Triangulation of Routine Antenatal HIV Prevalence Data and Adjusted HIV Estimates in Mozambique

BACKGROUND

Routine health system data are central to monitoring HIV trends. In Mozambique, the reported number of women receiving antenatal care (ANC) and antiretroviral therapy for prevention of mother-to-child transmission (PMTCT) has exceeded the Spectrum-estimated number of pregnant women since 2017. In some provinces, reported HIV prevalence in pregnant women has declined faster than epidemiologically plausible. We hypothesized that these issues are linked and caused by programmatic overenumeration of HIV-negative pregnant women at ANC.

METHODS

We triangulated program-reported ANC client numbers with survey-based fertility estimates and facility birth data adjusted for the proportion of facility births. We used survey-reported ANC attendance to produce adjusted time series of HIV prevalence in pregnant women, adjusted for hypothesized program double counting. We calibrated the Spectrum HIV estimation models to adjusted HIV prevalence data to produce adjusted adult and pediatric HIV estimates.

RESULTS

ANC client numbers were not consistent with facility birth data or modeled population estimates indicating ANC data quality issues in all provinces. Adjusted provincial ANC HIV prevalence in 2021 was median 45% [interquartile range 35%-52% or 2.3 percentage points (interquartile range 2.5-3.5)] higher than reported HIV prevalence. In 2021, calibrating to adjusted antenatal HIV prevalence lowered PMTCT coverage to less than 100% in most provinces and increased the modeled number of new child infections by 35%. The adjusted results better reconciled adult and pediatric antiretroviral treatment coverage and antenatal HIV prevalence with regional fertility estimates.

CONCLUSIONS

Adjusting HIV prevalence in pregnant women using nationally representative household survey data on ANC attendance produced estimates more consistent with surveillance data. The number of children living with HIV in Mozambique has been substantially underestimated because of biased routine ANC prevalence. Renewed focus on HIV surveillance among pregnant women would improve PMTCT coverage and pediatric HIV estimates.

Determinants of COVID-19 vaccine acceptance in Mozambique: The role of institutional trust

Background

Vaccination plays an imperative role in protecting public health and preventing avoidable mortality. Yet, the reasons for vaccine hesitancy in African countries are not well understood. This study investigates the factors associated with the acceptance of COVID-19 vaccine in Mozambique, with a focus on the role of institutional trust.

Methods

The data came from the three waves of the COVID-19 Knowledge, Attitudes and Practices (KAP) survey which followed a cohort of 1,371 adults in Mozambique over six months (N=3,809). We examined vaccine acceptance based on three measurements: willingness to take vaccine, perceived vaccine efficacy, and perceived vaccine safety. We conducted multilevel regression analysis to investigate the trajectories of, and the association between institutional trust and vaccine acceptance.

Results

One third of the survey participants (37%) would definitely take the vaccine. Meanwhile, 31% believed the vaccine would prevent the COVID-19 infection, and 27% believed the vaccine would be safe. There was a significant decrease in COVID-19 vaccine acceptance between waves 1 and 3 of the survey. Institutional trust was consistently and strongly correlated with different measures of vaccine acceptance. There was a greater decline in vaccine acceptance in people with lower institutional trust. The positive correlation between institutional trust and vaccine acceptance was stronger in younger than older adults. Vaccine acceptance also varied by gender and marital status.

Conclusions

Vaccine acceptance can be volatile even over short periods of time. Institutional trust is a central driver of vaccine acceptance and contributes to the resilience of the health system. Our study highlights the importance of health communication and building a trustful relationship between the general public and the institutions in the context of a global pandemic.

Integrating a Transdiagnostic Psychological Intervention Into Routine HIV Care: A Mixed-Methods Evaluation of the Common Elements Treatment Approach in Mozambique

INTRODUCTION

We integrated a transdiagnostic psychological intervention (Common Elements Treatment Approach [CETA]) into routine HIV care in Sofala, Mozambique. This task-shared program screens and treats newly diagnosed HIV+ patients with comorbid mental health symptoms.

METHODS

A mixed-methods evaluation included demographics, intake screening scores, mental health symptoms, and barriers/facilitators to implementation examined through interviews. Multilevel models were used to analyze factors associated with symptom improvement and loss to follow-up (LTFU).

RESULTS

From March 2019 to June 2020, 820 individuals were screened for CETA treatment; 382 (46.6%) showed clinically significant mental health symptoms and attended 1484 CETA sessions. Of CETA patients, 71.5% (n = 273/382) had general mental distress, 7.3% (n = 28) had alcohol abuse/dependence, 12.0% (n = 46) had suicidal ideation, and 3.7% (n = 14) had other violent ideation; 66.2% (n = 253) had experienced at least 1 traumatic event at intake. Mental health symptoms decreased by 74.1% (17.0 to 4.4) after 5 CETA sessions, and 37.4% of patients (n = 143) achieved a ≥50% symptom reduction from intake. LTFU was 29.1% (n = 111), but 59.5% of LTFU patients (n = 66) achieved a ≥50% symptom reduction before LTFU. Facilitators for CETA implementation included readiness for change given the unaddressed burden of mental illness. Barriers included complexity of the intervention and stigma.

CONCLUSIONS

Approximately 45% of newly diagnosed HIV+ individuals in Mozambique have clinically significant mental health symptoms at diagnosis. Integrating CETA into routine HIV platforms has in-context feasibility. Future implementation studies can optimize strategies for patient retention and scale-up.

CD4 Trends With Evolving Treatment Initiation Policies Among Children Living With HIV in Zambézia Province, Mozambique, 2012-2018

BACKGROUND

Historically, antiretroviral therapy (ART) initiation was based on CD4 criteria, but this has been replaced with "Test and Start" wherein all people living with HIV are offered ART. We describe the baseline immunologic status among children relative to evolving ART policies in Mozambique.

METHODS

This retrospective evaluation was performed using routinely collected data. Children living with HIV (CL aged 5-14 years) with CD4 data in the period of 2012-2018 were included. ART initiation "policy periods" corresponded to implementation of evolving guidelines: in period 1 (2012-2016), ART was recommended for CD4 <350 cells/mm3; during period 2 (2016-2017), the CD4 threshold increased to <500 cells/mm3; Test and Start was implemented in period 3 (2017-2018). We described temporal trends in the proportion of children with severe immunodeficiency (CD4 <200 cells/mm3) at enrollment and at ART initiation. Multivariable regression models were used to estimate associations with severe immunodeficiency.

RESULTS

The cohort included 1815 children with CD4 data at enrollment and 1922 at ART initiation. The proportion of children with severe immunodeficiency decreased over time: 20% at enrollment into care in period 1 vs. 16% in period 3 (P = 0.113) and 21% at ART initiation in period 1 vs. 15% in period 3 (P = 0.004). Children initiating ART in period 3 had lower odds of severe immunodeficiency at ART initiation compared with those in period 1 [adjusted odds ratio (aOR) = 0.67; 95% CI: 0.51 to 0.88]. Older age was associated with severe immunodeficiency at enrollment (aOR = 1.13; 95% CI: 1.06 to 1.20) and at ART initiation (aOR = 1.14; 95% CI: 1.08 to 1.21).

