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Globally, depressive symptoms among pregnant and postpartum (i.e., perinatal) women living with HIV (WLWH) are alarmingly high and associated with poor outcomes such as suboptimal adherence to antiretroviral therapy (ART), and early cessation of exclusive breastfeeding (EBF). Few qualitative studies have described the experience of perinatal depression among WLWH to identify the underlying social-structural determinants of poor mental health and potential strategies to intervene. We conducted a longitudinal qualitative study applying semi-structured interviews with 30 WLWH at three timepoints (28–38 weeks pregnant, 6-weeks postpartum and 5–7 months postpartum) to understand mental health experiences of perinatal WLWH in western Kenya. Financial insecurity emerged as the central theme impacting the mental health of women across time. Financial insecurity was often attributed to the loss of employment, related to pregnancy and the demands of breastfeeding and caring for an infant, as well as a lack of support from male partners. The loss of income and subsequent financial strain contributed to worsening levels of food insecurity and relationship stress and challenged engagement in HIV care. In this way, increased financial strain during the perinatal period negatively impacted the mental health of perinatal WLWH. Our findings suggest support to meet basic needs and remain engaged in HIV care during pregnancy and postpartum could improve perinatal mental health for WLWH in this setting.

Background Conditional cash transfers (CCTs) have been shown to improve retention in HIV care while they are provided, but their long-term effectiveness remains uncertain and effects may be time-limited, with cessation resulting in HIV care engagement deterioration. We explored CCT experiences, perceptions, and effects after cessation to investigate potential mechanisms of this observation and better understand the psychological mechanisms behind CCTs. Methods This qualitative study was nested within a larger trial, AdaPT-R (NCT02338739), focused on HIV care engagement in western Kenya. A subset of participants were purposively sampled from AdaPT-R participants: adults with HIV who had recently started ART, received CCTs for one year, completed one year of follow-up without missing a clinic visit, and were randomized to either continue or discontinue CCTs for one more year of follow-up. In-depth interviews were conducted by an experienced qualitative researcher using a semi-structed guide within a month of randomization. Interviews were conducted in the participants’ preferred language (Dholuo, Kiswahili, English). Data on patient characteristics, randomization dates, and clinic visit dates to determine care lapses were extracted from the AdaPT-R database. A codebook was developed deductively based on the guide and inductively refined based on initial transcripts. Transcripts were coded using Dedoose software, and thematic saturation was identified. Results Of 38 participants, 15 (39%) continued receiving incentives, while 23 (61%) were discontinued from receiving incentives. Half were female ( N  = 19), median age was 30 years (range: 19–48), and about three-quarters were married or living with partners. Both groups expressed high intrinsic motivation to engage in care, prioritized clinic attendance regardless of CCTs,and felt the incentives expanded their decision-making options. Despite high motivation, some participants reported that cessation of the CCTs affected their ability to access care, especially those with constrained financial situations. Participants also expressed concerns that incentives might foster dependency. Conclusions CCTs do not appear to exert their effects through motivation, but instead act through creating opportunities for better care engagement. This study helps us better understand the durability of financial incentives for HIV care engagement and support the idea that careful consideration be exercised when implementing incentives for sustainable engagement effects.

