Population size, HIV prevalence, and antiretroviral therapy coverage among key populations in sub-Saharan Africa: collation and synthesis of survey data, 2010-23.

BACKGROUND: Key population HIV programmes in sub-Saharan Africa require epidemiological information to ensure equitable and universal access to effective services. We aimed to consolidate and harmonise survey data among female sex workers, men who have sex with men, people who inject drugs, and transgender people to estimate key population size, HIV prevalence, and antiretroviral therapy (ART) coverage for countries in mainland sub-Saharan Africa. METHODS: Key population size estimates, HIV prevalence, and ART coverage data from 39 sub-Saharan Africa countries between 2010 and 2023 were collated from existing databases and verified against source documents. We used Bayesian mixed-effects spatial regression to model urban key population size estimates as a proportion of the gender-matched, year-matched, and area-matched population aged 15-49 years. We modelled subnational key population HIV prevalence and ART coverage with age-matched, gender-matched, year-matched, and province-matched total population estimates as predictors. FINDINGS: We extracted 2065 key population size data points, 1183 HIV prevalence data points, and 259 ART coverage data points. Across national urban populations, a median of 1·65% (IQR 1·35-1·91) of adult cisgender women were female sex workers, 0·89% (0·77-0·95) were men who have sex with men, 0·32% (0·31-0·34) were men who injected drugs, and 0·10% (0·06-0·12) were women who were transgender. HIV prevalence among key populations was, on average, four to six times higher than matched total population prevalence, and ART coverage was correlated with, but lower than, the total population ART coverage with wide heterogeneity in relative ART coverage across studies. Across sub-Saharan Africa, key populations were estimated as comprising 1·2% (95% credible interval 0·9-1·6) of the total population aged 15-49 years but 6·1% (4·5-8·2) of people living with HIV. INTERPRETATION: Key populations in sub-Saharan Africa experience higher HIV prevalence and lower ART coverage, underscoring the need for focused prevention and treatment services. In 2024, limited data availability and heterogeneity constrain precise estimates for programming and monitoring trends. Strengthening key population surveys and routine data within national HIV strategic information systems would support more precise estimates. FUNDING: UNAIDS, Bill & Melinda Gates Foundation, and US National Institutes of Health.

Trends in HIV prevalence and risk factors among men who have sex with men in Mozambique: implications for targeted interventions and public health strategies.

BACKGROUND: Men who have sex with Men (MSM) are known to contribute to increased HIV prevalence as an integral part of key populations with high vulnerability to HIV/AIDS due to their sexual behaviours. Mozambique conducted two rounds of bio-behavioral surveys (BBS) in this population with the main objective of estimating HIV prevalence and associated risk behaviors among MSM in Mozambique. The present study aims to estimate the trend of HIV prevalence and determine the correlations of HIV infection among MSM. METHODS: A repeated cross-sectional analytical study was conducted from secondary data from the first and second rounds of BBS in Mozambique conducted in 2011 and 2020-2021 respectively. Each round used a similar methodology which allowed for comparison between the two surveys. Chi-square test and logistic regression was used to compare the HIV prevalence between the BBS rounds, identify factors associated with HIV, and assess changes in HIV prevalence across selected risk factors. RESULTS: There was a significant increase in HIV prevalence among MSM (7.1-14.9%), living in Maputo (9.3-14.7%), uncircumcised (11.7-25.1%), and those who reported two sexual partners in the last year (5.2-14.4%). In contrast, there was a decrease in prevalence among adult MSM aged between 25 and 29 years (24.7-13.9%), aged 30 years or older (45.7-27.7%), married (29.1-16.8%), with higher education (16.7-5.9%) and moderate perception of HIV risk (10.9-3.4%). Multivariable analysis showed that factors such as age, marital status, religion, sexual identity, circumcision, and the use of lubrication during anal sex are significantly associated with the risk of HIV infection. CONCLUSIONS: This study underscores the continuing need for HIV prevention and education efforts. The rise in prevalence among specific population segments and the sustained presence of risk factors emphasize the requirement for holistic strategies tailored to the unique requirements of each subgroup. Understanding trends and risk factors is crucial to guiding public health policies and designing efficacious prevention programs that aim to curtail HIV transmission while enhancing the well-being of those impacted by the condition.

