Nyanza Reproductive Health Society

To continue working during menses, female sex workers (FSW) may use unhygienic absorbents to hide their menstrual status. The menstrual disc may provide a solution. Little is known about men's knowledge and views, specifically around sex during menstruation with FSW, a population who are particularly vulnerable to violence which may be heightened during menses. To identify constructs for successful and safe menstrual disc implementation we sought to identify knowledge and attitudes towards menstruation among male clients of FSW, including views on FSW menstrual disc use during intercourse. We conducted six focus group discussions comprising a total of 51 male clients of FSW, in Kisumu, Kenya, exploring their perceptions of menses and sex during menses. In preparation for future implementation of a menstrual disc intervention, we introduced the disc to participants with an information session, answering their questions and gathering their opinions on it. Thematic analysis found most clients had limited or inaccurate knowledge about menstruation, viewing blood and the menstruator, as dirty or unclean. Sources of knowledge included school, female relatives/partners, community or church. Those reporting formal education described the biological processes more accurately, while church education lent towards stigmatized perceptions. Most participants expressed negative views towards sex during menses (i.e., unpleasurable, forbidden or risky), usually stemming from misconceptions, and reported seeking FSW services because their wife / girlfriend was menstruating. Many felt deceived if a FSW was menstruating, were often aware of materials placed vaginally to absorb blood, but generally continued with the service. No clients had prior knowledge of the menstrual disc but accepted it as a safe, hygienic, and cost-effective alternative, with some voicing interest to purchase for their wife / girlfriend. We conclude there is a need to provide accurate information on menstruation to boys and men including in school curricula and faith teaching to address lack of knowledge and negativity. These findings suggest potential for adoption of menstrual discs by FSW with minimal adverse client reaction, and highlight possible partner support for women considering adopting a menstrual disc.

IntroductionThe COVID-19 pandemic caused school closures, which intensified the negative sexual and reproductive health (SRH) of adolescent girls in sub-Saharan Africa (SSA), including increases in transactional sexual partnerships, gender-based violence, risk of early pregnancy and sexually transmitted infections (STIs). We conducted a qualitative study to understand how adolescent girls experienced and reacted to the pandemic restrictions and perceived consequences on their schooling and sexual behaviours. In parallel, we sought community men’s perceptions and opinions on the same issues.MethodsSet in rural western Kenya, the study used six focus group discussions with adolescent girls and five with community males aged 19–41 years, conducted from June 2022 to January 2023.ResultsThematic analysis identified three key themes, parallel in girls and men: (1) impacts of COVID-19 on schooling: girls reported uncertainty around ever returning to education, consequently losing motivation to study, which was also observed by men; (2) drivers that increased sexual activity: transactional sex became a greater necessity due to acute poverty, while opportunity escalated through additional leisure time and (3) sexual behaviours and practices: girls increased the number of partners and frequency of sexual encounters, with power-imbalances reported. Men believed they were assisting girls through transactional sex but this was often conditional on receiving sex in return, viewing themselves as victims of girls’ seductive advances, and blaming girls for transmitting STIs.ConclusionSchool closure jeopardised girls’ SRH through acute poverty and increased opportunity for sexual exposure. Mitigation methods are needed now to prevent girls bearing the brunt of ensuing societal disruption and acute poverty in future catastrophes. Deeper understanding of men’s attitudes and behaviours towards adolescent girls are needed to improve the foundation for working with them to reduce power imbalance and compulsion in sexual interactions with adolescent girls.

