Objectives. To assess the effect of 2-way short message service (SMS) with a nurse on postpartum contraceptive use among individual women and couples. Methods. From 2016 to 2017, we conducted a randomized controlled trial at 2 public hospitals in western Kenya. We assigned eligible pregnant women to receive 2-way SMS with a nurse or no SMS, with the option to include male partners. We delivered automated family planning–focused SMS messages weekly until 6 months postpartum. Women and men receiving SMS could interact with nurses via SMS. In intention-to-treat analysis, we compared highly effective contraceptive (HEC) use at 6 months postpartum between groups using the χ2 test. We used Poisson regression in adjusted analysis. Results. We randomized 260 women to 2-way SMS or control, and we enrolled 103 male partners. At 6 months postpartum, 69.9% women receiving SMS reported HEC use, compared with 57.4% in control (relative risk = 1.22; 95% confidence interval [CI] = 1.01, 1.47; P = .04). In analysis adjusted for baseline demographic differences, the adjusted relative risk for HEC use in the SMS group was 1.26 (95% CI = 1.04, 1.52; P = .02). Conclusions. Two-way SMS with a nurse, including optional male participation, increased postpartum contraceptive use. Trial Registration. ClinicalTrials.gov; identifier: NCT02781714.

Objective To determine the risk and cofactors for HIV acquisition during pregnancy and postpartum. Design Prospective cohort study Methods Pregnant women in western Kenya were enrolled if HIV seronegative at that visit or within 3 months. Serial HIV nucleic acid amplification tests (NAATs) were conducted at 1–3 month intervals to 9 months postpartum. Genital swabs were collected for detection of chlamydia and gonorrhea at baseline, and for trichomonas, bacterial vaginosis (BV), and yeast at baseline and follow-up. Results Among 1304 pregnant women, median age was 22 years, 78% were married for a median of 4 years, 66% reported knowing partner HIV status, and 8% reported using condoms. Study retention was 98%. During 1235 person-years of follow-up, HIV incidence was 2.31/100 person-years (95% Confidence Interval [CI]:0.71–4.10). Incident HIV was associated with syphilis (Hazard Ratio [HR] 9.18, 95% CI:2.15–39.3), chlamydia (HR 4.49, 95% CI:1.34–15.0), BV (HR 2.91, 95% CI:1.25–6.76), yeast (HR 3.46, 95% CI:1.46–8.19), STI history (HR 3.48, 95%, CI:1.31–9.27), lifetime number of sex partners, (HR 1.19, 95% CI:1.03–1.37), partner age discordance (HR 1.07 per year, 95% CI:1.02–1.13) and shorter marriage (HR 1.19 per year, 95% CI:1.03–1.38). No women with incident HIV reported an HIV-infected partner. In multivariate analyses, chlamydia, older partners, and yeast infection remained significant; however, power was limited. Conclusions Pregnant and lactating women may not perceive HIV risk and rarely used condoms. Prevention and treatment of genital infections and risk stratification to identify women for pre-exposure prophylaxis (PrEP) could decrease HIV acquisition in pregnant/lactating women.

Background Unmet need for contraception is high during the postpartum period, increasing the risk of unintended subsequent pregnancy. We developed a client facing mobile phone-based family planning (FP) decision aid and assessed acceptability, feasibility, and utility of the tool among health care providers and postpartum women. Methods Semi-structured in-depth interviews (IDIs) were conducted among postpartum women ( n = 25) and FP providers ( n = 17) at 4 Kenyan maternal and child health clinics, 2 in the Nyanza region (Kisumu and Siaya Counties) and 2 in Nairobi. Stratified purposive sampling was used to enroll postpartum women and FP providers. Data were analyzed using an inductive content analysis approach by 3 independent coders, with consensual validation. Results FP providers stated that the Interactive Mobile Application for Contraceptive Choice (iMACC) tool contained the necessary information about contraceptive methods for postpartum women and believed that it would be a useful tool to help women make informed, voluntary decisions. Most women valued the decision aid content, and described it as being useful in helping to dispel myths and misconceptions, setting realistic expectations about potential side effects and maintaining confidentiality. Both women and providers expressed concerns about literacy and lack of familiarity with smart phones or tablets and suggested inclusion of interactive multimedia such as audio or videos to optimize the effectiveness of the tool. Conclusions The iMACC decision aid was perceived to be an acceptable tool to deliver client-centered FP counseling by both women and providers. Counseling tools that can support FP providers to help postpartum women make informed and individualized FP decisions in resource-limited settings may help improve FP counseling and contraceptive use in the postpartum period.

A combination of indicators routinely assessed in antenatal clinics was predictive of HIV risk and could be used to prioritize pregnant women for PrEP.

Background Tuberculosis (TB) during pregnancy in HIV-infected women is associated with poor maternal and infant outcomes. There are limited data on TB prevalence, optimal TB screening, and performance of rapid diagnostics in pregnant HIV-infected women. Methods We conducted a cross-sectional study among HIV-infected pregnant women seeking antenatal care in western Kenya. Following a standardized questionnaire, sputum smear microscopy for acid-fast bacilli (AFB), mycobacterial liquid culture, GeneXpert MTB/RIF (Xpert), urine lipoarabinomannan (LAM), and tuberculin skin testing (TST) were performed. We determined prevalence and correlates of culture-confirmed pulmonary TB, and compared diagnostic performance of World Health Organization (WHO) symptom screening and rapid diagnostic tests to sputum culture. Results Between July 2013 and July 2014, we enrolled 306 women. Among 288 women with a valid sputum culture result, 54% were on antiretroviral treatment, median CD4 cell count was 437 cell/mm3 (IQR 342–565), and prevalence of culture-confirmed pulmonary TB was 2.4% (CI 1.0–4.9%). Cough >2 weeks (p=0.04) and positive TST (≥5mm, p=0.03) were associated with pulmonary TB. Women with TB were 23-fold (95% CI 4.4–116.6) more likely to report a household member with TB symptoms (p=0.002). WHO symptom screen (43%), AFB smear (0%), Xpert (43%) and LAM (0%) had low sensitivity but high specificity (81%, 99%, 99% and 95%, respectively) for pulmonary TB. Conclusion HIV-infected pregnant women had appreciable prevalence of pulmonary TB despite modest immunosuppression. Current TB screening and diagnostic tools perform poorly in pregnant HIV-infected women. Adapted TB screening tools that include household member TB symptoms may be useful in this population.