Prevalence and correlates of hazardous alcohol drinking and drug use among female sex workers and men who have sex with men in Mozambique.

BACKGROUND: Hazardous drinking and drug consumption are associated with an increased risk of HIV due to the complex interplay of factors influencing decision-making capability, stigma and social marginalization. In this study, we explore the patterns of hazardous alcohol and drug use and correlates of risk factors among female sex workers (FSW) and men who as sex with men (MSM) in Mozambique. METHODS: We conducted a secondary data analysis of bio-behavioral surveys (BBS) among FSW and MSM using a respondent-driven sampling methodology conducted in five main urban areas of Mozambique from 2019 to 20. The survey included a standardized questionnaire, where hazardous drinking was assessed (using AUDIT-C scores ≥ 4 for men, ≥ 3 for women) and drug use in the last year (FSW). Chi-squared test was used to analyze the association between socio-demographic and behavioral variables, and multivariate logistic regression measured the impact of the associated factors. RESULTS: The prevalence of hazardous alcohol drinking was 47.1% (95% CI:44.8-49.5) for FSW and 46.5 (95% CI: 44.0-49.0) for MSM. Current drug use was reported in 13.3% of FSW. FSW engaging in hazardous alcohol drinking reported more sexual partners in the last month than those no reporting hazardous alcohol use (55.3% vs. 47,1%, p < 0.001), higher rates of self-reported STIs in the last year (62,5% vs. 48,2%, p < 0.001), physical (53.5% vs. 46.7%, p < 0.0001) and sexual violence (54.7% vs. 44.2%, p < 0.001), and HIV prevalence (55.2% vs. 44.2 p < 0.001). Among MSM with hazardous alcohol drinking, there was a higher prevalence of self-reported STIs (52.8% vs. 45.4%, p < 0.001), experiences of sexual violence (18.0% vs. 8.3%, p < 0.001), and HIV prevalence (53.0% vs. 46.3%, p < 0.001). In addition, FSW who reported illicit drug use were more likely to self-reported HIV own risk (14.2% vs. 9.7%), early start sexual activity (15.4% vs. 5.3%), self-reported STIs (17.9% vs. 10.2%), and experiences of both physical (17.4% vs. 7.0%) and sexual violence (18.6% vs. 8.9%). CONCLUSION: There is an immediate need for the introduction and integration of comprehensive substance use harm mitigation and mental health interventions into HIV prevention programs, particularly those targeting key populations in Mozambique.

People Who Inject Drugs in Mozambique: We need to normalize HIV treatment and care services in specialized community centers for people who inject drugs!

Globally, People Who Inject Drugs (PWID) have limited healthcare, treatment, and prevention services, and they frequently experience stigma and negative attitudes toward healthcare providers when accessing services. Mozambique, with a general population HIV prevalence of 12.5%, has one of the highest rates in the world, and the PWID population has the highest HIV prevalence among key populations, estimated at nearly 50%. Less than half of HIV positives who inject drugs are linked to HIV treatment and are retained in care. One of the main reasons is that HIV treatment is mainly provided in a public health facility and PWID delayed accessing healthcare since they anticipated mistreatment from multiple levels of healthcare providers. To improve the health outcomes in this group, we need to treat them where they feel comfortable and respected. In this commentary, we outline the importance of innovative approaches to enhance the management of HIV-positive PWID. As a country gets close to controlling the HIV epidemic, refocusing and targeting responses to the highest-risk groups becomes even more essential for shaping more effective HIV interventions and achieving epidemic control.

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.

Framework for determining the optimal course of action when efficiency and affordability measures differ by perspective in cost-effectiveness analysis-with an illustrative case of HIV treatment in Mozambique.