CONCLUSIONS

The proportion of children with severe immunodeficiency at ART initiation decreased alongside more inclusive ART initiation guidelines. Earlier treatment of children living with HIV is imperative.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

Antenatal care in Mozambique: Number of visits and gestational age at the beginning of antenatal care

OBJECTIVE

1)to assess the gestational age at the beginning of antenatal care and its covariates; 2)to assess the number of antenatal visits and its covariates; and 3)to identify the reasons for the late initiation of antenatal care and for attending less than four visits among postpartum women living in Nampula, Mozambique.

METHOD

cross-sectional study conducted with 393 mothers who answered a structured instrument in face-to-face interviews. Logistic regression was used to analyze the covariates of having initiated antenatal care up to the 16thgestational week, having attended four or more antenatal visits, and reporting both situations simultaneously.

RESULTS

all postpartum women underwent antenatal care, but only 39.9% started it until the 16thgestational week, 49.1% attended four or more visits, and 34.1% reported both events. Having concluded high school (ORadj=1.99; 95%CI=1.19-3.31) or college (ORadj=3.87; 95%CI=1.47-10.18) were aspects associated with reporting both situations. The reasons for the late initiation of antenatal care and attending less than four visits were as follows: not finding it important to attend several visits, not having easy access to the health facility, not being aware about pregnancy, and not having a companion for the visits.

CONCLUSION

the gestational age at the beginning of antenatal care and the number of antenatal visits are lower than the current recommendations in the country.

The cascade of care of HIV after one year of follow-up in a cohort of HIV-positive adult patients in three health settings of Morrumbene in rural Mozambique

OBJECTIVE

To assess the state of the retention in care of HIV patients in three health settings in Morrumbene, a rural district of Inhambane Province, Mozambique. We evaluated potential factors associated with early loss to follow-up (LTFU), retention in care and ART adherence during the first year of follow-up.

MATERIAL AND METHODS

Retrospective, cross-sectional, observational study. We collected data on patients diagnosed with HIV infection in 2017 in two permanent clinics and one mobile clinic. Demographic, clinical, immunological and therapeutic data were retrieved up to December 31st, 2018. Data on follow-up were collected at 6 and 12 months for medical visits and for ART adherence and analysed for factors associated with LTFU, retention in care and adherence to ART by Stata Version 14 and univariate and stepwise multiple unconditional logistic regression models.

RESULTS

In 2017, 960 patients were diagnosed with HIV infection. At 6-month follow-up, 49% attended the medical visit and 157 (25%) adhered to ART. After one year, 34% of patients were available for follow-up, and only 72 patients adhered to ART. In multivariate analysis, factors associated with early LTFU were male sex (p = 0.036) and immediate prescription of ART (p = 0.064). Older age (p < 0.001) and being followed in the mobile clinic (p = 0.001) favoured retention in care. Advanced WHO status (p = 0.005) and being pregnant or breastfeeding showed a negative correlation with adherence to treatment (p = 0.068).

CONCLUSIONS

Only one-third of patients were available for follow-up after one year, and only 13% adhered to ART. Young individuals, men and pregnant/breastfeeding women seem to be particularly at risk for LTFU and non-adherence to treatment.

Changes in Eye Health and Service Coverage in Nampula, Mozambique between 2011 and 2018

Purpose: Globally, there are few examples of repeated eye health surveys to assess changes in prevalence and causes of visual impairment, and service coverage over time. Two separate, unlinked rapid assessments of avoidable blindness (RAAB) were conducted in Nampula province, Mozambique in 2011 and 2018. This paper reports the observed changes and examines how the trends differ for males and females.Methods: Standard RAAB methodology was used in both studies. Two-stage cluster sampling was used to generate random samples of adults aged over 50 years. Participants underwent a simplified visual acuity (VA) exam, a lens exam and posterior segment exam using a direct ophthalmoscope for all subjects with presenting VA<6/18. Data were analysed using Stata and logistic regression models were developed to assess changes.Results: The 2011 study enrolled 3,050 people and examined 96.9% (2,954 people). The 2018 survey enrolled 4,191 people and examined 95.8% (4,015 people). Age- and sex-adjusted estimates of blindness decreased from 6.2% in 2011 to 4.5% in 2018 (z = -2.21, p = .028). Cataract surgical coverage was higher among males in both surveys (13.4% among males vs 7.7% among females in 2011, and 40.0% among males vs 19.4% among females in 2018) and the gender disparity grew between surveys.Conclusion: Significant changes were observed in the eye health and service coverage between 2011 and 2018. Further improvements to services are required to improve access for women and people with moderate visual impairment.

Loss to follow-up and opportunities for reengagement in HIV care in rural Mozambique: A prospective cohort study

Patients lost to follow-up (LTFU) over the human immunodeficiency virus (HIV) cascade have poor clinical outcomes and contribute to onward HIV transmission. We assessed true care outcomes and factors associated with successful reengagement in patients LTFU in southern Mozambique.Newly diagnosed HIV-positive adults were consecutively recruited in the Manhiça District. Patients LTFU within 12 months after HIV diagnosis were visited at home from June 2015 to July 2016 and interviewed for ascertainment of outcomes and reasons for LTFU. Factors associated with reengagement in care within 90 days after the home visit were analyzed by Cox proportional hazards model.Among 1122 newly HIV-diagnosed adults, 691 (61.6%) were identified as LTFU. Of those, 557 (80.6%) were approached at their homes and 321 (57.6%) found at home. Over 50% had died or migrated, 10% had been misclassified as LTFU, and 252 (78.5%) were interviewed. Following the visit, 79 (31.3%) reengaged in care. Having registered in care and a shorter time between LTFU and visit were associated with reengagement in multivariate analyses: adjusted hazards ratio of 3.54 [95% confidence interval (CI): 1.81-6.92; P < .001] and 0.93 (95% CI: 0.87-1.00; P = .045), respectively. The most frequently reported barriers were the lack of trust in the HIV-diagnosis, the perception of being in good health, and fear of being badly treated by health personnel and differed by type of LTFU.Estimates of LTFU in rural areas of sub-Saharan Africa are likely to be overestimated in the absence of active tracing strategies. Home visits are resource-intensive but useful strategies for reengagement for at least one-third of LTFU patients when applied in the context of differentiated care for those LTFU individuals who had already enrolled in HIV care at some point.

Tuberculosis Treatment Outcomes Among Children in Rural Southern Mozambique: A 12-year Retrospective Study

BACKGROUND

Globally, tuberculosis (TB) remains a serious cause of morbidity and mortality for children. Mozambique is 1 of 30 high TB and TB/HIV burden countries. This study aimed to assess treatment outcomes of childhood TB in Chókwè District, Mozambique.

METHODS

A retrospective cohort study of children <15-years-old treated for TB from 2006 to 2017 was conducted at Carmelo Hospital of Chókwè. Descriptive statistics were used to summarize patient characteristics. Treatment outcomes stratified by HIV status were compared with χ. Multivariable logistic regression was used to estimate the odds of a favorable TB treatment outcome. Kaplan-Meier curves were used to estimate the cumulative incidence of death.

RESULTS

Nine hundred thirty-three cases of childhood TB were enrolled, 45.9% of which were female and 49.6% were <5-years-old. Five hundred sixty-five (62%) children were HIV positive. Seven hundred sixty-two (83.6%) cases had a favorable TB treatment outcome. In comparison to children 0-4 years, the 5-14 age group had a higher odds of a favorable outcome [odds ratio: 2.02, 95% confidence interval: 1.42-3.05]. Being 5-14 years was associated with lower risk of death (hazard ratio: 0.435; 95% confidence interval: 0.299-0.632). Those starting anti-TB treatment ≤3 months after antiretroviral therapy initiation had a survival probability of approximately 75% at 1 year compared with 95% for those who were HIV negative.

