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Background: HIV drug resistance (DR) mutations can compromise antiretroviral therapy (ART) success among children living with HIV (CLHIV). We conducted a secondary analysis using data from a randomized control trial for ART monitoring among CLHIV in Kisumu County, Kenya from 2019 to 2023, to assess clinical, psychosocial, and structural factors associated with HIV DR. Methods: 704 CLHIV were followed for 12+ months, with characteristics captured at enrollment and follow-up visits in the “parent” randomized-controlled-trial (of point-of-care plasma viral load testing and for viremias ≥ 1000 copies/mL HIV genotyping for DR vs. standard-of-care) and an observational “extension” substudy (of participants on a dolutegravir-containing ART with genotyping performed on viremic specimens ≥ 200 copies/mL). A multivariate modified Poisson regression model was used to analyze factors associated with sequences yielding a Stanford HIVDR database DR penalty score (DR-PS) ≥ 30 to a nucleos(t)ides and/or non-nucleoside reverse transcriptase inhibitor, protease inhibitor (PI), and/or integrase inhibitor (INSTI). Results: Among 113 (16.1%) participants who underwent genotyping, 93 (82.3%) had a DR-PS ≥ 30. DR-PS ≥ 30 were associated with age 1–5 years (adjusted risk ratio (ARR) = 1.84; 95% confidence interval (CI): 1.07, 3.14), history of viremia ≥ 1000 copies/mL (ARR = 4.18; 95% CI: 2.77, 6.31), prescription of a PI- (ARR = 6.05; 95% CI: 3.43, 10.68) or INSTI-containing regimen (ARR = 1.83; 95% CI: 1.08, 3.11), poor adherence to ART (ARR = 1.91; 95% CI: 1.32, 2.76), lack of caregiver confidence in ART administration (ARR = 1.89; 95% CI: 1.11, 3.22), and mid-sized clinic populations (ARR = 0.55; 95% CI: 0.33, 0.92). Conclusion: Addressing social factors associated with DR-PS ≥ 30 may improve ART success among CLHIV.

Consumption of and trade in wild meat could result in infectious pathogen spillover into human populations. Such spillovers could propagate into sustained outbreaks in major cities where human aggregations potentially catalyze their spread. A better understanding of how urban wild meat value chains operate could assist in mitigating spillover events. We used key informant interviews and literature review to understand the structure and operations, actors, their practices, and health risk perceptions along a wild meat value chain supplying a rapidly urbanizing city in Africa, the Nairobi Metropolitan Area (NMA). The value chain operates via three main nodes: harvester, trader, and consumer nodes. We found wild meat to be harvested from peri-urban areas of the NMA, consumed or sold locally, or supplied to distant urban markets. Actors reported increased participation along the value chain during the dry season, and over the Christmas period. The value chain operated informally, creating a ‘rules in use’ framework focusing on sanction avoidance, while ignoring food safety concerns. Consequently, respondents reported slaughtering wild animals on the bare ground, handling wild meat with unwashed hands and uncleaned utensils. No value chain actors reported wearing personal protective equipment when handling wild meat. At the distant markets’ trader node where wild meat was sold as livestock meat, meat vendors engaged in similar unsafe practices. Actors had limited awareness of the specific health risks from wild meat. We speculate that the observed limited health risk awareness, and sanction avoidance attempts promotes unsafe practices during exploitation of wild animals for food, income and for medicinal purposes. Multisectoral efforts at the conservation and public health nexus, as well as community education on the potential health risks from wild meat are key in reducing potential spillovers.

Increasing HIV drug resistance (DR) among children with HIV (CHIV) on antiretroviral treatment (ART) is concerning. CHIV ages 1–14 years enrolled from March 2019 to December 2020 from five facilities in Kisumu County, Kenya, were included. Children were randomized 1:1 to control (standard-of-care) or intervention (point-of-care viral load (POC VL) testing every three months with targeted genotypic drug resistance testing (DRT) for virologic failure (VF) (≥1000 copies/mL)). A multidisciplinary committee reviewed CHIV with DRT results and offered treatment recommendations. We describe DR mutations and present logistic regression models to identify factors associated with clinically significant DR. We enrolled 704 children in the study; the median age was 9 years (interquartile range (IQR) 7, 12), 344 (49%) were female, and the median time on ART was 5 years (IQR 3, 8). During the study period, 106 (15%) children had DRT results (84 intervention and 22 control). DRT detected mutations associated with DR in all participants tested, with 93 (88%) having major mutations, including 51 (54%) with dual-class resistance. A history of VF in the prior 2 years (adjusted odds ratio (aOR) 11.1; 95% confidence interval (CI) 6.3, 20.0) and less than 2 years on ART at enrollment (aOR 2.2; 95% CI 1.1, 4.4) were associated with increased odds of major DR. DR is highly prevalent among CHIV on ART with VF in Kenya. Factors associated with drug resistance may be used to determine which children should be prioritized for DRT.

Introduction Lack of viral suppression (VS) among pregnant and breastfeeding women living with HIV poses challenges for maternal and infant health, and viral load (VL) monitoring via centralized laboratory systems faces many barriers. We aimed to determine the impact of point‐of‐care (POC) VL and targeted drug resistance mutation (DRM) testing in improving VS among pregnant and postpartum women on antiretroviral therapy. Methods We conducted a pre/post‐intervention prospective cohort study among 820 pregnant women accessing HIV care at five public‐sector facilities in western Kenya from 2019 to 2022. The pre‐intervention or “control” group consisted of standard‐of‐care (SOC) centralized VL testing every 6 months and the post‐intervention or “intervention” group consisted of a combined strategy of POC VL every 3 months, targeted DRM testing, and clinical management support. The primary outcome was VS (VL ≤1000 copies/ml) at 6 months postpartum; secondary outcomes included uptake and turnaround times for VL testing and sustained VS. Results At 6 months postpartum, 321/328 (98%) of participants in the intervention group and 339/347 (98%) in the control group achieved VS (aRR 1.00, 95% confidence interval [CI] 0.98, 1.02). When assessing VS using a threshold of <40 copies/ml, VS proportions were lower overall (90−91%) but remained similar between groups. Among women with viraemia (VL>1000 copies/ml) who underwent successful DRM testing in the intervention group, all (46/46, 100%) had some DRMs and 20 (43%) had major DRMs (of which 80% were nucleos(t)ide reverse transcriptase inhibitor mutations). POC VL testing uptake was high (>89%) throughout pregnancy, delivery, and postpartum periods, with a median turnaround time of 1 day (IQR 1, 4) for POC VL in the intervention group and 7 days (IQR 5, 9) for SOC VL in the control group. Sustained VS throughout follow‐up was similar between groups with either POC or SOC VL testing (90−91% for <1000 copies/ml, 62–70% for <40 copies/ml). Conclusions Our combined strategy markedly decreased turnaround time but did not increase VS rates, which were already very high, or sustained VS among pregnant and postpartum women living with HIV. Further research on how best to utilize POC VL and DRM testing is needed to optimize sustained VS among this population.