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ARV‐based HIV prevention methods available in pill, gel or ring formulations (broadly referred to as microbicides) offer the possibility of protection against HIV for women who find it difficult because they cannot ask their partners to use condoms or even refuse sex. Partial efficacy of ARV‐based medications has been demonstrated in a number of clinical trials around the world among various populations, building the evidence that ARV‐based technologies will contribute to reducing the AIDS epidemic worldwide. Disappointing results, however, from two trials in sub‐Saharan Africa, where poor adherence contributed to study closure due to futility, have raised questions about whether women at the centre of the epidemic are able to effectively use products that require routine use. Also, there are fears by some of risk compensation by decreased condom use because of the availability of microbicides when only partial efficacy has been demonstrated in microbicide trials to date. Of note, sub‐analyses of biologic measures of adherence in trials where this was possible have shown a strong correlation between good adherence and efficacy, reinforcing the necessity of good adherence. Research conducted in conjunction with clinical trials and post‐trials in advance of possible rollout of ARV‐based products have examined social and cultural factors, gender‐related and otherwise, influencing adherence and other aspects of women's use of products. These include HIV stigma, women's perception of risk, partner and community influences and the differing needs of women in various stages of life and in different circumstances. It is the purpose of this supplement to give voice to the needs of women who can benefit from woman‐initiated methods by presenting research results and commentary to contribute to the global conversation about optimizing women's experience with ARV‐based prevention.

The effective functioning of a research ethics committee (REC) can be evaluated using self-assessment tools. The Middle East Research Ethics Training Initiative (MERETI) tool can be used by one member, typically the Chair, to score an REC. The consistency of these scores across several members of an REC has never been evaluated. This study examined whether results would be consistent irrespective of who conducts the assessment. One REC's effective functioning was assessed by several members ( n = 13). The Chair's scores were compared with scores of other members in relation to their duration of REC membership, research ethics training, gender, and employer's institutional affiliation to the REC. The Chair's overall score was higher than the other members' scores by 11%. No significant differences in scores were obtained in relation to duration of REC membership ( p = .72), interval since last research ethics training ( p = .94), and gender ( p = .27). The MERETI tool is thus consistent irrespective of who performs the assessment.

BACKGROUND: We sought to understand the beliefs, social norms and logistical factors that affect human papillomavirus (HPV)-positive women's uptake of cryotherapy treatment as part of a two-part cervical cancer screening strategy in rural Kenya. METHODS: In-depth interviews within a parent cluster-randomised trial. SETTING: Government-run county hospital in western Kenya. PARTICIPANTS: 273 of 372 (73.4%) HPV-positive women who underwent cryotherapy RESULTS: Many women feared that an HPV infection meant they would develop cancer. Almost all women reported initial fear of the treatment procedure, followed by a more positive experience than anticipated. Lacking funds for transportation to the treatment site was the most common barrier. Women felt that decentralised treatment would be the most important facilitator of greater access. Spousal encouragement and financial support were key facilitators of treatment access, however many women felt that other husbands in the community would not be supportive. Women described successfully acquiring treatment as empowering, and almost all would recommend seeking cryotherapy to other women who test HPV-positive. Most felt eager to share their own experiences with others to encourage treatment. CONCLUSIONS: The main facilitators of treatment access were understanding of the health risks and sense of empowerment. A decentralised treatment model or transportation support may facilitate access, along with improved health messaging about HPV infection, cancer and the treatment process. Focusing on women's personal feelings of empowerment may further improve uptake and satisfaction. These data will be used to design a strategy to improve linkage to treatment. TRIAL REGISTRATION: NCT02124252.