CONCLUSIONS

Most children in this cohort had favorable TB treatment outcomes. Worse outcomes were observed for younger children and if anti-TB treatment started ≤3 months after initiation of antiretroviral therapy. Rigorous screening for TB and isoniazid preventative therapy may reduce the burden of TB in this population and lead to better outcomes.

Factors Associated with Stunting among Children Aged 0 to 59 Months from the Central Region of Mozambique

The objective of this study was to identify the major socio-demographic, health, and environmental determinants of stunting among children aged 0-59 months from the Tete province (Mozambique) and offering useful information for future healthcare strategies and interventions. A case-control study was conducted among 282 (162 boys; 120 girls) children under five years of age from the central region of Mozambique between 1 May and 3 June 2014. Children with stunting (HAZ < -2 SD according to the WHO Child Growth Standards in 2006) were considered as cases and those who had a Z-score < -2 SD were considered as controls. We collected data related to mothers and children and their environment, and they were assessed in two groups to find a possible association. The software used for data analysis was the SPSS®(version, 21.0) using descriptive statistics, t-test, ANOVA, chi-square analyses, bivariate comparisons, and stepwise multiple logistic regression analysis. The results showed that birth weight, mother's educational status, maternal occupation, living in a rural area, family size, number of children under five years of age in the household, cooking with charcoal, inhabiting wooden or straw housing or housing without proper floors, overall duration of breastfeeding as well as duration of exclusive breastfeeding, and time of initiation of complementary feeding were significantly related to stunting. Thus, appropriate nutritional intervention programmes considering these determinants and the dissemination of knowledge at the population level related to undernutrition are necessary to ameliorate the children´s nutritional status.

First description of HTLV-1/2 seroprevalence in HIV-infected inmates in Mozambique

No study has yet been conducted to estimate the burden of co-infection of HIV and HTLV-1/2 in inmates in sub-Saharan Africa. To investigate prevalence of co-infection in inmates in Mozambique, a total of 2140 inmates were screened for HIV, of which 515 were HIV seropositive. All HIV seropositive inmates were further screened for HTLV infection, and eight (1.55%) were co-infected. Co-infection was higher in females (3.45% [2/58; CI: 0.42-11.91]) as compared to males (1.35% [6/445; CI: 0.55-3.06]). Early screening of HTLV in prisons is urgently needed in Mozambique in order to improve the care provided to incarcerated individuals, including initiation of ART.

Mozambique's Debt and the International Monetary Fund's Influence on Poverty, Education, and Health

For nearly 30 years, Mozambique has been facing austerity measures regulated by the IMF. These austerity measures, grounded in macroeconomic policies, were supposed to lift Mozambique out of poverty, and improve its healthcare and education systems. By taking an in-depth look at the major etiologies of Mozambique's debt and the conditions which forced the country to accept austerity measures-despite their protests-prior to receiving IMF funding, this paper examines how IMF policies over the past 30 years have affected poverty, health, and the education system. The results of these policies have contributed to Mozambique's enduring classification as one of the poorest countries in the world. Aside from economic outcomes, Mozambique also has abysmal health and education systems, with one of the lowest life expectancies in Sub-Saharan Africa. It is time to re-evaluate how the current IMF macroeconomic policies negatively affect, health, education and the socioeconomic status of those who live in abject poverty. As short term macroeconomic policies of PARPA have been ineffective at reducing poverty, promoting education and improving health, the IMF should consider using longer term macroeconomic policies which invest in-rather than limit-public services such as health and education.

Health service availability and health seeking behaviour in resource poor settings: evidence from Mozambique

Low-income countries are plagued by a high burden of preventable and curable disease as well as unmet need for healthcare, but detailed microeconomic evidence on the relationship between supply-side factors and service use is limited. Causality has rarely been assessed due to the challenges posed by the endogeneity of health service supply.In this study, using data from Mozambique, we investigate the effect of healthcare service availability, measured as the type of health facilities and their level of staffing and equipment, on the individual decision to seek care. We apply an instrumental variable approach to test for causality in the effect of staff and equipment availability on the decision to seek care and we explore heterogeneous effects based on the distance of households to the closest health facility.We find that living in the proximity of a health facility increases the probability of seeking care. A greater availability of referral health services in the locality has no significant effect on decision to seek care, while greater availability of staff and equipment increases the probability of seeking care when ill. Demand side barriers to health care use exist, but have a smaller impact when health care services are available within one hour walking distance.

Health facility determinants and trends of ICD-10 outpatient psychiatric consultations across Sofala, Mozambique: time-series analyses from 2012 to 2014

BACKGROUND

Few peer-reviewed publications have taken a longitudinal or systems approach to mental healthcare (MH) utilization in low- and middle-income countries. We analyzed: (1) outpatient ICD-10 diagnoses over time and by gender; and (2) health facility determinants of MH service utilization.

METHODS

We reviewed a census of 15,856 outpatient psychiatric consultations conducted at Ministry clinics in Sofala province, Mozambique from January 2012-June 2014. Generalized estimating equations were used to model facility determinants of ICD-10 diagnoses.

RESULTS

Across the period, 48.9 % of consults were for epilepsy, 22.4 % for schizophrenia/delusional disorders, and 8.8 % for neurotic/stress-related disorders. The proportion of schizophrenia/delusional disorders has decreased over time (32 % in 2012; 13 % in 2014, p = 0.003), in favor of greater diversity of diagnoses. Epilepsy has increased significantly in absolute and proportional terms. Women are more likely to present for neurotic/stress-related conditions (12.8 % of consults for women, 5.7 % for men, p < 0.001), while men are more likely to present for substance use (1.9 % for women, 6.4 % for men, p < 0.001). Clinics with more psychiatric technicians have a 2.1-fold (CI: 1.2, 3.6) increased rate of schizophrenia/delusional disorder diagnoses. Rural clinics saw a higher proportion of epilepsy cases and a lower proportion of organic, substance use, schizophrenia, and mood disorder cases.

DISCUSSION AND CONCLUSIONS

Outpatient MH service provision is increasing in Mozambique, although currently focuses on epilepsy and schizophrenia/delusional disorders. Mid-level psychiatric providers appear to be associated with a higher proportion of schizophrenia/delusional disorder diagnoses. Due to diagnostic or utilization differences, rural clinics may be missing important cases of organic, substance use, schizophrenia, and mood disorders. Models and decision-support tools for mental healthcare integration with primary care practice are needed in Mozambique to allow further scale-up of mental health services.

Exploring competing experiences and expectations of the revitalized community health worker programme in Mozambique: an equity analysis

INTRODUCTION

Mozambique launched its revitalized community health programme in 2010 in response to inequitable coverage and quality of health services. The programme is focused on health promotion and disease prevention, with 20 % of community health workers' (known in Mozambique as Agentes Polivalentes Elementares (APEs)) time spent on curative services and 80 % on activities promoting health and preventing illness. We set out to conduct a health system and equity analysis, exploring experiences and expectations of APEs, community members and healthcare workers supervising APEs.

METHODS

This exploratory qualitative study captured the perspectives of a range of participants including women caring for children under 5 years (service clients), community leaders, service providers (APEs) and their supervisors. Participants in the Moamba and Manhiça districts, located in Maputo Province (Mozambique), were selected purposively. In total, 29 in-depth interviews and 9 focus group discussions were conducted in the local language and/or Portuguese. A framework approach was used for analysis, assisted by NVivo10 software.

