LVCT Health

BackgroundLess than 10% of pregnant women in Sub Saharan Africa achieve the World Health Organization recommended eight antenatal care (ANC) contacts for optimal pregnancy management. Robust strategies that involve community outreach programmes, integrated service delivery and continuity of care could help improve ANC uptake and quality. Kenya, as other countries, has promoted use of digital health records at the community and facility levels to improve quality and access to data and promote continuity of care. These records, however, are not always linked and access to data does not guarantee its use to drive quality improvement. C-it-DU-it (pronounced “See it, Do it”) is a two-arm pragmatic cluster-randomised trial set in Homabay County, Kenya. The trial will implement digital linkage of community and facility electronic patient data (control arm) and assess the impact of having quality improvement teams reviewing and acting on the linked data (intervention arm). While several areas are captured in the community health records, we will focus on uptake of ANC services as a lens.MethodsEighteen healthcare facilities (clusters) will be randomly allocated to either the control or intervention arms at a ratio of 1:1. A data linkage module will be deployed in all clusters, enabling digital referral of pregnant women between the community and health facilities. In each intervention cluster, work improvement teams will be established and trained on reviewing these electronic ANC data, identifying problems, developing and deploying context-specific solutions to these problems and evaluating the impact of their interventions. ANC data will be extracted for 1,440 recruited pregnant women. The primary outcome will be the proportion of pregnant women with at least eight ANC contacts. Secondary outcomes will be ANC uptake before 16 weeks gestation, adverse pregnancy outcomes, uptake of required investigations, medication and skilled birth attendance.DiscussionThis trial intends to generate evidence on the benefit of community work improvement teams to review and act on linked digital data to develop and deploy solutions to local problems. This strategy, if successful, will promote antenatal service uptake and quality resulting in improved pregnancy outcomes and progress towards sustainable development goals if appropriately scaled up.Clinical Trial Registration: https://clinicaltrials.gov/study/NCT05929586, identifier NCT05929586.

The right to development, an inherent human right for all, emphasizes that all individuals and communities have the right to participate in, contribute to, and benefit from development that ensures the full realization of human rights. In Kenya, where a significant portion of the population faces poverty and vulnerability to climate change, access to rights-based needs such as clean water, healthcare, and education still remains a critical challenge. This study explored the implementation of a Human Rights-Based approach to community development through a Public–Private Development Partnership model (PPDP), with a focus on alleviating poverty and improving access to rights-based services at the community level in Narok and Nakuru counties. The research aimed to identify critical success factors for scaling the PPDP model and explore its effects on socio-economic empowerment. The study employed a mixed-methods approach for data collection, using questionnaires to obtain quantitative data, focus group discussions, and key informant interviews with community members, local leaders, and stakeholders to gather qualitative data. We cleaned and analyzed all our data in R (version 4.4.3) and used the chi-square to establish the significance of differences between areas where the PPDP model was implemented and control areas where it was not. Results reveal that communities with the PPDP model experienced statistically significant improvements in employment, income levels, and access to rights-based services compared to control areas. The outcomes underscore the potential of the PPDP model to address inclusive and sustainable development. This study therefore proposes a scalable pathway beginning with access to rights-based needs, followed by improved service delivery, and culminating in economic empowerment. These findings offer valuable insights for governments, development practitioners, investment agencies, and researchers seeking community-driven developments in similar socio-economic contexts across Africa. For the first time, it can be adopted in the design and implementation of development projects in rural and local communities across Africa bringing into focus the need to integrate rights-based needs at the core of the project.