Background: We sought to understand the beliefs, social norms and logistical factors that affect human papillomavirus (HPV)-positive women's uptake of cryotherapy treatment as part of a two-part cervical cancer screening strategy in rural Kenya. Methods: In-depth interviews within a parent cluster-randomised trial. Setting: Government-run county hospital in western Kenya. Participants: 273 of 372 (73.4%) HPV-positive women who underwent cryotherapy Results: Many women feared that an HPV infection meant they would develop cancer. Almost all women reported initial fear of the treatment procedure, followed by a more positive experience than anticipated. Lacking funds for transportation to the treatment site was the most common barrier. Women felt that decentralised treatment would be the most important facilitator of greater access. Spousal encouragement and financial support were key facilitators of treatment access, however many women felt that other husbands in the community would not be supportive. Women described successfully acquiring treatment as empowering, and almost all would recommend seeking cryotherapy to other women who test HPV-positive. Most felt eager to share their own experiences with others to encourage treatment. Conclusions: The main facilitators of treatment access were understanding of the health risks and sense of empowerment. A decentralised treatment model or transportation support may facilitate access, along with improved health messaging about HPV infection, cancer and the treatment process. Focusing on women's personal feelings of empowerment may further improve uptake and satisfaction. These data will be used to design a strategy to improve linkage to treatment.

ObjectiveThroughout most of sub-Saharan Africa (SSA), prevention of mother-to-child transmission (PMTCT) services are readily available. However, PMTCT programs in SSA have had suboptimal performance compared to other regions of the world. The main objective of this study is to explore the socio-ecological and individual factors influencing the utilization of PMTCT services among HIV-positive pregnant women in western Kenya using a social ecological model as our analytical lens.MethodsData were collected using in-depth interviews with 33 HIV-infected women attending government health facilities in rural western Kenya. Women with HIV-infected infants aged between 6 weeks to 6 months with a definitive diagnosis of HIV in the infant, as well as those with an HIV-negative test result in the infant were interviewed between November 2012 and June 2013. Coding and analysis of the transcripts followed grounded theory tenets. Coding reports were discussed in a series of meetings held among the authors. We then employed constant comparative analysis to discover dominant individual, family, society and structural determinants of PMTCT use.ResultsBarriers to women's utilization of PMTCT services fell within the broad constructs of the socio-ecological model of individual, family, society and structural determinants. Several themes cut across the different steps of PMTCT cascade and relate to different constructs of the socio-ecological model. These themes include: self-motivation, confidence and resilience, family support, absence or reduced stigma, right provider attitude and quality of health services provided. We also found out that these factors ensured enhanced maternal health and HIV negative children.ConclusionThe findings of this study suggest that a woman's social environment is an important determinant of MTCT. PMTCT Interventions must comprehensively address multiple factors across the different ecological levels. More research is however required for the development of multi-component interventions that combine strategies at different ecological levels.

Throughout most of sub-Saharan Africa (SSA), prevention of mother-to-child transmission (PMTCT) services are readily available. However, PMTCT programs in SSA have had suboptimal performance compared to other regions of the world. The main objective of this study is to explore the socio-ecological and individual factors influencing the utilization of PMTCT services among HIV-positive pregnant women in western Kenya using a social ecological model as our analytical lens. Data were collected using in-depth interviews with 33 HIV-infected women attending government health facilities in rural western Kenya. Women with HIV-infected infants aged between 6 weeks to 6 months with a definitive diagnosis of HIV in the infant, as well as those with an HIV-negative test result in the infant were interviewed between November 2012 and June 2013. Coding and analysis of the transcripts followed grounded theory tenets. Coding reports were discussed in a series of meetings held among the authors. We then employed constant comparative analysis to discover dominant individual, family, society and structural determinants of PMTCT use. Barriers to women's utilization of PMTCT services fell within the broad constructs of the socio-ecological model of individual, family, society and structural determinants. Several themes cut across the different steps of PMTCT cascade and relate to different constructs of the socio-ecological model. These themes include: self-motivation, confidence and resilience, family support, absence or reduced stigma, right provider attitude and quality of health services provided. We also found out that these factors ensured enhanced maternal health and HIV negative children. The findings of this study suggest that a woman's social environment is an important determinant of MTCT. PMTCT Interventions must comprehensively address multiple factors across the different ecological levels. More research is however required for the development of multi-component interventions that combine strategies at different ...