RESULTS

Our analysis revealed that health equity is viewed as linked to the quality and coverage of the APE programme. Demand and supply factors interplay to shape health equity. The availability of responsive and appropriate services led to tensions between community expectations for curative services (and APEs' willingness to perform them) and official policy focusing APE efforts mainly on preventive services and health promotion. The demand for more curative services by community members is a result of having limited access to healthcare services other than those offered by APEs.

CONCLUSION

This study highlights the need to pay attention to the determinants of demand and supply of community interventions in health, to understand the opportunities and challenges of the difficult interface role played by APEs and to create communication among stakeholders in order to build a stronger, more effective and equitable community programme.

Supervision of community health workers in Mozambique: a qualitative study of factors influencing motivation and programme implementation

BACKGROUND

Community health workers (CHWs) in Mozambique (known as Agentes Polivalentes Elementares (APEs)) are key actors in providing health services in rural communities. Supervision of CHWs has been shown to improve their work, although details of how it is implemented are scarce. In Mozambique, APE supervision structures and scope of work are clearly outlined in policy and rely on supervisors at the health facility of reference. The aim of this study was to understand how and which aspects of supervision impact on APE motivation and programme implementation.

METHODS

Qualitative research methodologies were used. Twenty-nine in-depth interviews were conducted to capture experiences and perceptions of purposefully selected participants. These included APEs, health facility supervisors, district APE supervisors and community leaders. Interviews were recorded, translated and transcribed, prior to the development of a thematic framework.

RESULTS

Supervision was structured as dictated by policy but in practice was irregular and infrequent, which participants identified as affecting APE's motivation. When it did occur, supervision was felt to focus more on fault-finding than being supportive in nature and did not address all areas of APE's work - factors that APEs identified as demotivating. Supervisors, in turn, felt unsupported and felt this negatively impacted performance. They had a high workload in health facilities, where they had multiple roles, including provision of health services, taking care of administrative issues and supervising APEs in communities. A lack of resources for supervision activities was identified, and supervisors felt caught up in administrative issues around APE allowances that they were unable to solve. Many supervisors were not trained in providing supportive supervision. Community governance and accountability mechanisms were only partially able to fill the gaps left by the supervision provided by the health system.

CONCLUSION

The findings indicate the need for an improved supervision system to enhance support and motivation and ultimately performance of APEs. Our study found disconnections between the APE programme policy and its implementation, with gaps in skills, training and support of supervisors leading to sub-optimal supervision. Improved methods of supervision could be implemented including those that maximize the opportunities during face-to-face meetings and through community-monitoring mechanisms.

Temporal Trends in Patient Characteristics and Outcomes Among Children Enrolled in Mozambique's National Antiretroviral Therapy Program

BACKGROUND

During 2004-2009, >12,000 children (<15 years old) initiated antiretroviral therapy (ART) in Mozambique. Nationally representative outcomes and temporal trends in outcomes were investigated.

METHODS

Rates of death, loss to follow-up (LTFU) and attrition (death or LTFU) were evaluated in a nationally representative sample of 1054 children, who initiated ART during 2004-2009 at 25 facilities randomly selected using probability-proportional-to-size sampling.

RESULTS

At ART initiation during 2004-2009, 50% were male; median age was 3.3 years; median CD4% was 13%; median CD4 count was 375 cells/μL; median weight-for-age Z score was -2.1. During 2004-2009, median time from HIV diagnosis to care initiation declined from 33 to 0 days (P = 0.001); median time from care to ART declined from 93 to 62 days (P = 0.004); the percentage aged <2 at ART initiation increased from 16% to 48% (P = 0.021); the percentage of patients with prior tuberculosis declined from 50% to 10% (P = 0.009); and the percentage with prior lymphocytic interstitial pneumonia declined from 16% to 1% (P < 0.001). Over 2652 person-years of ART, 183 children became LTFU and 26 died. Twelve-month attrition was 11% overall but increased from 3% to 22% during 2004-2009, mainly because of increases in 12-month LTFU (from 3% to 18%).

CONCLUSION

Declines in the prevalence of markers of advanced HIV disease at ART initiation probably reflect increasing ART access. However, 12-month LTFU increased during program expansion, and this negated any program improvements in outcomes that might have resulted from earlier ART initiation.

Engagement of Traditional Healers and Birth Attendants as a Controversial Proposal to Extend the HIV Health Workforce

"Medical pluralism" is the use of multiple health systems and is common among people living with HIV/AIDS in sub-Saharan Africa. Healers and traditional birth attendants (TBAs) often are a patient's first and/or preferred line of treatment; this often results in delayed, interrupted, or abandoned diagnosis and therapy. Literature from the study of medical pluralism suggests that HIV care and treatment programs are infrequently and inconsistently engaging healers around the world. Mistrust and misunderstanding among patients, clinical providers, and traditional practitioners make the development of effective partnerships difficult, particularly regarding early HIV diagnosis and antiretroviral therapy. We provide recommendations for the development of successful collaboration health workforce efforts based on both published articles and case studies from our work in rural Mozambique.

Vulnerability of coastal livelihoods to shrimp farming: Insights from Mozambique

Millions of people around the world depend on shrimp aquaculture for their livelihoods. Yet, the phenomenal growth of shrimp farming has often given rise to considerable environmental and social damage. This article examines the impacts of commercial, export-oriented shrimp aquaculture on local livelihood vulnerability by comparing the exposure, sensitivity, and adaptive capacity of shrimp farm employees with non-farm employees in rural Mozambique. Exposure to stressors was similar between the two groups. Shrimp farm employees had higher assets and higher adaptive capacity than non-farm employees. However, because their income is heavily dependent on a single commodity, shrimp farm employees were highly susceptible to the boom crop nature of intensive shrimp farming. The implications for aquaculture policy and vulnerability research are discussed. The article argues that coastal vulnerability is dynamic, variable, and influenced by multiple processes operating at multiple scales.

Using theory and formative research to design interventions to improve community health worker motivation, retention and performance in Mozambique and Uganda

BACKGROUND

Community health workers (CHWs) are increasingly being used in low-income countries to address human resources shortages, yet there remain few effective, evidence-based strategies for addressing the enduring programmatic constraints of worker motivation, retention and performance. This paper describes how two interventions were designed by the Innovations at Scale for Community Access and Lasting Effects (inSCALE) project to address these constraints in Uganda and Mozambique drawing on behavioural theory and formative research results.

METHODS

A review of the work motivation and CHW motivation literature--incorporating influences on retention and performance--was conducted on articles sourced through electronic web searches. Formative research with a focus on the barriers and facilitators to CHW motivation, retention and performance was conducted with community health workers and key stakeholders in Uganda and Mozambique. An analytical induction approach to the thematic analysis of transcripts from 98 in-depth interviews and 26 focus group discussions was adopted across the country settings.

RESULTS

From the theoretical review, it was determined that the interventions should promote CHWs as members of a collective by highlighting a sense of shared experience, focus on alignment between worker and programme goals, and emphasise the actions that lead to good performance. The Social Identity Approach was selected as the theory most likely to lead to the development of effective, scalable and sustainable interventions by addressing the identified gap in the literature of the influence of CHW working context. The formative research indicated that CHWs value feedback and feeling connected to the health system and their community, are motivated by status and community standing, and want to be provided with the necessary tools to perform. Two interventions based on these results were developed: a participatory, local community approach and an information communication technology (ICT) approach.