IntroductionHIV incidence remains high among women in Africa, especially adolescent girls and young women (AGYW), despite existing oral pre‐exposure prophylaxis (PrEP) programmes. With expanding biomedical prevention options, understanding PrEP use patterns when women are offered choice can inform HIV prevention programming in Africa.MethodsThe CATALYST study offers informed PrEP choice through an enhanced service delivery package for women in 27 public health sites across Kenya, Lesotho, South Africa, Uganda, and Zimbabwe. Women attending sites who were HIV negative and interested in learning about HIV prevention were eligible. We describe uptake and use among those offered choice between oral PrEP and the monthly dapivirine ring from May 2023 through July 2024, explore factors associated with method choice using logistic regression, describe reasons for choice and assess time until PrEP discontinuation using survival analysis.ResultsOf 3967 participants, 44.9% were AGYW (15−24 years), 25.5% were sex workers, and 12.2% and 8.7% were breastfeeding and/or pregnant, respectively. At enrolment, 66.2% chose oral PrEP, 29.9% chose the dapivirine ring and 3.5% chose no method. Common reasons for choosing oral PrEP were ease of use (58.6%) and efficacy (31.7%); the ring was chosen due to ease of use (56.9%) and not needing to swallow pills (53.0%). In multivariable analysis, participants ≤ 24 years (p = 0.007) and participants who were pregnant (p = 0.002) or breastfeeding (p < 0.001) had lower odds of choosing the ring. Month 1 return was 32.7% for oral PrEP and 55.2% for the ring. Ring users reported higher adherence as compared to oral PrEP users (p < 0.001). Of participants returning for ≥ 1 PrEP refills, 12.1% switched methods at least once. Median time until PrEP discontinuation was 95 days (95% CI: 91, 110) for those choosing oral PrEP at enrolment and 169 days (95% CI: 139, 190) for those choosing the ring. Risk of discontinuation was greater for participants choosing oral PrEP at enrolment (p < 0.001) and those ≤ 24 years (p < 0.001), PrEP naïve at enrolment (p < 0.001) or not currently using contraception (p = 0.03).ConclusionsWe demonstrated that women took advantage of PrEP choice. PrEP use varied by product, with 1 month return and method continuation higher for the ring. AGYW had a greater risk of discontinuing either method, suggesting more support is needed.

HIVR4P 2024, the 5th HIV Research for Prevention Conference, took place in Lima, Peru, 6-10 October 2024. The conference focused on new developments in HIV prevention from basic research to new product development and implementation science. Sessions were assigned to one of five tracks: basic science; pre-exposure prophylaxis (PrEP) and antiretroviral (ARV)-based prevention; vaccines and broadly neutralizing antibodies (bNAbs); applied and implementation science; and other prevention modalities and cross-cutting issues. A team of rapporteurs covered each track and identified conference highlights. Strategies to elicit bNAb responses by vaccination are advancing to clinical trials, while combination bNAbs show promise as an alternative to ARV-based products. There is promising diversity in the PrEP product pipeline and twice-yearly lenacapavir has demonstrated exceptional efficacy, but barriers to widespread access and implementation remain, compounded by new challenges from the significant policy changes and funding reductions of the new US administration. Innovative ways of delivering PrEP to vulnerable communities that could benefit are being explored and, in some cases, have been successfully implemented. Choice in HIV prevention products and differentiated delivery models that enable clients to select options that meet their preferences and changing needs is essential. Additionally, the involvement of the community throughout the design, implementation and dissemination process is necessary to maximize the impact of HIV prevention. Ensuring equitable access in a rapidly changing context will involve policy changes, partnerships with local organizations and addressing social determinants that impact health outcomes. We are in an era with more tools than ever before to prevent HIV acquisition; now, we need to facilitate collaborations between diverse stakeholders, including researchers, community members, policymakers, healthcare providers and funders. The future of HIV prevention should lie in a holistic approach that respects individual choice, enhances service accessibility and is flexible to meet evolving challenges and opportunities. However, policy changes since the conference ended have profoundly altered the HIV prevention landscape and threaten the advances described in this report.

Infectious diseases remain a significant public health challenge in low- and middle-income countries (LMICs), with HIV, tuberculosis (TB), and malaria contributing significantly to morbidity and mortality. Community Health Workers (CHWs) play a pivotal role in addressing these diseases, yet evidence on the costs and cost-effectiveness of CHW-led interventions remains fragmented. We performed a scoping review, searching ten databases and the grey literature for original studies published between August 2015 and July 2024. Recognized search terms related to "Community Health Workers" and "Economic Evaluation(s)" in LMICs were utilized. Covidence software was employed to screen studies based on inclusion and exclusion criteria. Data on study methodology, costs and cost-related outcomes were then extracted, tabulated in a data-extraction form, and analysed using Microsoft Excel. Thirty-three studies representing 106 scenarios were included, predominantly from sub-Saharan Africa (61%). Over half the scenarios provide evidence about malaria (n = 59), followed by HIV (n = 31) and TB (n = 24). CHWs performed diverse roles, including delivering preventive education, case finding, diagnosis, treatment adherence support, counselling and referrals. The majority demonstrated that CHW programs were cost-effective compared to alternative service delivery models, most commonly facility-based care. These programs were particularly effective in improving treatment adherence and targeting high-priority populations. Costs per beneficiary ranged widely, from $1.20 to $26,556. This review highlights significant heterogeneity in methodologies and reporting, impeding comprehensive comparisons. Future research should emphasize standardized reporting, assess affordability, explore integrated CHW roles across multiple disease groups, and focus on generating evidence that supports priority-setting and resource allocation at the health system level.