BackgroundApproximately one in every five adolescent girls in Kenya has either had a live birth or is pregnant with her first child. There is an urgent need to understand the language and symbols used to represent adolescent pregnancy, if the current trend in adolescent pregnancy is to be reversed. Agreement on the definition of a societal problem is an important precursor to a social issue's political prioritization and priority setting.MethodsWe apply the Public Arenas Model to appraise the environments, definitions, competition dynamics, principles of selection and current actors involved in problem-solving and prioritizing adolescent pregnancy as a policy issue. Using a focused ethnographic approach, we undertook semi-structured interviews with 14 members of adolescent sexual reproductive health networks at the national level and conducted thematic analysis of the interviews.FindingsWe found that existing definitions center around adolescent pregnancy as a "disease" that needs prevention and treatment, socially deviant behaviour that requires individual agency, and a national social concern that drains public resources and therefore needs to be regulated. These competing definitions contribute to the rarity of the topic achieving traction within the political agenda and contribute to conflicting solutions, such as lowering the legal age of consenting to sex, while limiting access to contraceptive information and services to minors.ConclusionThis paper provides a timely theoretical approach to draw attention to the different competing definitions and subsequent divergent interpretations of the problem of adolescent pregnancy in Kenya. Adolescent reproductive health stakeholders need to be familiar with the existing definitions and deliberately reframe this important social problem for better political prioritization and resource allocation. We recommend a definition of adolescent pregnancy that cuts across different arenas, and leverages already existing dominant and concurrent social and economic issues that are already on the agenda table.

IntroductionAvoiding unintended pregnancies is important for the health of adolescents living with HIV and has the additional benefit of preventing potential vertical HIV transmission. Health facility providers represent an untapped resource in understanding the barriers and facilitators adolescents living with HIV face when accessing contraception. By understanding these barriers and facilitators to contraceptive use among adolescent females living with HIV, this study aimed to understand how best to promote contraception within this marginalized population.MethodsWe conducted structured in‐depth interviews with 40 providers at 21 Family AIDS Care & Education Services ‐ supported clinics in Homabay, Kisumu and Migori counties in western Kenya from July to August 2014. Our interview guide explored the providers' perspectives on contraceptive service provision to adolescent females living with HIV with the following specific domains: contraception screening and counselling, service provision, commodity security and clinic structure. Transcripts from the interviews were analyzed using inductive content analysis.ResultsAccording to providers, interpersonal factors dominated the barriers adolescent females living with HIV face in accessing contraception. Providers felt that adolescent females fear disclosing their sexual activity to parents, peers and providers, because of repercussions of perceived promiscuity. Furthermore, providers mentioned that adolescents find seeking contraceptive services without a male partner challenging, because some providers and community members view adolescents unaccompanied by their partners as not being serious about their relationships or having multiple concurrent relationships. On the other hand, providers noted that institutional factors best facilitated contraception for these adolescents. Integration of contraception and HIV care allows easier access to contraceptives by removing the stigma of coming to a clinic solely for contraceptive services. Youth‐friendly services, including serving youth on days separate from adults, also create a more comfortable setting for adolescents seeking contraceptive services.ConclusionsProviders at these facilities identified attitudes of equating seeking contraceptive services with promiscuity by parents, peers and providers as barriers preventing adolescent females living with HIV from accessing contraceptive services. Health facilities should provide services for adolescent females in a youth‐friendly manner and integrate HIV and contraceptive services.