CONCLUSIONS

Drawing on contextual data and theory that is sensitive to context can potentially lead to the development of appropriate and effective interventions when aiming to improve the motivation, retention and performance of CHWs in Uganda and Mozambique and other comparable settings. Evaluation of the developed interventions is crucial to assess this potential.

Incentives for non-physician health professionals to work in the rural and remote areas of Mozambique--a discrete choice experiment for eliciting job preferences

BACKGROUND

Successfully motivating and retaining health workers is critical for the effective performance of health systems. In Mozambique, a shortage of health care professionals and low levels of staff motivation in rural and remote areas pose challenges to the provision of equitable health care delivery. This study provides quantitative information on the job preferences of non-physician health professionals in Mozambique, examining how different aspects of jobs are valued and how health professionals might respond to policy options that would post them to district hospitals in rural areas.

METHODS

The study used a discrete choice experiment (DCE) to elicit the job preferences of non-physician health professionals. Data collection took place in four Mozambique provinces: Maputo City, Maputo Province, Sofala and Nampula. DCE questionnaires were administered to 334 non-physician health professionals with specialized or university training ('mid-level specialists' and N1 and N2 categories). In addition, questionnaires were administered to 123 N1 and N2 students to enable comparison of the results for those with work experience with those without and determine how new N1 and N2 graduates can be attracted to rural posts.

RESULTS

The results indicate that the provision of basic government housing has the greatest impact on the probability of choosing a job at a public health facility, followed by the provision of formal education opportunities and the availability of equipment and medicine at a health facility. The sub-group analysis suggests that job preferences vary according to stage of life and that incentive packages should vary accordingly. Recruitment strategies to encourage non-clinical professionals to work in rural/remote areas should also consider birthplace, as those born in rural/remote areas are more willing to work remotely.

CONCLUSION

The study was undertaken within an overarching project that aimed to develop incentive packages for non-physician health professionals assigned to work in remote/rural areas. Based on the DCE results, the project team, together with the Mozambique Ministry of Health, has developed a range of health workforce retention strategies focusing on the provision of housing benefits and professional development opportunities to be utilized when assigning non-physician health professionals to rural/remote areas.

The effect of pre-service training on post-graduation skill and knowledge retention among mid-level healthcare providers in Mozambique

BACKGROUND

Mozambique suffers from critical shortages of healthcare workers including non-physician clinicians, Tecnicos de Medicina Geral (TMGs), who are often senior clinicians in rural health centres. The Mozambique Ministry of Health and the International Training and Education Center for Health, University of Washington, Seattle, revised the national curriculum to improve TMG clinical knowledge and skills. To evaluate the effort, data was collected at graduation and 10 months later from pre-revision (initial) and revised curriculum TMGs to determine the following: (1) Did cohorts trained in the revised curriculum score higher on measurements of clinical knowledge, physical exam procedures, and solving clinical case scenarios than those trained in the initial curriculum; (2) Did TMGs in both curricula retain their knowledge over time (from baseline to follow-up); and (3) Did skills and knowledge retention differ over time by curricula? Post-graduation and over time results are presented.

METHODS

t-tests examine differences in scores between curriculum groups. Univariate and multivariate linear regression models assess curriculum-related, demographic, and workplace factors associated with scores on each of three evaluation methods at the p < 0.05 level. Paired t-tests examine within-group changes over time. ANOVA models explore differences between Health Training Institutes (HTIs). Generalized estimating equations determine whether change in scores over time differed by curricula.

RESULTS

Mean scores of initial curriculum TMGs at follow-up were 52.7%, 62.6%, and 40.0% on the clinical cases, knowledge test, and physical exam, respectively. Averages were significantly higher among the revised group for clinical cases (60.2%; p < 0.001) and physical exam (47.6%; p < 0.001). HTI was influential on clinical case and physical exam scores. Between graduation and follow-up, clinical case and physical exam scores decreased significantly for initial curriculum students; clinical case scores increased significantly among revised curriculum TMGs.

CONCLUSIONS

Although curriculum revision had limited effect, marginal improvements in the revised group show promise that these TMGs may have increased ability to synthesize clinical information. Weaknesses in curriculum and practicum implementation likely compromised the effect of curriculum revision. An improvement strategy that includes strengthened TMG training, greater attention to pre-service clinical practice, and post-graduation mentoring may be more advantageous than curriculum revision, alone, to improve care provided by TMGs.

Perspectives of key stakeholders regarding task shifting of care for HIV patients in Mozambique: a qualitative interview-based study with Ministry of Health leaders, clinicians, and donors

BACKGROUND

Task shifting is a common strategy to deliver antiretroviral therapy (ART) in resource-limited settings and is safe and effective if implemented appropriately. Consensus among stakeholders is necessary to formulate clear national policies that maintain high-quality care. We sought to understand key stakeholders' opinions regarding task shifting of HIV care in Mozambique and to characterize which specific tasks stakeholders considered appropriate for specific cadres of health workers.

METHODS

National and provincial Ministry of Health leaders, representatives from donor and non-governmental organizations (NGOs), and clinicians providing HIV care were intentionally selected to represent diverse viewpoints. Using open- and closed-ended questions, interviewees were asked about their general support of task shifting, its potential advantages and disadvantages, and whether each of seven cadres of non-physician health workers should perform each of eight tasks related to ART provision. Responses were tallied overall and stratified by current job category. Interviews were conducted between November 2007 and June 2008.

RESULTS

Of 62 stakeholders interviewed, 44% held leadership positions in the Ministry of Health, 44% were clinicians providing HIV care, and 13% were donors or employed by NGOs; 89% held a medical degree. Stakeholders were highly supportive of physician assistants performing simple ART-related tasks and unanimous in opposing community health workers providing any ART-related services. The most commonly cited motives to implement task shifting were to increase ART access, decrease physician workload, and decrease patient wait time, whereas chief concerns included reduced quality of care and poor training and supervision. Support for task shifting was higher among clinicians than policy and programme leaders for three specific task/cadre combinations: general mid-level nurses to initiate ART in adults (supported by 75% of clinicians vs. 41% of non-clinicians) and in pregnant women (75% vs. 34%, respectively) and physician assistants to change ART regimens in adults (43% vs. 24%, respectively).

CONCLUSIONS

Stakeholders agreed on some ART-related task delegation to lower health worker cadres. Clinicians were more likely to support task shifting than policy and programme leaders, perhaps motivated by their front-line experiences. Harmonizing policy and programme managers' views with those of clinicians will be important to formulate and implement clear policy.

Hydrocephalus in children less than 1 year of age in northern Mozambique

Background:

In developed countries, the incidence of neonatal hydrocephalus ranges from 3 to 5 cases per 1000 live births, but little is known about the frequency of hydrocephalus in Africa. In Mozambique, there is no primary information related to this disorder, but using the above data, the expected incidence of neonatal hydrocephalus would range from 2900 to 4800 cases per year.

Methods:

This study is based on 122 children younger than 1 year with neonatal hydrocephalus, followed up between January 2010 and December 2012, their origin and treatment, and aims to evaluate difficulties with diagnosis, treatment, and follow-up in northern Mozambique.

Results:

Identified cases were mainly less than 6 months old (77%), with severe macrocephaly and the classic stigmata of this condition. A high rate of follow-up loss (44.3%) was detected, particularly among children from more distant locations. Our findings contrast with the expected 1000-1700 cases that would occur in the area during the study period, being considerably lower.