Timely diagnosis of infant HIV infection is essential for antiretroviral therapy (ART) initiation. In a randomized controlled trial, we found the Texting Improves Testing (TextIT) intervention (a theory-based text messaging system) to be efficacious for improving infant HIV testing rates and maternal retention in prevention of mother-to-child HIV transmission (PMTCT) programs. Using an implementation science approach, we aimed to evaluate real-world effectiveness of the intervention. In a pragmatic, cluster-randomized, stepped-wedge trial with 2 time periods of observation, we randomly allocated 10 clinics to begin implementing the intervention immediately and 10 clinics to begin implementing 6 months later. To approximate real-world conditions, inclusion criteria were broad. Women at clinics implementing the intervention received up to 14 text messages during pregnancy and after delivery and had the option to respond to text messages, call, or send inquiry text messages to a designated clinic phone. The primary outcomes were infant HIV testing and maternal retention in care during the first 8 weeks after delivery. We used modified Poisson regression with robust variance estimation to estimate the relative risk and 95% confidence intervals (CIs). Generalized estimating equations were applied on individual-level data to account for clustering by site. Between February 2015 and December 2016, 4,681 women were assessed for study participation, and 2,515 were included. Participant characteristics at enrollment did not differ by study arm. Overall median age was 27 years (interquartile range [IQR] 23-30), median gestational age was 30 weeks (IQR 28-34), 99% were receiving ART, and 87% who enrolled during intervention phases owned a phone. Of 2,326 infants analyzed, 1,466 of 1,613 (90.9%) in the intervention group and 609 of 713 (85.4%) in the control group met the primary outcome of HIV virologic testing performed before 8 weeks after birth (adjusted relative risk [aRR] 1.03; 95% CI 0.97-1.10; P = 0.3). Of 2,472 women analyzed, 1,548 of 1,725 (90%) in the intervention group and 571 of 747 (76%) in the control group met the primary outcome of retention in care during the first 8 weeks after delivery (aRR 1.12; 95% CI 0.97-1.30; P = 0.1). This study had two main limitations. Staff at all facilities were aware of ongoing observation, which may have contributed to increased rates of infant HIV testing and maternal retention in care at both intervention and control facilities, and programmatic initiatives to improve maternal and infant retention in care were ongoing at all facilities at the time of this study, which likely limited the ability to demonstrate effectiveness of the trial intervention. In this study, a larger proportion of infants in the intervention group received HIV testing compared with the control group, but the difference was small and not statistically significant. There was also a nonsignificant increase in maternal postpartum retention in the intervention periods. Despite the lack of a significant effect of the intervention, key lessons emerged, both for strengthening PMTCT and for implementation research in general. Perhaps most important, improving the implementation of usual care may have been sufficient to substantially improve infant HIV testing rates. ClinicalTrials.gov Trial Number NCT02350140.

Background Option B+ is a comprehensive antiretroviral treatment (ART) designed for HIV-infected pregnant/ postpartum women. However, barriers to implementing Option B+ and establishing long-term ART adherence while facilitating retention in prevention of mother to child transmission of HIV (PMTCT) services remain. Community-based mentor mothers (cMMs) who can provide home-based support for PMTCT services may address some of the barriers to successful adoption and retention in Option B+. Thus, we evaluated the acceptability of using cMMs as home-based support for PMTCT services. Methods Gender-matched in-depth interviews were conducted between September–November 2014 for HIV-infected pregnant/postpartum women and their male partners living in southwestern Kenya ( n  = 40); additionally, we conducted four focus groups involving 30 health workers ( n  = 70) within four health facilities. Audio-recordings were transcribed, translated, and then coded using a thematic analytical approach in which data were deductively and inductively coded with support from prior literature, identified themes within the interview guides, and emerging themes from the transcripts utilizing Dedoose software. Results Overall, the study results suggest high acceptability of cMMs among individual participants and health workers. Stigma reduction, improvement of utilization of health care services, as well as ART adherence were most frequently discussed potential benefits of cMMs. Participants pictured a cMM as someone acting as a role model and confidant, and who was over 30 years old. Many respondents raised concerns about breaches of confidentiality and inadvertent disclosure. Respondent suggestions to overcome these issues included the cMM working in different communities than where she lives and attending home-visits with no identifying clothing as an HIV-related health worker. Conclusions The home-based cMM approach may be a beneficial and acceptable strategy for promoting ART adherence and retention within PMTCT services for pregnant/postpartum women living with HIV. Considering the risks of inadvertent disclosure of HIV-infected status and related negative consequences for pregnant/postpartum women living with HIV, similar cMM program designs may benefit from recognizing and addressing these risks. Trial registration The MOTIVATE! study was registered on July 7, 2015 at the ClinicalTrials.gov ( NCT02491177 ).

Background Factors influencing fertility desires among HIV-infected individuals remain poorly understood. With new recommendations for universal HIV treatment and increasing antiretroviral therapy (ART) access, we sought to evaluate how access to early ART influences fertility desires among HIV-infected ART-naïve women. Methods Semi-structured in-depth interviews were conducted with a select subgroup of 20 HIV-infected ART-naïve women attending one of 13 HIV facilities in western Kenya between July and August 2014 who would soon newly become eligible to initiate ART based on the latest national policy recommendations. The interviews covered four major themes: 1) definitions of family and children’s role in community; 2) personal, interpersonal, institutional, and societal factors influencing fertility desires; 3) influence of HIV-positive status on fertility desires; and 4) influence of future ART initiation on fertility desires. An iterative process of reading transcripts, applying inductive codes, and comparing and contrasting codes was used to identify convergent and divergent themes. Results The women indicated their HIV-positive status did influence—largely negatively—their fertility desires. Furthermore, initiating ART and anticipating improved health status did not necessarily translate to increased fertility desires. Instead, individual factors, such as age, parity, current health status, financial resources and number of surviving or HIV-infected children, played a crucial role in decisions about future fertility. In addition, societal influences, such as community norms and health providers’ expectations of their fertility desires, played an equally important role in determining fertility desires. Conclusions Initiating ART may not be the leading factor influencing fertility desires among previously ART-naïve HIV-infected women. Instead, individual and societal factors appear to be the major determinants of fertility desires among these women.