There is growing evidence that mobile health (mHealth) approaches including short messaging service (SMS) can improve antiretroviral therapy (ART) adherence, but consensus is lacking regarding communication of HIV-related information. Most interventions to date have delivered SMS that do not overtly refer to HIV or ART in order to avoid risk of status disclosure. In formative work for an ongoing randomized controlled trial (RCT) evaluating one-way and two-way educational SMS for prevention of mother-to-child-transmission (PMTCT) adherence in Kenya, we conducted 10 focus group discussions (FGDs) with 87 HIV-infected peripartum women to determine desirability and preferred terminology of HIV-related content. SMS for the RCT were developed based on FGD findings. Roughly half of FGD participants supported receiving SMS containing overtly HIV-related terms, such as ‘HIV’ and ‘medication’, citing desire for detailed educational messages about ART and PMTCT. Those opposed to overt content expressed concerns about confidentiality. Many participants argued that acceptability of HIV-related content depended on the recipient’s disclosure status and others’ access to her phone. Based on these findings, both covert and overt SMS were developed for the RCT and participants who owned their phone or had disclosed their HIV status to anyone with access to their phone were able to choose one of three options: (1) covert SMS only, (2) overt SMS only in response to HIV-related questions from the participant, (3) overt SMS routinely, initiated by the study. Of the 825 participants in the RCT, 94% were eligible to receive overt SMS. Of these, 66% opted to receive routine overt SMS and 10% to receive participant-initiated overt SMS. These findings show there may be interest in overt HIV-related information by SMS when risk of status disclosure is low, and support use of messaging strategies that allows participant choice in HIV-related content while protecting against undesired disclosure.

Background Lifelong antiretroviral therapy (ART) (Option B+) is recommended for all HIV-infected pregnant/postpartum women, but high adherence is required to maximize HIV prevention potential and maintain maternal health. Mobile health (mHealth) interventions may provide treatment adherence support for women during, and beyond, the pregnancy and postpartum periods. Methods and Design We are conducting an unblinded, triple-arm randomized clinical trial (Mobile WACh X) of one-way short message service (SMS) versus two-way SMS versus control (no SMS) to improve maternal ART adherence and retention in care by 2 years postpartum. We will enroll 825 women from Nairobi and Western Kenya. Women in the intervention arms receive weekly, semi-automated motivational and educational SMS and visit reminders via an interactive, human-computer hybrid communication system. Participants in the two-way SMS arm are also asked to respond to a question related to the message. SMS are based in behavioral theory, are tailored to participant characteristics through SMS tracks, and are timed along the pregnancy/postpartum continuum. After enrollment, follow-up visits are scheduled at 6 weeks; 6, 12, 18, and 24 months postpartum. The primary outcomes, virological failure (HIV viral load ≥1000 copies/mL), maternal retention in care, and infant HIV-free survival, will be compared in an intent to treat analysis. We will also measure ART adherence and drug resistance. Discussion Personalized and tailored SMS to support HIV-infected women during and after pregnancy may be an effective strategy to motivate women to adhere to ART and remain in care and improve maternal and infant outcomes.

BackgroundInvolving male partners in family planning (FP) education and counseling may improve FP utilization and help meet couples’ reproductive health needs in the postpartum period. We aimed to explore Kenyan men’s and women’s perspectives on an interactive short message service (SMS) approach to support postpartum FP decision-making, and inform intervention content for a randomized controlled trial (RCT).MethodsWe conducted four focus group discussions (FGD) among men (n = 35) and two among pregnant/postpartum women (n = 15) in western Kenya. Female participants were recruited at antenatal clinics; male participants were referred by antenatal attendees. FGDs included participant critique of pilot theory-based SMS messages. FGD transcripts were coded by two investigators and analyzed using an iterative, modified grounded theory approach. These data informed the intervention and RCT design, in which women had the option to refer male partners for trial enrollment.ResultsMen strongly desired inclusion in FP programs, and frequently discussed negative relationship consequences of women’s covert contraceptive use. Female and male participants voiced a variety of concerns about contraceptive side effects and potential harms, which were central to narratives of community influence on personal contraceptive choices. Most participants felt that receiving FP-focused SMS and including men would be beneficial. They perceived that SMS dialogue with a nurse about FP could reduce misperceptions and may stimulate communication within couples, thereby improving contraceptive access and continuation. Shared decision-making around FP within couple relationships, in consultation with clinicians, was highly valued.ConclusionsHealth concerns about FP and limited couple communication are perceived contributors to postpartum unmet contraceptive need. With women’s consent, the inclusion of male partners in FP services, and specifically in an mHealth SMS intervention, is acceptable and desired. Receiving SMS may trigger communication about postpartum FP within couples. SMS content should address contraceptive knowledge gaps, anticipated side effects and FP misperceptions, and allow for real-time method choice assistance.