Regional variations in contraceptive use in Kenya: comparison of Nyanza, Coast and Central Provinces

This paper analyses the regional variations in contraceptive use between Central, Nyanza and Coast Provinces in Kenya among currently married, fecund women drawn from the 2008-09 Kenya Demographic and Health Survey (KDHS) data. Specifically the study examined the role of socio-economic, cultural and demographic factors in explaining these variations using both bivariate and logistic regression. The analysis confirmed the higher use of contraception in Central compared to Nyanza and Coast. Current use of modern contraceptive methods in Central is 70 percent compared with 39 percent and 37 percent for Nyanza and Coast respectively. The higher contraceptive use in Central is attributed to the better socio-economic and cultural environment compared with the other two provinces. Central Province has very few cases of women with no education, a much lower percentage in the poorest wealth (9.6) category and the highest proportionin monogamous unions (97.1). The higher socio-economic status and better cultural environment has in turn created a favourable environment for the use of contraception through the intervening variables of knowledge on family planning and fertility preferences. The logistic regression results suggest that differences in contraceptive use between the three provinces could be narrowed by increasing the level of education in Coast and overcoming traditional practices such as polygyny in both Nyanza and Coast. Although mortality is still important, its effect has declined. However, the unexpected finding that contraceptive use is higher in rural areas of Central and Nyanza Provinces suggests further research to understand what could be responsible for the reversal

Access and Attitudes to HPV Vaccination amongst Hard-To-Reach Populations in Kenya.

BACKGROUND: Sub-Saharan Africa bears the greatest burden of cervical cancer. Human papillomavirus (HPV) vaccination programmes to prevent the disease will need to reach vulnerable girls who may not be able access health and screening services in the future. We conducted formative research on facilitators and barriers to HPV vaccination and potential acceptability of a future HPV vaccination programme amongst girls living in hard-to-reach populations in Kenya. METHODS: Stakeholder interviews with Ministry of Health staff explored barriers to and support for the uptake of HPV vaccination. A situation assessment was conducted to assess community services in Maasai nomadic pastoralist communities in Kajiado County and in Korogocho informal settlement in Nairobi city, followed by focus group discussions (n=14) and semi-structured interviews (n=28) with health workers, parents, youth, and community and religious leaders. These covered marriage, knowledge of cervical cancer and HPV, factors that might inhibit or support HPV vaccine uptake and intention to accept HPV vaccine if a programme was in place. RESULTS: Reported challenges to an HPV vaccination programme included school absenteeism and drop-out, early age of sex and marriage, lack of parental support, population mobility and distance from services. Despite little prior knowledge of cervical cancer and HPV, communities were interested in receiving HPV vaccination. Adequate social mobilisation and school-based vaccination, supplemented by out-reach activities, were considered important facilitating factors to achieve high coverage. There was some support for a campaign approach to vaccine delivery. CONCLUSIONS: Given the high level of support for a vaccine against cervical cancer and the experience of reaching pastoralist and slum-dwellers for other immunizations, implementing an HPV vaccine programme should be feasible in such hard-to-reach communities. This may require additional delivery strategies in addition to the standard school-based delivery, with vaccine offered at multiple venues, potentially through a campaign approach

The impact of Human Immunodeficiency Virus and Human Papillomavirus Co-Infection on HPV genotype distribution and cervical lesion grade in a semi-urban population in Tigoni, Kenya

http://www.uonbi.ac.ke/journals/kesobap/Background: Cervical cancer, a common cause of death among women, is attributable to human papilloma virus (HPV). Human immunodeficiency virus (HIV) infection can potentially alter the incidence of cervical cancer. Prophylactic HPV vaccines are a major advance against cervical cancer. Epidemiological research on HPV and cervical cancer is therefore justified. Objective: To determine the impact of HIV and HPV co-infection on the HPV genotype distribution and cervical lesion grade in Tigoni, Kenya. Methodology: This was a cross-sectional study. Women aged 25 to 60 years were invited for cervical cancer and HIV screening. HPV typing was done by PCR on residual cervical samples after cytology reporting. Results: Of 438 samples, 140 (31.96%) were positive for at least one type of HPV. The most frequent HPV types were 16, 56, 53, 35, and 39. When co-infection with HIV was examined, 37 (32.5%) were HPV-/HIV+, 63 (19.4%) were HPV+/HIV-, 77 (67.5%) were HPV+/HPV+ (p<0.0001). High risk (HR)-types were the more frequent across all positive samples; HR-HPV+/HIV+ were 43 (37.7%), (p<0.0001). Conclusion: HIV infection was a significant risk factor in HPV infection with 65.5% of cases being both HPV and HIV infected. Over 77% of those individuals who had a CIN III or greater were HPV positive. HR-HPV types were found across all diagnostic categories in the cases that had a cervical tissue biopsy with HPV type 16 being the most dominant type, particularly in high grade lesions