Conclusions:

Hydrocephalus is a serious problem in sub-Saharan Africa, whose effects can be minimized by a better organization of the health system in hydrocephalus prevention, referral, and follow-up. New management alternatives to provide treatment to more children with this disorder and reduction of the follow-up difficulties caused due to geographical reasons for the children undergoing treatment are essential.

The prevention of mother-to-child transmission of HIV cascade analysis tool: supporting health managers to improve facility-level service delivery

BACKGROUND

The objective of the prevention of Mother-to-Child Transmission (pMTCT) cascade analysis tool is to provide frontline health managers at the facility level with the means to rapidly, independently and quantitatively track patient flows through the pMTCT cascade, and readily identify priority areas for clinic-level improvement interventions. Over a period of six months, five experienced maternal-child health managers and researchers iteratively adapted and tested this systems analysis tool for pMTCT services. They prioritized components of the pMTCT cascade for inclusion, disseminated multiple versions to 27 health managers and piloted it in five facilities. Process mapping techniques were used to chart PMTCT cascade steps in these five facilities, to document antenatal care attendance, HIV testing and counseling, provision of prophylactic anti-retrovirals, safe delivery, safe infant feeding, infant follow-up including HIV testing, and family planning, in order to obtain site-specific knowledge of service delivery.

RESULTS

Seven pMTCT cascade steps were included in the Excel-based final tool. Prevalence calculations were incorporated as sub-headings under relevant steps. Cells not requiring data inputs were locked, wording was simplified and stepwise drop-offs and maximization functions were included at key steps along the cascade. While the drop off function allows health workers to rapidly assess how many patients were lost at each step, the maximization function details the additional people served if only one step improves to 100% capacity while others stay constant.

CONCLUSIONS

Our experience suggests that adaptation of a cascade analysis tool for facility-level pMTCT services is feasible and appropriate as a starting point for discussions of where to implement improvement strategies. The resulting tool facilitates the engagement of frontline health workers and managers who fill out, interpret, apply the tool, and then follow up with quality improvement activities. Research on adoption, interpretation, and sustainability of this pMTCT cascade analysis tool by frontline health managers is needed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02023658, December 9, 2013.

The development of a public optometry system in Mozambique: a Cost Benefit Analysis

BACKGROUND

The economic burden of uncorrected refractive error (URE) is thought to be high in Mozambique, largely as a consequence of the lack of resources and systems to tackle this largely avoidable problem. The Mozambique Eyecare Project (MEP) has established the first optometry training and human resource deployment initiative to address the burden of URE in Lusophone Africa. The nature of the MEP programme provides the opportunity to determine, using Cost Benefit Analysis (CBA), whether investing in the establishment and delivery of a comprehensive system for optometry human resource development and public sector deployment is economically justifiable for Lusophone Africa.

METHODS

A CBA methodology was applied across the period 2009-2049. Costs associated with establishing and operating a school of optometry, and a programme to address uncorrected refractive error, were included. Benefits were calculated using a human capital approach to valuing sight. Disability weightings from the Global Burden of Disease study were applied. Costs were subtracted from benefits to provide the net societal benefit, which was discounted to provide the net present value using a 3% discount rate.

RESULTS

Using the most recently published disability weightings, the potential exists, through the correction of URE in 24.3 million potentially economically productive persons, to achieve a net present value societal benefit of up to $1.1 billion by 2049, at a Benefit-Cost ratio of 14:1. When CBA assumptions are varied as part of the sensitivity analysis, the results suggest the societal benefit could lie in the range of $649 million to $9.6 billion by 2049.

CONCLUSION

This study demonstrates that a programme designed to address the burden of refractive error in Mozambique is economically justifiable in terms of the increased productivity that would result due to its implementation.

Traditional uses of plants in a rural community of Mozambique and possible links with Miombo degradation and harvesting sustainability

BACKGROUND

Miombo woodlands play an important role in the livelihood of people living in sub-equatorial African countries, contributing to satisfy basic human needs such as food, medicine, fuelwood and building materials. However, over-exploitation of plant resources and unsustainable harvest practices can potentially degrade forests. The aim of this study was to document the use of Miombo plant products, other than medicinal plants, in local communities, within a wider framework in which we discussed possible links between traditional uses and conservation status of the used species and of the whole Miombo environment.

METHODS

Fieldwork took place in four communities of Muda-Serração, central Mozambique. We conducted semi-structured interviews with 52 informants about their knowledge, use and harvesting practices of useful plants. A survey on local Miombo vegetation was also carried out in order to assess abundance and distribution of useful woody plants cited in the interviews in areas exposed to different exploitation rates. A Conservation Priority index was also applied to rank conservation values of each used woody species.

RESULTS

Ninety-eight plants cited by the informants were botanically identified. The most relevant general category was represented by food plants (45 species), followed by handicraft plants (38 species) and domestic plants (37 species). Among the 54 woody species observed in vegetation plots, 52% were cited as useful in the interviews. Twenty-six woody species found in 'natural' Miombo areas were not found in 'degraded' ones: of these, 46% were cited in the interviews (58% in the food category, 50% in the handicraft category, 25% in the domestic category and 8% in the fishing category). Results of conservation ranking showed that 7 woody species deserve conservation priority in the investigated area.

CONCLUSIONS

This study shows that the communities investigated rely heavily on local forest products for their daily subsistence requirements in food, firewood/charcoal and building materials. However, over-exploitation and destructive collection seem to threaten the survival of some of the woody species used. A sustainable approach including the involvement of local communities in the management of woody species is recommended.

HIV scale-up in Mozambique: exceptionalism, normalisation and global health

The large-scale introduction of HIV and AIDS services in Mozambique from 2000 onwards occurred in the context of deep political commitment to sovereign nation-building and an important transition in the nation's health system. Simultaneously, the international community encountered a willing state partner that recognised the need to take action against the HIV epidemic. This article examines two critical policy shifts: sustained international funding and public health system integration (the move from parallel to integrated HIV services). The Mozambican government struggles to support its national health system against privatisation, NGO competition and internal brain drain. This is a sovereignty issue. However, the dominant discourse on self-determination shows a contradictory twist: it is part of the political rhetoric to keep the sovereignty discourse alive, while the real challenge is coordination, not partnerships. Nevertheless, we need more anthropological studies to understand the political implications of global health funding and governance. Other studies need to examine the consequences of public health system integration for the quality of access to health care.

Integrated maternal and child health services in Mozambique: structural health system limitations overshadow its effect on follow-up of HIV-exposed infants

BACKGROUND

The follow-up of HIV-exposed infants remains a public health challenge in many Sub-Saharan countries. Just as integrated antenatal and maternity services have contributed to improved care for HIV-positive pregnant women, so too could integrated care for mother and infant after birth improve follow-up of HIV-exposed infants. We present results of a study testing the viability of such integrated care, and its effects on follow-up of HIV-exposed infants, in Tete Province, Mozambique.

METHODS

Between April 2009 and September 2010, we conducted a mixed-method, intervention-control study in six rural public primary healthcare facilities, selected purposively for size and accessibility, with random allocation of three facilities each for intervention and control groups. The intervention consisted of a reorganization of services to provide one-stop, integrated care for mothers and their children under five years of age. We collected monthly routine facility statistics on prevention of mother-to-child HIV transmission (PMTCT), follow-up of HIV-exposed infants, and other mother and child health (MCH) activities for the six months before (January-June 2009) and 13 months after starting the intervention (July 2009-July 2010). Staff were interviewed at the start, after six months, and at the end of the study. Quantitative data were analysed using quasi-Poisson models for significant differences between the periods before and after intervention, between healthcare facilities in intervention and control groups, and for time trends. The coefficients for the effect of the period and the interaction effect of the intervention were calculated with their p-values. Thematic analysis of qualitative data was done manually.