BACKGROUND: Cost-effectiveness analysis (CEA) is a standard tool for evaluating health programs and informing decisions about resource allocation and prioritization. Most CEAs evaluating health interventions in low- and middle-income countries adopt a health sector perspective, accounting for resources funded by international donors and country governments, while often excluding out-of-pocket expenditures and time costs borne by program beneficiaries. Even when patients' costs are included, a companion analysis focused on the patient perspective is rarely performed. We view this as a missed opportunity. METHODS: We developed methods for assessing intervention affordability and evaluating whether optimal interventions from the health sector perspective also represent efficient and affordable options for patients. We mapped the five different patterns that a comparison of the perspective results can yield into a practical framework, and we provided guidance for researchers and decision-makers on how to use results from multiple perspectives. To illustrate the methodology, we conducted a CEA of six HIV treatment delivery models in Mozambique. We conducted a Monte Carlo microsimulation with probabilistic sensitivity analysis from both patient and health sector perspectives, generating incremental cost-effectiveness ratios for the treatment approaches. We also calculated annualized patient costs for the treatment approaches, comparing the costs with an affordability threshold. We then compared the cost-effectiveness and affordability results from the two perspectives using the framework we developed. RESULTS: In this case, the two perspectives did not produce a shared optimal approach for HIV treatment at the willingness-to-pay threshold of 0.3 × Mozambique's annual GDP per capita per DALY averted. However, the clinical 6-month antiretroviral drug distribution strategy, which is optimal from the health sector perspective, is efficient and affordable from the patient perspective. All treatment approaches, except clinical 1-month distributions of antiretroviral drugs which were standard before Covid-19, had an annual cost to patients less than the country's annual average for out-of-pocket health expenditures. CONCLUSION: Including a patient perspective in CEAs and explicitly considering affordability offers decision-makers additional insights either by confirming that the optimal strategy from the health sector perspective is also efficient and affordable from the patient perspective or by identifying incongruencies in value or affordability that could affect patient participation.

Young key populations left behind: The necessity for a targeted response in Mozambique.

INTRODUCTION: The first exposure to high-risk sexual and drug use behaviors often occurs during the period of youth (15-24 years old). These behaviors increase the risk of HIV infection, especially among young key populations (KP)-men how have sex with men (MSM), female sex workers (FSW), and people who inject drugs (PWID). We describe the characteristics of young KP participants in the first Biobehavioral Surveillance (BBS) surveys conducted in Mozambique and examine their risk behaviors compared to adult KP. METHODS: Respondent-driven sampling (RDS) methodology was used to recruit KP in three major urban areas in Mozambique. RDS-weighted pooled estimates were calculated to estimate the proportion of young KP residing in each survey city. Unweighted pooled estimates of risk behaviors were calculated for each key population group and chi-square analysis assessed differences in proportions between youth (aged less than 24 years old) and older adult KP for each population group. RESULTS: The majority of MSM and FSW participants were young 80.7% (95% CI: 71.5-89.9%) and 71.9% (95% CI: 71.9-79.5%), respectively, although not among PWID (18.2%, 95% CI: 13.2-23.2%). Young KP were single or never married, had a secondary education level or higher, and low employment rates. They reported lower perception of HIV risk (MSM: 72.3% vs 56.7%, p<0.001, FSW: 45.3% vs 24.4%, p<0.001), lower HIV testing uptake (MSM: 67.5% vs 72.3%, p<0.001; FSW: 63.2% vs 80.6%; p<0.001, PWID: 53.3% vs 31.2%; p = 0.001), greater underage sexual debut (MSM: 9.6% vs 4.8%, p<0.001; FSW: 35.2% vs 22.9%, p<0.001), and greater underage initiation of injection drug use (PWID: 31.9% vs 7.0%, p<0.001). Young KP also had lower HIV prevalence compared to older KP: MSM: 3.3% vs 27.0%, p<0.001; FSW: 17.2% vs 53.7%, p<0.001; and PWID: 6.0% vs 55.0%, p<0.001. There was no significant difference in condom use across the populations. CONCLUSION: There is an immediate need for a targeted HIV response for young KP in Mozambique so that they are not left behind. Youth must be engaged in the design and implementation of interventions to ensure that low risk behaviors are sustained as they get older to prevent HIV infection.

Who Are the Men Who Pay for Sex in Mozambique? Results from the National HIV/AIDS Indicator Survey 2015.