The Impact of Human Immunodeficiency Virus and Human Papillomavirus Co-Infection on HPV Genotype Distribution and Cervical Lesion Grade in a Semi-Urban Population in Tigoni, Kenya

1. IntroductionCervical cancer is an important global public healthproblem and a common cause of death among women,and it is attributable to human papillomavirus (HPV)(Walboomers et al, 1999; Parkin et al, 2008). In a largeseries of invasive cervical cancer from around theworld, HPV-DNA was detected in 99.7% of the tumors,leading to the conclusion that HPV was a necessarycause of cervical cancer (Bosch et al, 1995; Walboomerset al, 1999; Bosch et al, 2007). The identification ofHPV’s role in cervical cancer has led to importantadvances in primary prevention through vaccinationand diagnosis through HPV detection (Stanley et al,2008; Bosch et al, 2008). However, tangible reductionin the incidence of cervical cancer and the impact onglobal public health will probably take decades. As HPVtypes are divergent, efficacy of current vaccines is typerestricted,and therefore development of the nextgeneration of HPV vaccines will require inclusion ofrelevant antigens from several HPV types (Lowy, 2008).Geographical profiling of HPV type distribution will beimportant in making vaccines more relevant for targetpopulations.Most women will be infected with HPV sometime intheir lifetime. Results from large meta-analyses studiesindicate that at any given point in time, 10.4% (95%confidence interval (CI) 10.2-10.7) of womenworldwide are positive for cervical HPV DNA (Bosch etal, 2008). The prevalence of HPV is higher in lessdeveloped regions (13.4%; 95% CI: 13.1-13.7) than inthe more developed regions (8.4%; 95% CI: 8.3-8.6)(Bosch et al, 2008). The same studies indicate thatAfrican women at 22.1% (95% CI: 20.9-23.4) and EastAfrican women in particular, have the highest HPVprevalence rates (31.6%; 95% CI: 29.5-33.8) (Bosch etal, 2008). HPV type 16 is the most common in allcontinents, with an estimated point prevalence of 2.6%(95% CI: 2.5-2.8) worldwide, and HPV type 18 thesecond most frequently detected type (Clifford et al,2005). Regional differences are thought to be related togeographical and immunogenetic factors, such asdefects in cellular immunity through chronic cervicalinflammation, malnutrition and more recently, HIVinfection; Type 16 though appears to be less influencedby immune impairment than other types (Clifford et al,2005).Although many women get infected with HPV, most donot develop cervical cancer. Several co-factors arepostulated to influence the disease process. Thepotential co-factors include exogenous factors such astobacco smoking, hormonal contraceptives, and coinfectionswith other sexually transmitted infections(Munoz et al, 2006). In addition, viral co-factors, suchspecific HPV types, viral load, and viral integration, aswell as host co-factors such as endogenous hormones,genetic factors, and factors related to the immuneresponse may variably influence the course of HPVinfection (Munoz et al, 2006).Women with HIV infection have been shown to be morelikely not only to have a concurrent HPV infection butalso to have an increased risk for a high grade cervicalsquamous intraepithelial lesion (La Ruche et al, 1998;Temmerman et al, 1999; Womack et al, 2000; Baay et al,2004; Hawes et al, 2006; Didelot-Rousseau et al, 2006;Ngándwe et al, 2007). HPV is the commonest sexuallytransmitted infection, with more than 75% of sexuallyactive adults acquiring one or more genotypes in theirlifetime (Bosch et al, 2008). However, by age 30 years,most women clear the infection due to an effective cellmediatedimmune response, and only a small numberthereafter are diagnosed with a HPV-associated lesion(Schiffman, 1992). It is thought that it is through itseffect on CD4+ cells and regulation of immuneresponses to a variety of antigens that HIV attenuatesthe systemic response to HPV (Palefsky, 2006).The prevalence of HIV among adult Kenyan women was13% in 2003 with trends reported to have decreased to5.1% by 2006 (KDHS, 2003). The high prevalence ofHIV may increase the incidence of cervical pre-cancerand potentially, of cervical cancer. Gichangi et al (2002),however, demonstrated that a two to three-foldincrease in HIV prevalence did not translate to aproportionate increment in incidence of cervical cancer.They hypothesized that HIV-infected women die fromHIV-related opportunistic infections before theydevelop invasive cervical cancer. The mean survivaltime for women with HIV in 2008 was reported to be 5years (Yamada et al, 2008) while typically more than 10years elapse before the development of cervical cancerafter HPV infection. Yamada et al (2008) also advancedthe possibility that sub-clinical cervical cancer may bemissed in many women dying prematurely from AIDSrelatedopportunistic infections.This study was carried out to establish whether the coinfectionof HIV and HPV has an influence on HPVgenotype distribution and on the prevalence and gradeof cervical neoplasia

