James Ayieko

Introduction: Mobile populations experience difficulties maintaining antiretroviral therapy (ART) adherence and HIV care engagement. We sought to explore participant perceptions of a patient-centred model aimed at enhancing care engagement through ‘dynamic choice’ treatment services for mobile individuals. Methods: We conducted 23 qualitative interviews with participants (N = 18) and healthcare providers (N = 5) from eight communities in southwest Uganda and western Kenya enrolled in a dynamic choice intervention that provided six-month and community ART refills; a “travel pack” with a travel checklist, discreetly packed ART, and an emergency supply of ART; phone access to a mobility coordinator; and facilitated transfers to distal clinics. Interviews explored participant life and mobility contexts, intervention experiences and preferences (as recipient or provider), and patient-provider relations. We employed a framework analysis of selected codes to identify emergent themes around intervention components and recommendations for improvement. Results: Participants liked all options, the travel pack being most preferred. Longer times between refills allowed participants to concentrate on ART adherence, rather than on managing clinic appointments in the context of uncertain mobility. Viral load counselling was appreciated for explaining the relationship between medication adherence, viral load, and opportunistic infections. Poverty and food insecurity remain obstacles to ideal ART adherence. Recommendations: Participants suggested scaling up these support services to the whole community, incorporating services to treat additional diseases, and food or employment support to help improve overall health outcomes. Care providers also recommended strengthening supply chains and deploying electronic medical records country-wide to facilitate care for mobile individuals.

Alcohol-serving venues are high-risk sites for HIV transmission in East Africa. Understanding how venue characteristics influence HIV screening outcomes may help to target venue-based outreach. In eight rural communities in Kenya and Uganda, we mapped all alcohol-serving venues (N = 530) and invited owners to participate in a cluster-randomized trial to promote biomedical HIV prevention uptake: 527 (99%) owners agreed to participate. We distributed cards recruiting adults ( ≥ 18 years) for free HIV testing with rapid initiation of HIV biomedical prevention or treatment. We characterized the yield of venue-based recruitment and evaluated venue-level correlates of being newly diagnosed with HIV, being previously diagnosed but out-of-care, and having self-reported HIV risk. Of 480 participating venues (Kenya = 89, Uganda = 391; 41 closed pre-recruitment and 6 had no one present), 61 (13%) had rooms for sex work; 91 (19%) offered condoms, and the median patrons/venue was 10/weekend-day. Staff distributed 9,375 cards and 7,744 (83%) adults participated in HIV screening. Of those screened, the median age was 34 years (IQR:26–43), 62% were men, and 1,620 (21%) had HIV. Among persons without known HIV, 141/6,265 (2.3%) were newly-diagnosed with HIV. Among persons with known HIV, 78/1,479 (5.3%) were out-of-care. Among persons without HIV, 2,285/6,124 (37%) reported HIV risk. The odds of having newly-diagnosed HIV increased significantly with each additional patron/weekend-day at a given venue (adjusted odds ratio [aOR]=1.03, 95%CI:1.00-1.05, p = 0.025). The odds of being previously diagnosed but out-of-care were significantly lower among attendees at venues with condoms on site (aOR=0.39, 95%CI:0.16-0.99, p = 0.047). The odds of reporting HIV risk were significantly higher among attendees at venues with condoms (aOR=1.25, 95%CI:1.04-1.49, p = 0.015), more patrons/weekday (aOR=1.01, 95%CI:1.00-1.02, p = 0.022), and more barmaids (aOR=1.07, 95%CI:1.01-1.13, p = 0.013). Alcohol-serving venue characteristics were predictive of the yield of persons with untreated HIV or high HIV risk, and could aid programs in targeting venues for HIV prevention and treatment.

For many health conditions, there are highly efficacious treatment and prevention products. Maximizing their impact requires strategies that improve the reach of health screening in order to establish who could benefit. For example, HIV prevention strategies aim to expand risk screening and to improve uptake of pre‐exposure prophylaxis (PrEP) among those experiencing risk. Often, these strategies induce changes at the group‐level (e.g., health clinics or communities) and are evaluated through cluster randomized trials. This scenario creates a complex, multilevel‐mediation‐missing data problem for the following reasons: First, the strategy is delivered at the cluster‐level, while health screening and outcomes are at the individual‐level. Second, the strategy improves health outcomes directly and indirectly through improved health screening. Third, everyone has an “underlying” status, which is only observed among those screened. To formally define the total effect in such settings, we use Counterfactual Strata Effects: causal estimands where the outcome is only relevant for a group whose membership is subject to missingness and/or impacted by the exposure of interest. To identify and estimate the corresponding statistical estimand, we propose a novel extension of Two‐Stage targeted minimum loss‐based estimation (TMLE). Simulations demonstrate the practical performance of our approach as well as the limitations of existing approaches.