IntroductionInnovative interventions are needed to improve HIV outcomes among adolescents and young adults (AYAs) living with HIV. Engaging AYAs in intervention development could increase effectiveness and youth acceptance, yet research is limited. We applied human-centred design (HCD) to refine adherence-support interventions pretrial and assessed HCD workshop acceptability.MethodsWe applied an iterative, four-phased HCD process in Kenya that included: (1) systematic review of extant knowledge, (2) prioritisation of design challenges, (3) a co-creation workshop and (4) translation tables to pair insights with trial intervention adaptations. The co-creation workshop was co-led by youth facilitators employing participatory activities to inform intervention adaptations. Iterative data analysis included rapid thematic analysis of visualised workshop outputs and notes using affinity mapping and dialogue to identify key themes. We conducted a survey to assess workshop acceptability among participants.ResultsTwenty-two participants engaged in the 4-day workshop. Co-creation activities yielded recommendations for improving planned interventions (eg, message frequency and content; strategies to engage hard-to-reach participants), critical principles to employ across interventions (eg, personalisation, AYA empowerment) and identification of unanticipated AYA HIV treatment priorities (eg, drug holidays, transition from adolescent to adult services). We revised intervention content, peer navigator training materials and study inclusion criteria in response to findings. The youth-led HCD workshop was highly acceptable to participants.ConclusionsResearch employing HCD among youth can improve interventions preimplementation through empathy, youth-led inquiry and real-time problem solving. Peer navigation may be most influential in improving retention when engagement with young people is based on mutual trust, respect, privacy and extends beyond HIV-specific support. Identifying opportunities for personalisation and adaptation within intervention delivery is important for AYAs. Patient engagement interventions that target young people should prioritise improved transition between youth and adult services, youth HIV status disclosure, AYA empowerment and healthcare worker responsiveness in interactions and episodic adherence interruptions.

Exclusive breastfeeding for the first 6 months and continued breastfeeding for 24 months or longer is recommended for all mothers world-wide, including women living with HIV (WLWH). Given evidence of suboptimal infant feeding and the need to understand context specific barriers, we explored experiences of perinatal WLWH in Kisumu, Kenya. We applied a longitudinal qualitative approach (4 in-depth interviews) with 30 women from pregnancy to 14–18 months postpartum. Cross-sectional profiling led to a narrative description of infant feeding across time. The majority of women breastfed exclusively for 6 months and weaned by 18 months. Severe financial and food insecurity were primary challenges as women worked through when/how to breastfeed or stop breastfeeding in the setting of multiple competing priorities/pressures across time. Financial and food support and increased support for breastfeeding beyond 18 months have the potential to reduce women’s stress and uncertainty associated with infant feeding as well as optimize infant health and nutrition in this setting.

Safer conception strategies can prevent HIV transmission between HIV-discordant partners while allowing them to conceive. However, HIV care providers in sub-Saharan Africa report they are not trained in safer conception, and patients are not routinely offered safer conception services. This mixed-methods pilot study evaluated the impact, acceptability, and feasibility of a novel Safer Conception Counseling Toolkit among providers and patients in Kenya. We enrolled 20 HIV-positive women, 10 HIV-discordant couples, and 10 providers from HIV care and treatment clinics. Providers completed questionnaires before/after training, and then counseled HIV-affected patients. Change in patient knowledge was assessed before/after counseling. Qualitative interviews were conducted among providers and patients. The Toolkit was associated with large, significant increases in patient knowledge, and provider confidence, knowledge, and favorable attitudes toward safer conception counseling; 20% felt confident before versus 100% after training (p < 0.01).