The Impact of Human Immunodeficiency Virus and Human Papillomavirus Co-Infection on HPV Genotype Distribution and Cervical Lesion Grade in a Semi-Urban Population in Tigoni, Kenya

1. IntroductionCervical cancer is an important global public healthproblem and a common cause of death among women,and it is attributable to human papillomavirus (HPV)(Walboomers et al, 1999; Parkin et al, 2008). In a largeseries of invasive cervical cancer from around theworld, HPV-DNA was detected in 99.7% of the tumors,leading to the conclusion that HPV was a necessarycause of cervical cancer (Bosch et al, 1995; Walboomerset al, 1999; Bosch et al, 2007). The identification ofHPV’s role in cervical cancer has led to importantadvances in primary prevention through vaccinationand diagnosis through HPV detection (Stanley et al,2008; Bosch et al, 2008). However, tangible reductionin the incidence of cervical cancer and the impact onglobal public health will probably take decades. As HPVtypes are divergent, efficacy of current vaccines is typerestricted,and therefore development of the nextgeneration of HPV vaccines will require inclusion ofrelevant antigens from several HPV types (Lowy, 2008).Geographical profiling of HPV type distribution will beimportant in making vaccines more relevant for targetpopulations.Most women will be infected with HPV sometime intheir lifetime. Results from large meta-analyses studiesindicate that at any given point in time, 10.4% (95%confidence interval (CI) 10.2-10.7) of womenworldwide are positive for cervical HPV DNA (Bosch etal, 2008). The prevalence of HPV is higher in lessdeveloped regions (13.4%; 95% CI: 13.1-13.7) than inthe more developed regions (8.4%; 95% CI: 8.3-8.6)(Bosch et al, 2008). The same studies indicate thatAfrican women at 22.1% (95% CI: 20.9-23.4) and EastAfrican women in particular, have the highest HPVprevalence rates (31.6%; 95% CI: 29.5-33.8) (Bosch etal, 2008). HPV type 16 is the most common in allcontinents, with an estimated point prevalence of 2.6%(95% CI: 2.5-2.8) worldwide, and HPV type 18 thesecond most frequently detected type (Clifford et al,2005). Regional differences are thought to be related togeographical and immunogenetic factors, such asdefects in cellular immunity through chronic cervicalinflammation, malnutrition and more recently, HIVinfection; Type 16 though appears to be less influencedby immune impairment than other types (Clifford et al,2005).Although many women get infected with HPV, most donot develop cervical cancer. Several co-factors arepostulated to influence the disease process. Thepotential co-factors include exogenous factors such astobacco smoking, hormonal contraceptives, and coinfectionswith other sexually transmitted infections(Munoz et al, 2006). In addition, viral co-factors, suchspecific HPV types, viral load, and viral integration, aswell as host co-factors such as endogenous hormones,genetic factors, and factors related to the immuneresponse may variably influence the course of HPVinfection (Munoz et al, 2006).Women with HIV infection have been shown to be morelikely not only to have a concurrent HPV infection butalso to have an increased risk for a high grade cervicalsquamous intraepithelial lesion (La Ruche et al, 1998;Temmerman et al, 1999; Womack et al, 2000; Baay et al,2004; Hawes et al, 2006; Didelot-Rousseau et al, 2006;Ngándwe et al, 2007). HPV is the commonest sexuallytransmitted infection, with more than 75% of sexuallyactive adults acquiring one or more genotypes in theirlifetime (Bosch et al, 2008). However, by age 30 years,most women clear the infection due to an effective cellmediatedimmune response, and only a small numberthereafter are diagnosed with a HPV-associated lesion(Schiffman, 1992). It is thought that it is through itseffect on CD4+ cells and regulation of immuneresponses to a variety of antigens that HIV attenuatesthe systemic response to HPV (Palefsky, 2006).The prevalence of HIV among adult Kenyan women was13% in 2003 with trends reported to have decreased to5.1% by 2006 (KDHS, 2003). The high prevalence ofHIV may increase the incidence of cervical pre-cancerand potentially, of cervical cancer. Gichangi et al (2002),however, demonstrated that a two to three-foldincrease in HIV prevalence did not translate to aproportionate increment in incidence of cervical cancer.They hypothesized that HIV-infected women die fromHIV-related opportunistic infections before theydevelop invasive cervical cancer. The mean survivaltime for women with HIV in 2008 was reported to be 5years (Yamada et al, 2008) while typically more than 10years elapse before the development of cervical cancerafter HPV infection. Yamada et al (2008) also advancedthe possibility that sub-clinical cervical cancer may bemissed in many women dying prematurely from AIDSrelatedopportunistic infections.This study was carried out to establish whether the coinfectionof HIV and HPV has an influence on HPVgenotype distribution and on the prevalence and gradeof cervical neoplasia