RESULTS

One-stop, integrated care for mother and child was feasible in all participating healthcare facilities, and staff evaluated this service organisation positively. We observed in both study groups an improvement in follow-up of HIV-exposed infants (registration, follow-up visits, serological testing), but frequent absenteeism of staff and irregular supply of consumables interfered with healthcare facility performance for both intervention and control groups.

CONCLUSIONS

Despite improvement in various aspects of the follow-up of HIV-exposed infants, we observed no improvement attributable to one-stop, integrated MCH care. Structural healthcare system limitations, such as staff absences and irregular supply of essential commodities, appear to overshadow its potential effects. Regular technical support and adequate basic working conditions are essential for improved performance in the follow-up of HIV-exposed infants in peripheral public healthcare facilities in Mozambique.

Becoming and remaining community health workers: perspectives from Ethiopia and Mozambique

Many global health practitioners are currently reaffirming the importance of recruiting and retaining effective community health workers (CHWs) in order to achieve major public health goals. This raises policy-relevant questions about why people become and remain CHWs. This paper addresses these questions, drawing on ethnographic work in Addis Ababa, the capital of Ethiopia, between 2006 and 2009, and in Chimoio, a provincial town in central Mozambique, between 2003 and 2010. Participant observation and in-depth interviews were used to understand the life histories that lead people to become CHWs, their relationships with intended beneficiaries after becoming CHWs, and their social and economic aspirations. People in Ethiopia and Mozambique have faced similar political and economic challenges in the last few decades, involving war, structural adjustment, and food price inflation. Results suggest that these challenges, as well as the socio-moral values that people come to uphold through the example of parents and religious communities, influence why and how men and women become CHWs. Relationships with intended beneficiaries strongly influence why people remain CHWs, and why some may come to experience frustration and distress. There are complex reasons why CHWs come to seek greater compensation, including desires to escape poverty and to materially support families and other community members, a sense of deservingness given the emotional and social work involved in maintaining relationships with beneficiaries, and inequity vis-à-vis higher-salaried elites. Ethnographic work is needed to engage CHWs in the policy process, help shape new standards for CHW programs based on rooting out social and economic inequities, and develop appropriate solutions to complex CHW policy problems.

Labor migration and child mortality in Mozambique

Male labor migration is widespread in many parts of the world, yet its consequences for child outcomes and especially childhood mortality remain unclear. Male labor migration could bring benefits, in the form of remittances, to the families that remain behind and thus help child survival. Alternatively, the absence of a male adult could imperil the household's well-being and its ability to care for its members, increasing child mortality risks. In this analysis, we use longitudinal survey data from Mozambique collected in 2006 and 2009 to examine the association between male labor migration and under-five mortality in families that remain behind. Using a simple migrant/non-migrant dichotomy, we find no difference in mortality rates across migrant and non-migrant men's children. When we separated successful from unsuccessful migration based on the wife's perception, however, stark contrasts emerge: children of successful migrants have the lowest mortality, followed by children of non-migrant men, followed by the children of unsuccessful migrants. Our results illustrate the need to account for the diversity of men's labor migration experience in examining the effects of migration on left-behind households.

Exploring audience segmentation: investigating adopter categories to diffuse an innovation to prevent famine in rural Mozambique

Audience segmentation is a useful tool for designing effective campaigns. Further, the efficiency promised in diffusion science rests to some degree on the existence of adopter categories that can be identified and used to strategically disseminate prevention innovations. This study investigates the potential to identify adopter categories in potential recipients (n = 127) of an innovation to prevent food shortages in Mozambique. A 5-class model was found using latent class analysis, but it showed important differences from existing descriptions of adopter categories. Implications for theory and practice are discussed.

Geographic differentials in mortality of children in Mozambique: their implications for achievement of Millennium Development Goal 4

In the light of Mozambique's progress towards the achievement of Millennium Development Goal 4 of reducing mortality of children aged less than five years (under-five mortality) by two-thirds within 2015, this study investigated the relationship between the province of mother's residence and under-five mortality in Mozambique, using data from the 2003 Mozambican Demographic and Health Survey. The analyses included 10,326 children born within 10 years before the survey. Results of univariate and multivariate analyses showed a significant association between under-five mortality and province (region) of mother's residence. Children of mothers living in the North provinces (Niassa, Cabo Delgado, and Nampula) and the Central provinces (Zambezia, Sofala, Manica, and Tete) had higher risks of mortality than children whose mothers lived in the South provinces, especially Maputo province and Maputo city. However, controlling for the demographic, socioeconomic and environmental variables, the significance found between the place of mother's residence and under-five mortality reduced slightly. This suggests that other variables (income distribution and trade, density of population, distribution of the basic infrastructure, including healthcare services, climatic and ecologic factors), which were not included in the study, may have confounding effects. This study supports the thought that interventions aimed at reducing under-five mortality should be tailored to take into account the subnational/regional variation in economic development. However, research is warranted to further investigate the potential determinants behind the observed differences in under-five mortality.

Prevalence and clinical features of HIV and malaria co-infection in hospitalized adults in Beira, Mozambique

BACKGROUND

Mozambique presents a very high prevalence of both malaria and HIV infection, but the impact of co-cancel infection on morbidity in this population has been rarely investigated. The aim of this study was to describe the prevalence and clinical characteristics of malaria in hospitalized adult HIV-positive patients, treated and untreated with combination anti-retroviral therapy (ART) and cotrimoxazole (CTX)-based chemoprophylaxis, compared to HIV negatives.

METHODS

From November to December 2010, all adult patients consecutively admitted to the Department of Internal Medicine of Beira Central Hospital, Sofala Province, Mozambique, were submitted to HIV testing, malaria blood smear (MBS) and, in a subgroup of patients, also to the rapid malaria test (RDT). Socio-demographical and clinical data were collected for all patients. The association of both a positive MBS and/or RDT and diagnosis of clinical malaria with concomitant HIV infection (and use of CTX and/or ART) was assessed statistically. Frequency of symptoms and hematological alterations in HIV patients with clinical malaria compared to HIV negatives was also analysed. Sensitivity and specificity for RDT versus MBS were calculated for both HIV-positive and negative patients.

RESULTS

A total of 330 patients with available HIV test and MBS were included in the analysis, 220 of whom (66.7%) were HIV-positive. In 93 patients, malaria infection was documented by MBS and/or RDT. RDT sensitivity and specificity were 94% and 96%, respectively. According to laboratory results, the initial malaria suspicion was discarded in about 10% of cases, with no differences between HIV-positive and negative patients. A lower malaria risk was significantly associated with CTX prophylaxis (p=0.02), but not with ART based on non nucleoside reverse-transcriptase inhibitors (NNRTIs). Overall, severe malaria seemed to be more common in HIV-positive patients (61.7%) compared to HIV-negatives (47.2%), while a significantly lower haemoglobin level was observed in the group of HIV-positive patients (9.9 ± 2.8 mg/dl) compared to those HIV-negative (12.1 ± 2.8 mg/dl) (p=0.003).