Current WHO guidelines recommend lifelong antiretroviral therapy (ART) for all HIV-positive individuals, including pregnant and breastfeeding women (Option B+) in settings with generalized HIV epidemics. While Option B+ is scaled-up in Kenya, insufficient adherence and retention to care could undermine the expected positive impact of Option B+. To explore challenges to the provision of Option B+ at the health facility level, we conducted forty individual gender-matched in-depth interviews with HIV-positive pregnant/postpartum women and their male partners, and four focus groups with thirty health care providers at four health facilities in western Kenya between September-November 2014. Transcripts were coded with the Dedoose software using a coding framework based on the literature, topics from interview guides, and emerging themes from transcripts. Excerpts from broad codes were then fine-coded using an inductive approach. Three major themes emerged: 1) Option B+ specific challenges (same-day initiation into treatment, health care providers unconvinced of the benefits of Option B+, insufficient training); 2) facility resource constraints (staff and drug shortages, long queues, space limitations); and 3) lack of client-friendly services (scolding of patients, inconvenient operating hours, lack of integration of services, administrative requirements). This study highlights important challenges at the health facility level related to Option B+ rollout in western Kenya. Addressing these specific challenges may increase linkage, retention and adherence to life-long ART treatment for pregnant HIV-positive women in Kenya, contribute towards elimination of mother-to-child HIV transmission, and improve maternal and child outcomes. Les directives actuelles de l’OMS recommandent une thérapie antirétrovirale permanente (ART) pour tous les individus séropositifs, y compris les femmes enceintes et allaintantes (Option Bþ) dans les environnements où l’épidémie de VIH est généralisée. Alors que l’Option Bþest renforcée au Kenya, un recours insuffisant aux soins, et le manque de leur maintien pourraient déstabiliser l’impact positif attendu de l’Option Bþ. Afin d’explorer les défis posés par la dispositin de l’Option Bþau niveau des établissements de santé, nous avons réalisé quarante entretiens individuels approfondis appariés auj genre auprès de femmes enceintes/postpartum séropositives et de leurs partenaires masculins, et organisé quatre groupes de discussion comprenant trente prestataires de soins dans quatre établissements de santé du Kenya occidental entre Septembre et Novembre 2014. Les transcriptions ont été codées à l’aide du logiciel Dedoose utilisant un système de codification basé sur les publications, les sujets tirés des guides des’entretiens, et les thèmes émergeant des notes. Des extraits de codes généraux ont alors été codés finement par ’une approche inductive. Trois thèmes majeurs ont émergé: 1) Défis spécifiques de l’Option Bþ(démarrage du traitement le jour même, prestataires de soins de santé peu convaincus des avantages de l’Option Bþ, formation insuffisante); 2) obstables aux ressources des établissements (pénurie de personnel et de médicaments, longues files d’attente, manque d’espace); 3) manque de services accueillants (réprimande des parents, horaires de fonctionnement peu pratiques, manque d’intégration des services, exigences administratives). Cette étude met l’accent sur les défis importants à relever au niveau des établissements de santé en matière de déploiement de l’Option Bþdans le Kenya occidental. Faire face à ces défis spécifiques peut favoriser le lien, l’adhésion et le maintien d’un traitement ART permanent pour les femmes enceintes séropositives au Kenya, contribuant ainsi à l’élimination de la transmission mère-enfant du VIH, et à l’amélioration des résultats maternels et infantiles. 现行WHO指南建议HIV阳性者终生接受抗逆转录病毒治疗 （ART）, 在HIV普遍流行地区, 妊娠和哺乳妇女也接受治疗 （B+选项）。虽然肯尼亚推广了B+选项, 但治疗依从性和续 检不足会削弱预期的效果。为了探讨卫生机构提供B+选项的 困难, 我们于2014年9月至11月在肯尼亚西部对HIV阳性孕产 妇及其男性伴侣进行了40次性别匹配的深度访谈, 并在四个卫 生机构对30位卫生服务提供者进行了四次焦点小组讨论。记 录采用Dedoose软件编码, 根据文献建立编码框架, 从访谈指 导中获取主题, 以及记录中反复出现的主题。采用归纳法, 对 宽泛编码中摘取的片段进行更细的编码。出现的三大主题 是： 1） B+选项特有的困难 （当天开始治疗、卫生服务提供 者不确信B+选项有益、培训不足）； 2）机构资源限制 （人 员和药物短缺、候诊人数多、空间有限）； 3）缺少对患者友 好的服务 （责骂患者、操作时间不便、服务未整合、行政要 求） 。本研究凸显了在肯尼亚西部, 与推行B+选项相关的卫 生机构层面的重要挑战。应对这些挑战可提高肯尼亚HIV阳 性孕妇对终生ART治疗的初检、续检和依从, 有利于消除HIV 母婴传播, 改善孕产妇和儿童健康。 Las pautas actuales de la OMS recomiendan la terapia antirretroviral (TAR) a lo largo de toda la vida para todas los individuos VIH-positivos, incluyendo las mujeres embarazadas y lactantes (Opción B+) en entornos con epidemias generalizadas de VIH. Si bien la Opción B+ ha sido implementada a escala en Kenia, la insuficiente adherencia y retención en el cuidado podrían debilitar el impacto positivo esperado de la Opción B+. Para explorar los desafíos a la provisión de la Opción B+ a nivel de la instalación de salud, llevamos a cabo cuarenta entrevistas individuales en profundidad con mujeres VIH-positivas embarazadas/postparto y sus parejas masculinas, y cuatro grupos focales con treinta proveedores de cuidado de la salud en cuatro instalaciones de salud en el oeste de Kenia entre septiembre y noviembre de 2014. Las transcripciones se codificaron con el software Dedoose usando un marco de codificación basado en la literatura, guías de temas de las entrevistas y temas emergentes de las transcripciones. Los extractos de los códigos amplios fueron codificados con precisión mediante un enfoque inductivo. Surgieron tres temas principales: 1) desafíos específicos a la Opción B+(iniciación del tratamiento el mismo día, proveedores de cuidado de la salud no convencidos de los beneficios de la Opción B+, formación insuficiente); 2) limitaciones de recursos de la instalación (escasez de personal y medicamentos, largas filas, limitaciones de espacio); y 3) falta de servicios amigables con el cliente (reprimendas de los pacientes, horarios de funcionamiento inconvenientes, falta de integración de servicios, requisitos administrativos). Este estudio destaca desafíos importantes a nivel de los establecimientos de salud relacionados con la Opción B+ implementada en el oeste de Kenia. Abordar estos desafíos específicos puede aumentar la vinculación, la retención y la adherencia al tratamiento de TAR para toda la vida de las mujeres embarazadas VIH-positivas en Kenia, contribuir a la eliminación de la transmisión del VIH de madre a hijo y mejorar los resultados maternos e infantiles.