Frequent HIV testing, or “retesting,” the practice of regular HIV testing following a negative test result, among persons at high risk of HIV exposure is critical for initiating treatment early among newly infected persons and reducing the risk of HIV transmission. However, barriers to HIV retesting, such as fear of stigma, underestimating risk after a prior negative HIV test, and navigating the logistics of accessing an HIV test, have contributed to lower-than-desired retesting rates in Sub-Saharan Africa, where median time from infection to diagnosis is over 2.5 years. The Innovative Behavioral Intervention Strategies (IBIS) study aims to encourage re-testing by utilizing principles of behavioral economics and human-centered-design in a many-arm randomized trial (known as a “megatrial”) of avatar-delivered video-based messages and text messages to promote HIV retesting. In 2025, we conducted two-day focus groups in Kenya and Uganda to prototype the messages among community members and healthcare workers. An expert team engaged participants in various activities and discussions to elicit their feedback, where they reflected on factors such as local relevance, clarity, and visual appeal for each prototype. Key changes as a result of workshop feedback include standardized greetings for each arm, clearer language and refined translations, SMS language which protects participant privacy, and avatar updates for local acceptability, while maintaining core behavioral theory. The workshops generated important insights that shaped the final avatars, scripts, and messages encouraging HIV retesting which will be incorporated in the eventual trial. This study demonstrates the value of engaging end-users early in the intervention development process, and gives insight into the application of artificial intelligence (AI) to improve health behaviors in resource-limited settings.

In Kenya, the primary driver of perinatal HIV transmission is disengagement from care. Virologic monitoring can reinforce adherence and enable timely intervention, yet results are often delayed. Among pregnant (≥ 27 weeks) and postpartum (≤ 6 months) women in HIV care in Kisumu Kenya, we conducted a pilot study in which Mentor Mothers (peer support) returned viral load results (GeneXpert) after a clinic visit between June-December 2023. We assessed feasibility, acceptability, and factors associated with time from sample collection to results to participants via generalized estimating equations with log-transformed time as the outcome and report geometric mean ratios (GMR). We assessed the potential impact on viremia after 6 months using two control groups (one retrospective, one prospectively enrolled). Among 545 participants (273 pilot,123 prospective and 149 retrospective controls), the median age overall was 30 years (interquartile range [IQR] 26–35) and 40% were pregnant. In the pilot, Mentor Mothers returned 100% of 422 viral load results of which 90% were suppressed. The median time from sample collection to result return was 27.0 h (IQR 23.3–54.6). We observed a trend towards slower times among women with prior viremia (adjusted-GMR 1.22, 95%CI: 0.98–1.52). The odds of subsequent viremia did not differ between pilot and control groups (adjusted-OR 1.30, 95%CI: 0.71–2.38). Mentor Mothers reported this approach was a good use of their time. In conclusion, Mentor Mothers rapidly delivered viral load results though we did not observe an impact on viremia. This approach could complement other strategies to optimize person-centered care for pregnant and postpartum women. Trial registry NCT05845619.