Urbanization is rapidly increasing across Africa, including in Nairobi, Kenya. Many people, recent migrants and long-term residents, live within dense and dynamic urban informal settlements. These contexts are fluid and heterogeneous, and deepening the understanding of how vulnerabilities and marginalization are experienced is important to inform pointed action, service delivery and policy priorities. The aim of this paper is to explore vulnerabilities and marginalization within Korogocho and Viwandani informal settlements in Nairobi and generate lessons on the value of a spectrum of community based participatory research approaches for understanding health and well-being needs and pinpointing appropriate interventions. In the exploratory stages of our ARISE consortium research, we worked with co-researchers to use the following methods: social mapping, governance diaries, and photo voice. Social mapping (including the use of Focus Group Discussions) identified key vulnerable groups: marginalized and precarious child heads of households (CHHs), Persons with disability who face multiple discrimination and health challenges, and often isolated older adults; and their priority needs, including health, education, water and sanitation. The governance diaries generated an understanding of the perceptions of the particularly vulnerable and marginalized informal settlement residents regarding the various people and institutions with the power to influence health and wellbeing; while photo voice highlighted the lived experiences of vulnerability and marginality. Understanding and responding to fluid and intersecting marginalities and vulnerabilities within growing urban informal settlements is particularly critical to achieving inclusive urbanization, where no one is left behind, a theme central to the Sustainable Development Goals and Kenya's Vision 2030.

BackgroundMicroarray patches (MAPs), a novel drug delivery system, are being developed for HIV pre-exposure prophylaxis (PrEP) delivery and as a multipurpose prevention technology (MPT) to protect from both HIV and unintended pregnancy. Prevention technologies must meet the needs of target audiences, be acceptable, easy to use, and fit health system requirements.MethodologyWe explored perceptions about MAP technology and assessed usability, hypothetical acceptability, and potential programmatic fit of MAP prototypes using focus group discussions (FGD), usability exercises, and key informant interviews (KII) among key populations in Kiambu County, Kenya. Adolescent girls and young women (AGYW), female sex workers (FSW), and men who have sex with men (MSM) assessed the usability and acceptability of a MAP prototype. Male partners of AGYW/FSW assessed MAP acceptability as partners of likely users. We analyzed data using NVivo, applying an inductive approach. Health service providers and policymakers assessed programmatic fit. Usability exercise participants applied a no-drug, no-microneedle MAP prototype and assessed MAP features.ResultsWe implemented 10 FGD (4 AGYW; 2 FSW; 2 MSM; 2 male partners); 47 mock use exercises (19 AGYW; 9 FSW; 8 MSM; 11 HSP); and 6 policymaker KII. Participants reported high interest in MAPs due to discreet and easy use, long-term protection, and potential for self-administration. MAP size and duration of protection were key characteristics influencing acceptability. Most AGYW preferred the MPT MAP over an HIV PrEP-only MAP. FSW saw value in both MAP indications and voiced need for MPTs that protect from other infections. Preferred duration of protection was 1–3 months. Some participants would accept a larger MAP if it provided longer protection. Participants suggested revisions to the feedback indicator to improve confidence. Policymakers described the MPT MAP as “killing two birds with one stone,” in addressing AGYW needs for both HIV protection and contraception. An MPT MAP is aligned with Kenya's policy of integrating health care programs.ConclusionsMAPs for HIV PrEP and as an MPT both were acceptable across participant groups. Some groups valued an MPT MAP over an HIV PrEP MAP. Prototype refinements will improve usability and confidence.