Mozambique has one of the highest burdens of HIV in the world, where the prevalence is estimated at 13.2% among adults aged 15-49 years. Men who pay for sex (MPS) are considered a bridging population for HIV infection. However, the characteristics of MPS in Mozambique are poorly understood. The objective of this study was to estimate the prevalence of paid sex among men 15-49 years and investigate risk factors associated with paid sex. We analyzed data collected from 4724 men, aged 15-49 years, as part of the 2015 Mozambique AIDS Indicator Survey. Chi-squared tests and logistic regression models accounting for survey design were used to assess the associations between paying for sex and demographic characteristics and the number of lifetime and recent sex partners, condom use at last sex, and self-reported sexually transmitted infection symptoms. The prevalence of paid sex in the last 12 months was 10.4% (95% CI 9.0-12.1), with Cabo Delgado province having the highest prevalence (38.8%). MPS in the last 12 months were most frequently between the ages of 20-24 years (13.5%), not in a relationship (17.8%), had a primary education (11.9%), from poor households (14.0%), had more than three sexual partners excluding their spouse in the last 12 months (44.7%), and self-reported a STI in the past 12 months (44.2%). HIV prevalence was higher among men who ever paid for sex compared with men who did not (13.1% vs. 9.4%, p = .02). Men who reported 10+ lifetime partner (aOR 7.7; 95% CI 4.5-13.0; p < .001), from Cabo Delgado (aOR 4.0; 95% CI 2.2-7.4; p < .001), who reported STI symptoms in the past 12 months (aOR 2.7; 95% CI 1.7-4.2; p < .001), and HIV positive (aOR 1.6; 95% CI 1.0-3.7; p = .05) were more likely to have paid for sex in the last 12 months. These findings present the HIV prevalence among Mozambican MPS and highlight the need for a comprehensive behavioral, structural, and biomedical approach to interventions to reduce the risks of commercial and transactional sex.

Evaluation of prevention of mother-to-child transmission national health information system for HIV/AIDS, in southern region of Mozambique, April to November 2016.

INTRODUCTION: Mozambique has a generalized HIV epidemic, among pregnant women, HIV prevalence is estimated at 15.8% with a vertical transmission rate of 14%, more than double global targets. We evaluate electronic national health information system (SIS-MA) performance to verify if the data flow procedures met its objectives and evaluated the prevention of mother-to-child transmission (PMTCT) surveillance system to access its attributes and usefulness. METHODS: we conducted a descriptive, cross-sectional evaluation of the PMTCT surveillance system in eight facilities in Gaza and Inhambane provinces using the centers for disease control and prevention guidelines (2001). For data quality, we cross-referenced patient registries from health facilities against the SIS-MA. We also interviewed 34 health technicians, using a Likert scale, to assess the following attributes of the PMTCT surveillance system: simplicity, stability, flexibility, acceptability, timeliness and data quality, usefulness of the system and knowledge of PMTCT. RESULTS: regarding the simplicity measure, we verified that the registry books contain more than 30 variables. The system was 83% flexible in maintaining functionality with the introduction of new health facilities in the system. The completeness of the data was 50% and concordance of data from the register book and monthly reports was 89%. CONCLUSION: the PMTCT SIS-MA is useful in supporting the collection, analysis, interpretation and continuous and systematic dissemination of health data that are used to define and monitor public health policies in Mozambique. However, continued efforts are needed to improve data quality to ensure that the SIS-MA can adequately monitor the PMTCT program and contribute to reduced vertical transmission.

Low engagement in HIV services and progress through the treatment cascade among key populations living with HIV in Mozambique: alarming gaps in knowledge of status.