IntroductionMillions of women worldwide annually undergo manual vacuum aspiration (MVA) with no pain medication, which is a violation of their basic human dignity. We designed a novel device (Chloe SED®) to administer paracervical block (PCB) during MVA in countries where pain medication is not typically given due to the high cost of the necessary tools.MethodsWe conducted a single-blinded, randomized controlled non-inferiority trial including 61 patients at two hospitals in Kisumu, Kenya, to validate Chloe SED® for administration of PCB during MVA. PCB administered with Chloe SED® was compared to PCB administered with a standard spinal needle. Patients requiring MVA were block randomized in blocks of six, each provider completing six PCBs—three with the Chloe SED® and three with the standard spinal needle. The trial was registered with the Kenya Pharmacy and Poisons Board, ECCT/19/03/01 (https://ctr.pharmacyboardkenya.org/applications/index/protocol_no:RUNDVC8xOS8wMy8wMQ__/filter:/investigator:/sites:/pages:5/start_date:/end_date:/disease_condition:/users:/ercs:/stages). An intention-to-treat analysis was completed. The primary outcome was the non-inferiority of the pain score during uterine evacuation with a non-inferiority margin of 2 points on an 11-point numerical rating scale. Secondary outcomes included the non-inferiority of the pain score at four other time points and patient satisfaction.ResultsChloe SED® showed non-inferiority of the primary outcome with a mean pain score during evacuation of 3.8 [90% confidence interval (CI): 3.1–4.6] compared with the spinal needle at 4.1 (90% CI: 3.5–4.7). Non-inferiority of the pain score was shown at all time points. Most patients expressed a desire for the continued use of the device to administer PCB for MVA. No adverse events were noted.ConclusionIn summary, the Chloe SED® appears non-inferior to the spinal needle and desirable for the administration of PCB during MVA.

Kenya, like many countries, shuttered schools during COVID-19, with subsequent increases in poor mental health, sexual activity, and pregnancy. We sought to understand how the COVID-19 pandemic may mediate risk of reproductive tract infections. We hypothesized that greater COVID-19 related stress would mediate risk via mental health, feeling safe inside the home, and sexual exposure, given the pandemic mitigation-related impacts of school closures on these factors. We analyzed data from a cohort of 436 girls enrolled in secondary school in rural western Kenya. Baseline, 6-, 12-, and 18- month study visits occurred April 2018 - December 2019 (pre-COVID), and 30-, 36-, and 48- month study visits occurred September 2020 - July 2022 (COVID period). At study visits, participants self-completed a survey for sociodemographics and sexual practices, and provided self-collected vaginal swabs for Bacterial vaginosis (BV) testing, with STI testing at annual visits. COVID-related stress was measured with a standardized scale and dichotomized at highest quartile. Mixed effects modeling quantified how BV and STI changed over time, and longitudinal mediation analysis quantified how the relationship between COVID-19 stress and increased BV was mediated. BV and STI prevalence increased from 12.1% and 10.7% pre-COVID to 24.5% and 18.1% during COVID, respectively. This equated to a 26% (95% CI 1.00 - 1.59) and 36% (95% CI 0.98 - 1.88) increased relative prevalence of BV and STIs, respectively, in the COVID-19 period compared to pre-COVID, adjusted for numerous sociodemographic and behavioral factors. Higher COVID-related stress was associated with elevated depressive symptoms and feeling less safe inside the home, which were each associated with increased likelihood of having a boyfriend. In longitudinal mediation analyses, the direct effect of COVID-related stress on BV was small and non-significant, indicating increased BV was due to the constellation of factors that were impacted during the COVID-pandemic. In this cohort of adolescent girls, BV and STIs increased following COVID-related school closures. These results highlight modifiable factors to help maintain sexual and reproductive health resiliency, such as anticipating and mitigating mental health impacts, domestic safety concerns, and maintaining sexual health services to prevent and treat reproductive tract infections.