Regional variations in contraceptive use in Kenya: comparison of Nyanza, Coast and Central Provinces

This paper analyses the regional variations in contraceptive use between Central, Nyanza and Coast Provinces in Kenya among currently married, fecund women drawn from the 2008-09 Kenya Demographic and Health Survey (KDHS) data. Specifically the study examined the role of socio-economic, cultural and demographic factors in explaining these variations using both bivariate and logistic regression. The analysis confirmed the higher use of contraception in Central compared to Nyanza and Coast. Current use of modern contraceptive methods in Central is 70 percent compared with 39 percent and 37 percent for Nyanza and Coast respectively. The higher contraceptive use in Central is attributed to the better socio-economic and cultural environment compared with the other two provinces. Central Province has very few cases of women with no education, a much lower percentage in the poorest wealth (9.6) category and the highest proportion in monogamous unions (97.1). The higher socio-economic status and better cultural environment has in turn created a favourable environment for the use of contraception through the intervening variables of knowledge on family planning and fertility preferences. The logistic regression results suggest that differences in contraceptive use between the three provinces could be narrowed by increasing the level of education in Coast and overcoming traditional practices such as polygyny in both Nyanza and Coast. Although mortality is still important, its effect has declined. However, the unexpected finding that contraceptive use is higher in rural areas of Central and Nyanza Provinces suggests further research to understand what could be responsible for the reversal

Long-Acting Reversible Contraception Uptake and Associated Factors among Women of Reproductive Age in Rural Kenya

In the last two decades, the use of short-acting methods of contraception has driven the increase of contraceptive use in Kenya. We assessed the factors associated with uptake of long-acting reversible contraception by women seeking family planning services in public health facilities in Kakamega County, Kenya. A mixed methods cross-sectional study through client exit surveys among 423 women seeking family planning services was done at 12 public health facilities in Kakamega County. Twelve in-depth interviews with health care providers from the study facilities further explored practices in provision of long-acting reversible contraception (LARC). Among women initiating contraceptive use, LARC method utilization was 20.6%. Women’s tertiary education level, Protestant Christian religion, age at first birth, and having no desire for more children were significantly associated with utilization of LARC. Structural factors including shortage of human resource, provider bias and lack of adequate skills on provision of services were identified as key barriers to uptake of long-acting reversible contraception services.</jats:p

Long-Acting Reversible Contraception Uptake and Associated Factors among Women of Reproductive Age in Rural Kenya

In the last two decades, the use of short-acting methods of contraception has driven the increase of contraceptive use in Kenya. We assessed the factors associated with uptake of long-acting reversible contraception by women seeking family planning services in public health facilities in Kakamega County, Kenya. A mixed methods cross-sectional study through client exit surveys among 423 women seeking family planning services was done at 12 public health facilities in Kakamega County. Twelve in-depth interviews with health care providers from the study facilities further explored practices in provision of long-acting reversible contraception (LARC). Among women initiating contraceptive use, LARC method utilization was 20.6%. Women&#8217;s tertiary education level, Protestant Christian religion, age at first birth, and having no desire for more children were significantly associated with utilization of LARC. Structural factors including shortage of human resource, provider bias and lack of adequate skills on provision of services were identified as key barriers to uptake of long-acting reversible contraception services