themselves as selling sex. In smaller towns where illegal gold panning or trucking routes were found, young women migrated in from surrounding rural areas specifically to sell sex. Young women who sell sex are different from each other, and do not work with or attend the same services as adult sex workers. Our findings are being used to inform appropriate intervention activities targeting these vulnerable young women, and to identify effective strategies for recruiting them into the DREAMS process and impact evaluations.

Integration of HIV and maternal healthcare in a high HIV-prevalence setting: analysis of client flow data over time in Swaziland.

OBJECTIVE: Maternal and child health (MCH) care may provide an entry point for HIV services in high HIV-prevalence settings. Our objective was to assess integration of HIV with MCH services in public sector facilities in Swaziland. DESIGN: In 2009, 2010 and 2012, client flow assessments (CFAs) were conducted over 5 days in the MCH units of eight government facilities, purposively selected as intervention or comparison sites. PARTICIPANTS: 8263 MCH visits with female clients were tracked: 3261 in 2009, 2086 in 2010 and 2916 in 2012. INTERVENTION: Activities and resources to strengthen integration of HIV services into postnatal care (PNC), 2009-2010. MAIN OUTCOME MEASURES: The proportion of all visits in which an HIV/sexually transmitted infection (STI) testing, counselling or treatment was received together with an MCH service; the proportion of all visits in which a client receives HIV counselling. RESULTS: Across facilities, the proportion of visits in which HIV/STI and MCH services were received varied considerably, for example, from 9% to 49% in 2009. HIV/STI services were integrated most frequently with child health (CH), antenatal care (ANC) and family planning (FP)-the most common reasons for women's attendance-and least often with PNC and cervical screening (CS). There was no meaningful difference in integration over time by design group and considerable heterogeneity across facilities. Receipt of integrated services increased in one intervention and two comparison facilities, where HIV counselling also rose, and fell in one intervention and two comparison facilities. CONCLUSIONS: Provision of HIV/STI services with MCH care occurred at all facilities, yet relatively few women receive integrated services. Increases in integration were driven by increases in HIV counselling, while sharp declines in some facilities indicate that integration is difficult to sustain. Opportunities for intensifying HIV integration lie with ANC, CH and FP, while HIV-PNC integration will remain limited until more women attend PNC. TRIAL REGISTRATION NUMBER: Current Controlled Trials NCT01694862.

Child sexual abuse and links to HIV and orphanhood in urban Zimbabwe.

BACKGROUND: Evidence of a link between sexual violence and HIV is growing; however, studies among children are scarce. The authors sought to characterise child sexual abuse in Harare, Zimbabwe, and explore its links with HIV and orphanhood. METHODS: Records for new clients attending a child sexual abuse clinic from July 2004 to June 2005 were computerised and reviewed. Information on characteristics, medical examinations, laboratory tests and perpetrators were summarised. Orphan prevalence was compared with Demographic and Health Survey (DHS) 2005/2006 data for Harare, and a household-based survey in a neighbouring community. RESULTS: Over 1 year, 1194 new clients (90% female) aged 7 weeks to 16 years were assessed, with 93% of boys and 59% of girls classified clinically as prepubertal. 94% of clients reported penetrative sexual abuse, occurring most often in the child's home. Most perpetrators were identified as relatives or neighbours by children under 12 years, and 'boyfriends' by adolescent girls. At presentation, 31/520 (6%) clients tested were HIV-positive. Where recorded, 39 (6%) clients presented within 3 days of abuse, and 36 were given postexposure prophylaxis for HIV (PEP). Among female clients, orphan prevalence was higher than in the DHS (OR=1.7; 1.4 to 2.2) and neighbouring community (OR=1.7; 0.7 to 4.3). CONCLUSIONS: High numbers of children in Harare experience penetrative sexual abuse, and most present too late for PEP. More immediate presentation of sexual abuse can help to prevent HIV and recurrent abuse, and assist in examination and prosecution. Orphanhood emerged as a possible risk factor for sexual abuse and an important area for further research.

From affected to infected? Orphanhood and HIV risk among female adolescents in urban Zimbabwe.

BACKGROUND: Despite the 15 million children orphaned by AIDS, and fears of sexual vulnerability, little is known about the link between orphanhood and HIV risk. METHODS: A random sample of 1283 15 to 19-year-old girls in a high-density suburb of Harare was identified in a cross-sectional survey in 2004. A total of 863 agreed to be interviewed and 839 provided a specimen for HIV and herpes simplex virus type-2 (HSV-2) testing. Sexual health outcomes, sexual behaviours and marriage were assessed by type and timing of orphanhood. RESULTS: Half of the participants were single or double orphans. Prevalence of HIV and/or HSV-2 was higher among orphans than non-orphans [17 versus 12%; age-adjusted odds ratio (aOR) = 1.5; 95% confidence interval (CI) 1.0-2.3]. Associations with orphan status were only significant among the 743 never-married participants. In comparison with non-orphaned peers, increased sexual risk (defined as HSV2-positive, HIV-positive or ever pregnant) was seen among maternal orphans (aOR = 3.6; 95% CI, 1.7-7.8), double orphans (aOR = 2.4; 95% CI, 1.2-4.9), and girls who lost their father before age 12 (aOR = 2.1; 95% CI, 0.9-4.8) but not later (aOR = 0.8; 95% CI, 0.3-2.2). Maternal and double orphans were most likely to initiate sex early and to have had multiple partners. Maternal orphans were least likely to have used a condom at first sex, and to have a regular sexual partner. Experience of forced sex was high in all groups. CONCLUSIONS: In urban Zimbabwe, female adolescent orphans are at increased risk of HIV and HSV-2 infection. Infection rates vary by type and age of orphanhood, and marital status, and are associated with high-risk sexual behaviours.