BackgroundPenile microbiome composition has been associated with HSV-2 and HIV in men and with bacterial vaginosis (BV) and HSV-2 in female sex partners. This study sought to 1) characterize penile microbiome composition over a 1-year period and 2) identify factors associated with penile microbiome composition over time.MethodsThis prospective study of community-recruited heterosexual couples in Kenya measured penile and vaginal microbiomes via 16S ribosomal RNA gene amplicon sequencing at 4 time points over 1 year (1, 6, and 12 months after baseline). We used longitudinal mixed-effects modeling to assess associated demographic, behavioral, and disease factors and changes in community type, meatal taxa with the highest mean relative abundance, and alpha and beta diversity measures. We estimated group-based trajectories to elucidate compositional trends.ResultsAmong 218 men with 740 observations, men had a median age of 26 years, 11.6% were living with HIV, and 46.1% were HSV-2 seropositive. We identified 7 penile community types that varied with circumcision status, female partner vaginal microbiome community state type (CST), condom use, and penile washing. Across varying analytic approaches, 50%–60% of men had stable penile microbiome compositions. Alpha diversity measures were lower for circumcised men and those who reported condom use; they were stable over time but higher if female partners had diverse CSTs or BV. BV was positively associated with the relative abundance of numerous individual penile taxa. The decreased Bray–Curtis similarity was more common for men with HSV-2, and HSV-2 was also associated with a lower relative abundance of Corynebacterium and Staphylococcus.ConclusionsOver a 1-year period, penile microbiome composition was stable for a substantial proportion of men and was influenced by men’s circumcision status, sexual practices, female partner’s vaginal CST and BV status, and men’s HSV-2 status. In the female genital tract, a diverse CST is often associated with poorer health outcomes. Our results contribute toward understanding whether this framework extends to the penile microbiome and whether diversity and the associated penile microbiome compositions influence susceptibility or resilience to poorer health outcomes in men. Focusing on understanding how these factors influence the penile microbiome may lead to therapeutic avenues for reduced HSV-2 and BV infections in men and their female sex partners.

HIV prevention method preferences were evaluated among Kenyan men who have sex with men (MSM) and transgender women (TW) from three sites: Kisumu, Nairobi and the Coast. Information sessions detailing the attributes, duration of protection, route of administration and probable visibility were attended by 464 HIV negative participants, of whom 423 (median age: 24 years) agreed to be interviewed. Across pairwise comparisons daily PrEP was by far the least preferred (1%); quarterly injections (26%) and monthly pills (23%) were most preferred, followed by yearly implant (19%) and condoms (12%). When participants were "forced" to choose their most preferred PrEP option, only 10 (2.4%) chose the daily pill; more (37.1%) chose the quarterly injection than the monthly pill (34.8%) and the yearly implant (25.8%). TW preferred the yearly implant over the quarterly injection. To achieve the rates of PrEP uptake and adherence necessary for protecting large proportions of vulnerable MSM and TW, a variety of long-acting products should be developed and made accessible to appeal to a diversity of preferences.

Gay and bisexual men and other men who have sex with men (GBMSM) experience many sexual orientation-related stressors that negatively influence physical and mental health, making it imperative to understand their experiences of resilience-promoting resources such as social support. We utilized qualitative and participatory methodologies to examine sources of social support and types of social support received by GBMSM in Western Kenya through in-depth interviews with 60 GBMSM, including both peer educators and community members. GBMSM received emotional, informational, and instrumental support from six different relationship types: friends and peer groups, family of origin, sexual and romantic partners, healthcare providers, peer educators, and other people including work colleagues and police officers. A key finding from this study is the centrality of sexuality-specific support across all sources and types of support. Implications for clinics and LGBTQ organizations, policy, and future research are discussed.

Background:Schistosoma mansoni infection is hyperendemic in Lake Victoria communities and associated with cervicovaginal immune alterations and HIV acquisition. We assessed the hypothesis that schistosomiasis correlates with greater rectal inflammation in men who have sex with men (MSM) in Kisumu, Kenya. Methods: In this cross-sectional study of 38 HIV-negative MSM aged 18-35years, schistosomiasis was diagnosed by urine circulating cathodic antigen (CCA). Microbiome was assessed in rectal swabs by 16S rRNA gene amplicon sequencing, and rectal inflammation by quartile normalized summative score of inflammatory cytokines (IL-1α, IL-1β, IL-8, and TNF-α). Elastic net (EN) regression identified taxa associated with inflammation. Multivariable linear regression estimated the association between inflammation score and schistosomiasis and bacteria identified in EN. Results: Most men were CCA positive (24/38; 63%), and median rectal inflammation score was significantly higher in these participants (11 vs. 8, p = 0.04). In multivariable regression, CCA-positive men had 2.85-point greater inflammation score (p = 0.009). The relative abundance of Succinivibrio (coefficient = -1.13, p = 0.002) and Pseudomonas (coefficient = -1.04, p = 0.001) were negatively associated with inflammation. Discussion: CCA positivity was associated with rectal mucosal inflammation, controlling for rectal microbiome composition. Given its high prevalence and contribution to inflammation, schistosomiasis may have important implications for HIV transmission in this vulnerable population.