BACKGROUND: Mozambique has a generalized HIV epidemic of 13.5% among the general population. Early modeling exercises in Mozambique estimate that key populations (KP), defined as men who have sex with men (MSM), female sex workers (FSW), and people who inject drugs (PWID), along with their partners account for about one third of all new infections. There is limited data describing the engagement of KP living with HIV in testing, care and treatment services. METHODS: We conducted a secondary data analysis of HIV-positive participants in the first Bio-behavioral Surveillance (BBS) surveys in Mozambique conducted 2011-2014 in order to assess service uptake and progress though the HIV treatment cascade among MSM, FSW, and PWID. Unweighted pooled estimates were calculated for each key population group. RESULTS: Among HIV-positive MSM, 63.2% of participants had ever received an HIV test, 8.8% were aware of their status, 6.1% reported having been linked to care, while 3.5% initiated ART and were currently on treatment. Of the HIV-infected FSW participants, 76.5% reported a previous HIV test and 22.4% were previously aware of their status. Linkage to care was reported by 20.1%, while 12.7% reported having initiated ART and 11.8% reported being on treatment at the time of the survey. Among HIV-infected PWID participants, 79.9% had previously received an HIV test, 63.2% were aware of their HIV status, and 49.0% reported being linked to care for their HIV infection. ART initiation was reported by 42.7% of participants, while 29.4% were on ART at the time of the survey. CONCLUSION: Among the three high risk populations in Mozambique, losses occurred throughout critical areas of service uptake with the most alarming breakpoint occurring at knowledge of HIV status. Special attention should be given to increasing HIV testing and linkage to ART treatment. Future surveys will provide the opportunity to monitor improvements across the cascade in line with global targets and should include viral load testing to guarantee a more complete picture of the treatment cascade.

Prevalence of HIV, viral hepatitis B/C and tuberculosis and treatment outcomes among people who use drugs: Results from the implementation of the first drop-in-center in Mozambique.

BACKGROUND: People who use drugs (PWUD) which includes both people who inject drugs (PWID) and non-injection drug users (NIDU) are marginalized, experience high levels of stigma and discrimination, and are likely to have challenges with accessing health services. Mozambique implemented the first drop-in center (DIC) for PWUD in Maputo City in 2018. This analysis aims to assess the prevalence of HIV, viral hepatitis B (HBV) and C (HCV) and tuberculosis (TB) among PWUD, and assess their linkage to care and associated correlates. METHODS: We conducted a cross-sectional retrospective analysis of routine screening data collected from the first visit at the drop-in center (DIC) during the period of May 2018 to November 2019 (18 months). Descriptive and multivariable logistic regression analysis were conducted to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) of HIV, HBV, HCV and TB infections among PWID and NIDU. Cox proportional hazards models of determinants were used to estimate time from HIV diagnosis to linkage to care for PWUD. RESULTS: A total of 1,818 PWUD were screened at the DIC, of whom 92.6% were male. The median age was 27 years (range:14-63). Heroin was the most consumed drug (93.8%), and among people who used it, 15.5% injected it. Prevalence of HIV (43.9%), HCV (22.6%) and HBV (5.9%) was higher among PWID (p<0.001). Linkage to HIV care was observed in 40.5% of newly diagnosed PWID. Factors associated with shorter time to linkage to care included drug injection (aHR=1.6) and confirmed TB infection (aHR=2.9). CONCLUSION: This was the first analysis conducted on the implementation of the DIC in Mozambique and highlights the importance of targeted services for this high-risk population. Our analysis confirmed a high prevalence of HIV, HBV and HCV, and highlight the challenges with linkage to care among PWID. The expansion of DIC locations to other high-risk localities to enhance HIV testing, treatment services and linkage to care to reduce ongoing transmission of HIV, HBV, HCV and TB and improve health outcomes.

Recognizing the hidden: strengthening the HIV surveillance system among key and priority populations in Mozambique.

High quality, representative data from HIV surveillance systems that have country ownership and commitment are critical for guiding national HIV responses, especially among key and priority populations given their disproportionate role in the transmission of the virus. Between 2011 to 2013, the Mozambique Ministry of Health has conducted five Biobehavioral Surveillance Surveys among key populations (female sex workers, men who has sex with men and people who inject drugs) and priority populations (long distance truck drives and miners) as part of the national HIV surveillance system. We describe the experience of strengthening the HIV surveillance system among those populations through the implementation of these surveys in Mozambique. We document the lessons learned through the impact on coordination and collaboration; workforce development and institutional capacity building; data use and dissemination; advocacy and policy impact; financial sustainability and community impact. Key lessons learned include the importance of multisectoral collaboration, vital role of data to support key populations visibility and advocacy efforts, and institutional capacity building of government agencies and key populations organizations. Given that traditional surveillance methodologies from routine data often do not capture these hidden populations, it will be important to ensure that Biobehavioral Surveillance Surveys are an integral part of ongoing HIV surveillance activities in Mozambique.