Introduction: Despite oral HIV pre‐exposure prophylaxis (PrEP) effectiveness, uptake and adherence remains a challenge. Newer HIV prevention technologies, including long‐acting injectable cabotegravir (CAB‐LA), are promising for addressing known barriers to oral PrEP uptake and adherence, yet research remains limited on experiences with CAB‐LA among at‐risk adults in community settings. This descriptive qualitative study explored experiences with CAB‐LA among adults participating in the SEARCH Dynamic Choice HIV Prevention (DCP) trial in rural Kenya and Uganda, which evaluated HIV prevention uptake through a structured, person‐centred DCP model. Methods: We conducted in‐depth semi‐structured interviews in July−October 2023 with a purposively selected sample of 47 DCP trial participants who initiated CAB‐LA and had at least two injections. Interviews explored participants’ reasons for choosing CAB‐LA and their experiences with the method. We also included 10 participants who subsequently discontinued CAB‐LA or switched to another method. Data were analysed using inductive coding, memoing and framework analysis. Results: The 47 participants ranged from 20 to 59 years of age; 13 were men and 34 were women. Participants were enthusiastic about CAB‐LA. They perceived it as novel, efficacious and advantageous relative to oral daily PrEP, which had been hindered by stigma, interruptions due to work, family visits and travel, side effects, and pill attributes (size and smell). Two major advantages of CAB‐LA over PrEP were improved protection from HIV stigma and from HIV acquisition due to easier adherence. Participants felt CAB‐LA was clearly distinguishable from antiretroviral therapy and would not mark them (mistakenly) as living with HIV; among women, clandestine use to guard against stigma from family members was more achievable compared to oral PrEP. Appointments for injections were rare enough (monthly, then bimonthly) that they could be kept, especially with reminders from providers, although for some, unpredictable work and travel schedules hindered their uptake of CAB‐LA. Participants cited injection‐site pain as the main drawback. Conclusions: CAB‐LA overcame several known barriers to HIV prevention uptake and adherence for women and men. In contexts of continued HIV‐related stigma, CAB‐LA met some participants’ preferences for a product that permitted prevention to be visibly distinguishable from treatment, enabling HIV prevention uptake to feel safer. Moreover, adherence was more easily achieved with CAB‐LA compared to PrEP, boosting confidence in prevention efficacy.

Alcohol-serving venues are high-risk sites for HIV transmission in East Africa. Understanding how venue characteristics influence HIV screening outcomes may help to target venue-based outreach. In eight rural communities in Kenya and Uganda, we mapped all alcohol-serving venues (N=530) and invited owners to participate in a cluster-randomized trial to promote biomedical HIV prevention uptake: 527 (99%) owners agreed to participate. We distributed cards recruiting adults ( ≥ 18 years) for free HIV testing with rapid initiation of HIV biomedical prevention or treatment. We characterized the yield of venue-based recruitment and evaluated venue-level correlates of being newly diagnosed with HIV, being previously diagnosed but out-of-care, and having self-reported HIV risk. Of 480 participating venues (Kenya=89, Uganda=391; 41 closed pre-recruitment and 6 had no one present), 61 (13%) had rooms for sex work; 91 (19%) offered condoms, and the median patrons/venue was 10/weekend-day. Staff distributed 9,375 cards and 7,744 (83%) adults participated in HIV screening. Of those screened, the median age was 34 years (IQR:26-43), 62% were men, and 1,620 (21%) had HIV. Among persons without known HIV, 141/6,265 (2.3%) were newly-diagnosed with HIV. Among persons with known HIV, 78/1,479 (5.3%) were out-of-care. Among persons without HIV, 2,285/6,124 (37%) reported HIV risk. The odds of having newly-diagnosed HIV increased significantly with each additional patron/weekend-day at a given venue (adjusted odds ratio [aOR]=1.03, 95%CI:1.00-1.05, p=0.025). The odds of being previously diagnosed but out-of-care were significantly lower among attendees at venues with condoms on site (aOR=0.39, 95%CI:0.16-0.99, p=0.047). The odds of reporting HIV risk were significantly higher among attendees at venues with condoms (aOR=1.25, 95%CI:1.04-1.49, p=0.015), more patrons/weekday (aOR=1.01, 95%CI:1.00-1.02, p=0.022), and more barmaids (aOR=1.07, 95%CI:1.01-1.13, p=0.013). Alcohol-serving venue characteristics were predictive of the yield of persons with untreated HIV or high HIV risk, and could aid programs in targeting venues for HIV prevention and treatment.