BackgroundMSM are disproportionately affected by HIV and STIs compared to men who have sex with women (MSWomen). This may be due in part to different burden of mucosal inflammation. We compared penile microbial composition between MSM and MSWomen and association with mucosal inflammation.MethodsIn this cross-sectional study, we enrolled 43 MSM and 43 MSWomen, who were HIV negative and matched on age and circumcision status. The penile microbiome was assessed via meatal swab, with 16S rRNA gene amplicon sequencing. Urinary cytokine concentrations (TNF-α/IL-1β/IL-8/IL-10/IP-10) were measured using Luminex. Random Forest (RF) identified genus-level taxa differing between MSM and MSWomen. Taxa from RF were regressed on cytokine outcomes, with multiple testing correction and information criterion model selection.ResultsMen were median age 24 and 77% circumcised. There were substantial differences in educational attainment, employment, alcohol and drug use, condom use, and number of sexual partners, with MSM having greater behavioral risks. Microbiome composition differed markedly between MSM and MSWomen: RF discriminated between MSM and MSWomen with 84% accuracy. Taxa with greatest discriminating influence were Lactobacillus, Anaerococcus, and Staphylococcus. In crude analysis, cytokines TNF-α/IP-10/IL-10 were elevated among MSWomen (p<0.05, each); IL-8 did not differ by group; IL-1β was higher among MSM (p=0.03). Cytokine concentration increased in response to Corynebacterium (IL-8/TNF-α/IP-10/IL-1β), Gardnerella (IL-8/IP-10/IL-1β), Veillonella (IL-8/IP-10/IL-1β), and Peptoniphilus (IL-8/IL-1β). Microbiome composition did not account for the difference in TNF-α, IP-10, or IL-10 between groups; the difference in IL-1β became non-significant after accounting for taxa. Among MSWomen, IL-1β (p=0.01) and IL-8 (p=0.05) were elevated if the female partner had BV.ConclusionTo our knowledge, this is the first comparison between MSM and MSWomen of penile microbiome and urinary cytokines. Future studies should examine whether microbiome and mucosal inflammation differences between MSM and MSWomen cause differential risk of HIV/STI acquisition or differential impact on efficacy of HIV/STI interventions.DisclosureNo significant relationships.

ObjectivesIn settings where laboratory capacity is limited, the WHO recommends presumptive treatment for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) in asymptomatic men who have sex with men (MSM) at high risk for these infections. However, little is known about how best to target this intervention. We aimed to identify correlates of anorectal NG/CT infection in Kenyan MSM with and without anorectal symptoms and evaluate the performance of an empirical, model-based risk score to identify cases in asymptomatic men.MethodsAnorectal NG/CT infections were diagnosed by the Abbott RealTime NG/CT nucleic acid amplification testamong 698 MSM at enrolment into the Anza Mapema study. Multivariable logistic regression was used to identify correlates of anorectal NG/CT infection in men with and without anorectal symptoms. Using coefficients from the final multivariable model for asymptomatic men, we calculated a risk score for each participant. Risk score performance was determined by calculating the sensitivity, specificity and number needed to treat (NNT) to identify one NG/CT infection.ResultsOverall anorectal NG/CT infection prevalence was 5.2% (n=36), of which 58.3% (n=21) were asymptomatic. Factors associated with anorectal NG/CT infection in asymptomatic men were aged 18–24 years (aOR=7.6; 95% CI: 1.7 to 33.2), HIV positive serostatus (aOR=6.9; 95% CI: 2.2 to 21.6) and unprotected anal sex in the past 3 months (aOR=3.8; 95% CI: 1.2 to 11.9). Sensitivity and specificity were optimal (81.0% and 66.1%, respectively) at a model-derived risk score cut-point ≥3, and the NNT was 12.ConclusionsA model-derived risk score based on correlates of anorectal NG/CT infection in asymptomatic participants would be sensitive and efficient (i.e, low NNT) for targeting presumptive treatment. If validated in other settings, this risk score could improve on the WHO algorithm and help reduce the burden of asymptomatic anorectal NG/CT infections among MSM in settings where diagnostic testing is not available.