High burden of self-reported sexually transmitted infections among key populations in Mozambique: the urgent need for an integrated surveillance system.

BACKGROUND: Key populations - men who have sex with men (MSM), female sex workers (FSW) and people who inject drugs (PWID) - are at high risk for sexually transmitted infections (STI) given their sexual risk behaviours along with social, legal and structural barriers to prevention, care and treatment services. The purpose of this secondary analysis is to assess the prevalence of self-reported STIs and to describe associated risk factors among participations of the first Biological Behavioural Surveillance (BBS) in Mozambique. METHODS: Responses from the first BBS surveys conducted in 2011-2014 were aggregated across survey-cities to produce pooled estimates for each population. Aggregate weighted estimates were computed to analyse self-reported STI prevalence. Unweighted pooled estimates were used in multivariable logistic regression to identify risk factors associated with self-reported STI. RESULTS: The prevalence of self-reported STI was 11.9% (95% CI, 7.8-16.0), 33.6% (95% CI, 29.0-41.3), and 22.0% (95% CI, 17.0-27.0) among MSM, FSW and PWID, respectively. MSM who were circumcised, had HIV, reported drug use, reported receptive anal sex, and non-condom use with their last male partner had greater odds of STI self-report. STI-self report among FSW was associated with living in Beira, being married, employment aside from sex work, physical violence, sexual violence, drug use, access to comprehensive HIV prevention services, non-condom use with last client, and sexual relationship with a non-client romantic partner. Among PWID, risk factors for self-reported STI included living in Nampula/Nacala, access to HIV prevention services, and sex work. CONCLUSION: The high-burden of STIs among survey participants requires integrated HIV and STI prevention, treatment, and harm reduction services that address overlapping risk behaviours, especially injection drug use and sex work. A robust public health response requires the creation of a national STI surveillance system for better screening and diagnostic procedures within these vulnerable populations.

Population Size Estimate of Men Who Have Sex With Men, Female Sex Workers, and People Who Inject Drugs in Mozambique: A Multiple Methods Approach.

BACKGROUND: Accurate estimates of key population size are necessary to design programs and policies to prevent and reduce new HIV infections and to monitor the dynamics of the epidemic. The first bio-behavioral surveillance surveys, with population size estimation activities, were conducted in Mozambique in 2010 to 2014. METHODS: We used multiple methods-sequential sampling, unique object, unique event, and service multipliers-to estimate the numbers of men who have sex with men (MSM), female sex workers (FSW), and people who inject drugs (PWID) living in major cities in Mozambique. Results were applied to population sizes to estimate the number of people living with HIV and those unaware of their status. RESULTS: Our results suggest that Maputo has 5182 MSM, which constitutes 1.0% of the adult male population (plausibility bounds, 0.5%-2.6%); Beira, 1796 (1.4%, 1.0%-2.2%); and Nampula, 874 (0.6%, 0.4%-1.6%). The number of FSW population is 1514 (0.6%; plausibility bounds, 0.4%-1.6% of adult female city population) in Maputo, 2616 (2.2%, 1.3%-6.0%) in Beira, and 2052 (1.4%, 0.8%-5.9%) in Nampula. The number of people who inject drugs is 2518 (0.4%; plausibility bounds, 0.3%-0.5% of adult male city population) in Maputo and 1982 (1.2%, 0.6%-1.9%) in Nampula. People living with HIV ranged from 25 to 497 MSM, 382 to 664 FSW, and 712 to 1340 PWID, whereas people living with HIV unaware of their HIV positive serostatus ranged from 24 to 486 MSM, 327 to 552 FSW, and 265 to 468 PWID. CONCLUSIONS: Although estimates generally fell within the range of those from the literature, the triangulation of survey and programmatic data over time will increasingly refine population size estimates and support the optimal allocation of limited resources.

Access to and use of health and social services among people who inject drugs in two urban areas of Mozambique, 2014: qualitative results from a formative assessment.