BACKGROUND:Despite guidelines for cervical cancer prevention in low-resource countries, a very small proportion of women in these settings undergo screening, and even fewer women are successfully treated. Using pilot data from western Kenya and World Health Organization recommendations, we developed a protocol to implement evidence-based cervical cancer screening and linkage to treatment strategies to the rural communities. We describe the protocol for a cluster-randomized trial to compare two implementation strategies for human-papillomavirus (HPV)-based cervical cancer screening program using metrics described in the RE-AIM (reach, efficacy, adaption, implementation and maintenance) framework. METHODS:The study is a three-year, two-phase cluster-randomized trial in 18 communities in western Kenya. During Phase 1, six control communities were offered screening in health facilities; and six intervention communities were offered screening in community health campaigns. Screening was done with human-papillomavirus testing through self-collected specimens. Phase 1 ended and we are working in partnership with communities to further contextualize the implementation strategy for screening, and develop an enhanced linkage to treatment plan. This plan will be tested in an additional six communities in Phase 2 (enhanced intervention). We will compare the reach, efficacy, cost-effectiveness and adaptability of the implementation strategies. DISCUSSION:Effective low-cost cervical cancer prevention technologies are becoming more widely available in low- and middle-income countries. Despite increasing government support for cervical cancer prevention, there remains a sizeable gap in service availability. We will use implementation science to identify the most effective strategies to fill this gap through development of context-specific evidence-based solutions. This protocol design and results can help guide implementation of cervical cancer screening in similar settings, where women are most underserved and at highest risk ...

BACKGROUND:Despite guidelines for cervical cancer prevention in low-resource countries, a very small proportion of women in these settings undergo screening, and even fewer women are successfully treated. Using pilot data from western Kenya and World Health Organization recommendations, we developed a protocol to implement evidence-based cervical cancer screening and linkage to treatment strategies to the rural communities. We describe the protocol for a cluster-randomized trial to compare two implementation strategies for human-papillomavirus (HPV)-based cervical cancer screening program using metrics described in the RE-AIM (reach, efficacy, adaption, implementation and maintenance) framework. METHODS:The study is a three-year, two-phase cluster-randomized trial in 18 communities in western Kenya. During Phase 1, six control communities were offered screening in health facilities; and six intervention communities were offered screening in community health campaigns. Screening was done with human-papillomavirus testing through self-collected specimens. Phase 1 ended and we are working in partnership with communities to further contextualize the implementation strategy for screening, and develop an enhanced linkage to treatment plan. This plan will be tested in an additional six communities in Phase 2 (enhanced intervention). We will compare the reach, efficacy, cost-effectiveness and adaptability of the implementation strategies. DISCUSSION:Effective low-cost cervical cancer prevention technologies are becoming more widely available in low- and middle-income countries. Despite increasing government support for cervical cancer prevention, there remains a sizeable gap in service availability. We will use implementation science to identify the most effective strategies to fill this gap through development of context-specific evidence-based solutions. This protocol design and results can help guide implementation of cervical cancer screening in similar settings, where women are most underserved and at highest risk for disease. TRIAL REGISTRATION:This trial is registered at ClinicalTrials.gov , NCT02124252 .

Following the Fogarty International Center-supported "Mentoring the Mentors" workshops in South America, Africa, and Asia, approaches and guidelines for mentorship at institutions within these low- and middle-income country (LMIC) contexts, appropriate for the respective regional resources and culture, were implemented. Through the presentation of case studies from these three geographic regions, this article illustrates the institutional mentorship infrastructure before the workshop and the identified gaps used to implement strategies to build mentorship capacity at the Universidad Peruana Cayetano Heredia (Peru), Kenya Medical Research Institute (Kenya), Saint John's Research Institute (India), and Eduardo Mondlane University (Mozambique). These case studies illustrate three findings: first, that mentorship programs in LMICs have made uneven progress, and institutions with existing programs have exhibited greater advancement to their mentoring capacity than institutions without formal programs before the workshops. Second, mentoring needs assessments help garner the support of institutional leadership and create local ownership. Third, developing a culture of mentorship that includes group mentoring activities at LMIC institutions can help overcome the shortage of trained mentors. Regardless of the stage of mentoring programs, LMIC institutions can work toward developing sustainable, culturally effective mentorship models that further the partnership of early career scientists and global health.