Introduction: Clinic‐based hypertension screening and treatment for people with and without HIV depends on consistent clinic engagement. Retention is challenging in rural areas, especially for people with severe hypertension, which typically requires more frequent visits than clinically stable HIV. We hypothesised that Ministry of Health (MoH) community health workers (CHWs) could improve severe hypertension detection and treatment through an integrated hypertension/HIV intervention.Methods: In rural Uganda and Kenya, we added HIV testing and a status‐neutral hypertension intervention to CHW workflow in an ongoing cluster‐randomised population‐level study (SEARCH:NCT05768763). Data spans March 2023–August 2024. Trained CHWs screened all adults aged ≥ 40 years in intervention communities for hypertension, referring those with blood pressure (BP) ≥ 140/90 mmHg to MoH HIV/primary care clinics. After initial in‐clinic evaluation, adults with BP ≥ 160/100 mmHg were offered choice of clinic‐based or telehealth (CHW home visit, clinician telehealth evaluation, medication delivery) follow‐up care. Telehealth used a MoH‐compatible CHW smartphone app that syncs with electronic clinic records, prompts CHW follow‐up visits and facilitates clinician telehealth assessment/medication prescribing. We report hypertension control achieved through the implementation of CHW‐supported screening and telehealth and used targeted minimum loss‐based estimation to estimate the change in population prevalence of uncontrolled hypertension from baseline to 1 year.Results: Across eight communities, 198 CHWs measured BP in 14,378/15,879 adults aged ≥ 40 years at baseline (91%) and 13,334/15,879 after 1 year (84%); 55% were female and 19% living with HIV. Estimated population prevalence of BP ≥ 140/90 mmHg decreased from 16.0% at baseline to 6.4% at year 1 (9.6% absolute decrease, 95% CI 8.6%, 10.6%). Among people with HIV aged ≥ 40 years (n = 3036), the prevalence of BP ≥ 140/90 mmHg decreased from 10.5% to 4.7% (5.9% absolute decrease, 95% CI 3.0%, 8.8%). In the subset with BP ≥ 160/100 who enrolled in the intervention (n = 919), 96% received antihypertensive medication, 81% were retained in care at 1 year and 79% achieved BP control; people with HIV (n = 120) had similar retention (80%) and BP control (80%).Conclusions: Within the context of a pragmatic trial, leveraging existing CHWs in an integrated HIV/hypertension model reduced the population‐level prevalence of uncontrolled hypertension by 60% among people with and without HIV, extending health services into the community at scale.

Introduction: Injectable cabotegravir (CAB‐LA) is highly effective for HIV prevention, but real‐world implementation studies in Africa are ongoing. We assessed feasibility and acceptability among participants who used CAB‐LA in the SEARCH Dynamic Choice HIV Prevention extension study in rural Uganda and Kenya.Methods: From January 2023 to December 2024, we followed females and males who were aged ≥ 15 years, with self‐assessed risk for HIV acquisition, in the intervention arm of the SEARCH Dynamic Choice HIV Prevention extension study, and received at least one CAB‐LA injection during the first 48 weeks. To assess the feasibility and acceptability of CAB‐LA, we designed quantitative surveys based on the Theoretical Framework for Acceptability. Surveys were administered at CAB‐LA initiation, after 24 and 48 weeks of use, and discontinuation of CAB‐LA.Results: Of 487 intervention arm participants, 274 (56%) started CAB‐LA (183 females; 91 males; 79 youth aged 15–24 years). Of whom, 264 completed the survey at initiation, 206 after 24 weeks on CAB‐LA, 201 after 48 weeks on CAB‐LA and 69 at discontinuation of CAB‐LA. Most participants (65%; 171/264) reported choosing CAB‐LA because it was easier to take than pills, and nearly all (99%; 261/264) had limited knowledge of CAB‐LA prior to the study. Concerns for side effects were the largest anticipated and experienced barrier to CAB‐LA. Overall and with subgroups, satisfaction with CAB‐LA was high at 24 weeks (97%; 200/206) and 48 weeks (96%; 193/201). Nearly all participants reported that taking CAB‐LA was easy at 24 weeks (95%; 195/206) and 48 weeks (99%; 198/201). At CAB‐LA discontinuation, 83% (57/69) were likely to extremely likely to recommend CAB‐LA to a friend: 80% (20/25) of males, 84% (37/44) of females, 100% (19/19) of youth and 76% (38/50) of older adults.Conclusions: In rural Uganda and Kenya, over half of participants in the SEARCH trial who were offered choice of oral PrEP/PEP or CAB‐LA chose and started CAB‐LA during the first 48 weeks. For both males and females and younger and older adults, CAB‐LA was both feasible and acceptable to deliver with satisfaction remaining high throughout the study, and nearly all reporting ease of use.Clinical Trial Number: 05549726