Introduction To develop a patient‐centred financial incentive delivery strategy to improve antiretroviral treatment adherence in adolescents and young adults (AYA) living with HIV in Kisumu, Kenya, we conducted a mixed methods study exploring preferences. Methods A discrete choice experiment (DCE) and focus group discussion (FGD) were conducted simultaneously to identify preferences for five incentive delivery strategy features: value, eligibility, recipient, format and disbursement frequency. We used consecutive sampling to recruit AYA (14–24 years) living with HIV attending three health facilities in Kisumu, Kenya. We calculated mean preferences, willingness to trade, latent class membership and predictors of latent class membership. The FGD explored preferred incentive features, and, after deductive and inductive coding, qualitative findings were triangulated with DCE results. Results Two hundred and seven AYA living with HIV (46% 14–17 years, 54% 18–24 years; 33% male sex, 89% viral load <50 copies/ml) were recruited to the study (28 October–16 November 2020). Two distinct preference phenotypes emerged from the DCE analysis (N = 199), 44.8% of the population fell into an “immediate reward” group, who wanted higher value cash or mobile money distributed at each clinic visit, and 55.2% fell into a “moderate spender” group, who were willing to accept lower value incentives in the form of cash or shopping vouchers, and accrued payments. The immediate reward group were willing to trade up to 200 Kenyan Shillings (KSH)—approximately 2 US dollars (USD)—of their 500 KSH (∼5 USD) incentive to get monthly as opposed to accrued yearly payments. The strongest predictor of latent class membership was age (RR 1.45; 95% CI: 1.08–1.95; p = 0.006). Qualitative data highlighted the unique needs of those attending boarding school and confirmed an overwhelming preference for cash incentives which appeared to provide the greatest versatility for use. Conclusions Providing small financial incentives as cash was well‐aligned with AYA preferences in this setting. AYA should additionally be offered a choice of other incentive delivery features (such as mobile money, recipient and disbursement frequency) to optimally align with the specific needs of their age group and life stage.