CONCLUSIONS

Malaria infection was rare in HIV-positive individuals treated with CTX for opportunistic infections, while no independent anti-malarial effect for NNRTIs was noted. When HIV and malaria co-infection occurred, a high risk of complications, particularly anaemia, should be expected.

Glucose-6-phosphate dehydrogenase deficiency, chlorproguanil-dapsone with artesunate and post-treatment haemolysis in African children treated for uncomplicated malaria

BACKGROUND

Malaria is a leading cause of mortality, particularly in sub-Saharan African children. Prompt and efficacious treatment is important as patients may progress within a few hours to severe and possibly fatal disease. Chlorproguanil-dapsone-artesunate (CDA) was a promising artemisinin-based combination therapy (ACT), but its development was prematurely stopped because of safety concerns secondary to its associated risk of haemolytic anaemia in glucose-6-phosphate dehydrogenase (G6PD)-deficient individuals. The objective of the study was to assess whether CDA treatment and G6PD deficiency are risk factors for a post-treatment haemoglobin drop in African children<5 years of age with uncomplicated malaria.

METHODS

This case-control study was performed in the context of a larger multicentre randomized clinical trial comparing safety and efficacy of four different ACT in children with uncomplicated malaria. Children, who after treatment experienced a haemoglobin drop≥2 g/dl (cases) within the first four days (days 0, 1, 2, and 3), were compared with those without an Hb drop (controls). Cases and controls were matched for study site, sex, age and baseline haemoglobin measurements. Data were analysed using a conditional logistic regression model.

RESULTS

G6PD deficiency prevalence, homo- or hemizygous, was 8.5% (10/117) in cases and 6.8% (16/234) in controls (p=0.56). The risk of a Hb drop≥2 g/dl was not associated with either G6PD deficiency (adjusted odds ratio (AOR): 0.81; p=0.76) or CDA treatment (AOR: 1.28; p=0.37) alone. However, patients having both risk factors tended to have higher odds (AOR: 11.13; p=0.25) of experiencing a Hb drop≥2 g/dl within the first four days after treatment, however this finding was not statistically significant, mainly because G6PD deficient patients treated with CDA were very few. In non-G6PD deficient individuals, the proportion of cases was similar between treatment groups while in G6PD-deficient individuals, haemolytic anaemia occurred more frequently in children treated with CDA (56%) than in those treated with other ACT (29%), though the difference was not significant (p=0.49).

CONCLUSION

The use of CDA for treating uncomplicated malaria may increase the risk of haemolytic anaemia in G6PD-deficient children.

Frequency of human immunodeficiency virus type-2 in hiv infected patients in Maputo City, Mozambique

The HIV/AIDS pandemic is primarily caused by HIV-1. Another virus type, HIV-2, is found mainly in West African countries. We hypothesized that population migration and mobility in Africa may have facilitated the introduction and spreading of HIV-2 in Mozambique. The presence of HIV-2 has important implications for diagnosis and choice of treatment of HIV infection. Hence, the aim of this study was to estimate the prevalence of HIV-2 infection and its genotype in Maputo, Mozambique.HIV-infected individuals (N = 1,200) were consecutively enrolled and screened for IgG antibodies against HIV-1 gp41 and HIV-2 gp36 using peptide-based enzyme immunoassays (pepEIA). Specimens showing reactivity on the HIV-2 pepEIA were further tested using the INNO-LIA immunoblot assay and HIV-2 PCR targeting RT and PR genes. Subtype analysis of HIV-2 was based on the protease gene.After screening with HIV-2 pepEIA 1,168 were non-reactive and 32 were reactive to HIV-2 gp36 peptide. Of this total, 30 specimens were simultaneously reactive to gp41 and gp36 pepEIA while two samples reacted solely to gp36 peptide. Only three specimens containing antibodies against gp36 and gp105 on the INNO-LIA immunoblot assay were found to be positive by PCR to HIV-2 subtype A.The proportion of HIV-2 in Maputo City was 0.25% (90%CI 0.01-0.49). The HIV epidemic in Southern Mozambique is driven by HIV-1, with HIV-2 also circulating at a marginal rate. Surveillance program need to improve HIV-2 diagnosis and consider periodical survey aiming to monitor HIV-2 prevalence in the country.

Barriers to antiretroviral therapy adherence in rural Mozambique

BACKGROUND

HIV is treated as a chronic disease, but high lost-to-follow-up rates and poor adherence to medication result in higher mortality, morbidity, and viral mutation. Within 18 clinical sites in rural Zambézia Province, Mozambique, patient adherence to antiretroviral therapy has been sub-optimal.

METHODS

To better understand barriers to adherence, we conducted 18 community and clinic focus groups in six rural districts. We interviewed 76 women and 88 men, of whom 124 were community participants (CP; 60 women, 64 men) and 40 were health care workers (HCW; 16 women, 24 men) who provide care for those living with HIV.

RESULTS

While there was some consensus, both CP and HCW provided complementary insights. CP focus groups noted a lack of confidentiality and poor treatment by hospital staff (42% CP vs. 0% HCW), doubt as to the benefits of antiretroviral therapy (75% CP vs. 0% HCW), and sharing medications with family members (66% CP vs. 0%HCW). Men expressed a greater concern about poor treatment by HCW than women (83% men vs. 0% women). Health care workers blamed patient preference for traditional medicine (42% CP vs. 100% HCW) and the side effects of medication for poor adherence (8% CP vs. 83% CHW).

CONCLUSIONS

Perspectives of CP and HCW likely reflect differing sociocultural and educational backgrounds. Health care workers must understand community perspectives on causes of suboptimal adherence as a first step toward effective intervention.

Phytoliths in woody plants from the Miombo woodlands of Mozambique

BACKGROUND AND AIMS

There are no descriptions of phytoliths produced by plants from the 'Zambezian' zone, where Miombo woodlands are the dominant element of the largest single phytochorion in sub-Saharan Africa. The preservation of phytoliths in fossil records of Africa makes phytoliths a tool to study early plant communities. Paleo-ethnobotanical interpretation of phytoliths relies on the comparison of ancient types with morphotypes extracted from living reference collections.

METHODS

Phytoliths were extracted from plant samples representing 41 families, 77 genera and 90 species through sonic cleaning, dry ashing and acid treatment; and phytoliths thus extracted were quantified. For each species, an average of 216 phytoliths were counted. The percentage of each morphotype identified per species was calculated, and types were described according to the descriptors from the International Code for Phytolith Nomenclature. Phytolith assemblages were subject to discriminant analysis, cluster analysis and principal component analysis.

KEY RESULTS

Phytoliths were grouped into 57 morphotypes (two were articulated forms and 55 were discrete shapes), and provide a reference collection of phytolith assemblages produced by Miombo woody species. Common and unique morphotypes are described and taxonomic and grouping variables are looked into from a statistical perspective.

CONCLUSIONS

The first quantitative taxonomy of phytoliths from Miombos is presented here, including new types and constituting the most extensive phytolith key for any African ecoregion. Evidence is presented that local woody species are hypervariable silica producers and their phytolith morphotypes are highly polymorphic. The taxonomic significance of these phytoliths is largely poor, but there are important exceptions that include the morphotypes produced by members from >10 families and orders. The typical phytolithic signal that would allow scientists to identify ancient woodlands of 'Zambezian' affiliation comprises only half of the original number of phytoliths originally produced and might favour the more resilient blocky, cylindroid, globular and tabular forms.