BACKGROUND: Prior to 2014, data about health seeking behaviors or service uptake for People who inject drugs (PWID) in Mozambique did not exist. We present the results from the formative assessment component of the Biological and Behavioral Survey (BBS). METHODS: Standardized interview guides were used during key informant interviews (KII) and focus group discussions (FGD) in Maputo and Nampula/Nacala to discuss issues related to risk behaviors and access to and utilization of health and social services by PWID. The target sample size was not defined a priori, but instead KII and FGD were conducted until responses reached saturation. Data analysis was based on the principles of grounded theory related to qualitative research. RESULTS: Eighty-eight respondents, ages 15 to 60, participated in KIIs and FGDs. Participants were majority male from diverse income and education levels and included current and former PWID, non-injection drug users, health and social service providers, peer educators, and community health workers. Respondents reported that PWID engage in high-risk behaviors such as needle and syringe sharing, exchange of sex for drugs or money, and low condom use. According to participants, PWID would rather rent, share or borrow injection equipment at shooting galleries than purchase them due to stigma, fear of criminalization, transportation and purchase costs, restricted pharmacy hours, personal preference for needle sharing, and immediacy of drug need. Barriers to access and utilization of health and social services include distance, the limited availability of programs for PWID, lack of knowledge of the few programs that exist, concerns about the quality of care provided by health providers, lack of readiness as a result of addiction and perceived stigma related to the use of mental health services offering treatment to PWID. CONCLUSIONS: Mozambique urgently needs to establish specialized harm reduction programs for PWID and improve awareness of available resources. Services should be located in hot spot areas to address issues related to distance, transportation and the planning required for safe injection. Specific attention should go to the creation of PWID-focused health and social services outside of state-sponsored psychiatric treatment centers.

Prevalence and risk factors associated with HIV/hepatitis B and HIV/hepatitis C co-infections among people who inject drugs in Mozambique.

BACKGROUND: There is scare information about HIV co-infections with hepatitis B virus (HBV) and/or hepatitis C virus (HCV) among People Who Inject Drugs (PWID) in Mozambique. This information is critical to ensure the treatment necessary to decrease the progression of liver disease and the transmission of both HIV and hepatitis. We assess the prevalence of HIV, HBV and HCV co-infections as well as associated risk factors among PWID. METHODS: The first Bio-Behavioral Surveillance Survey was conducted in 2013-2014 among persons who self-reported to have ever injected drugs. Using respondent-driven sampling, PWID aged 18 years and older were recruited in two cross-sectional samples in Maputo and Nampula/Nacala, two large urban centers of Mozambique. Rapid screening of HIV, HBV (HBsAg) and HCV was performed on site. Data from participants in both cities were pooled to conduct RDS-weighted bivariate analyses with HIV/HBV and HIV/HCV co-infections as separate outcomes. Unweighted bivariate and multivariate logistic regression analyses were conducted to assess correlates of co-infection. RESULTS: Among 492 eligible PWID, 93.3% were male and median age was 32 years [IQR: 27-36]. HIV, HBV and HCV prevalence were respectively 44.9% (95% CI:37.6-52.3), 32.8% (95% CI:26.3-39.5) and 38.3 (95% CI:30.6-45.9). Co-infections of HIV/HBV, HIV/HCV and HIV/HBV/HCV were identified in 13.1% (95% CI:7.2-18.9), 29.5% (95% CI:22.2-36.8) and 9.2% (95% CI:3.7-14.7) of PWID, respectively. Older age, history of needle/syringe sharing and history of injection with used needle/syringe was associated with HIV/HBV co-infection. Living in Maputo city, have older age, history of needle/syringe sharing and history of injection with used needle/syringe was associated with HIV/HCV co-infection. CONCLUSION: There is a high burden of HBV and HCV among HIV-infected PWID in Mozambique. Our results highlight the need for targeted harm reduction interventions that include needle exchange programs and integrated services for the diagnosis and treatment of HIV, HBV and HCV to address these epidemics among PWID. Efforts should be made to strengthen ART coverage in the population as an important treatment strategy for both viruses.

Young people who inject drugs in Mozambique: should we emphasize them in the National Harm Reduction Plan?

Mozambique has one of the highest burdens of HIV globally, and people who inject drugs (PWID) have one of the highest HIV infection rates in Africa. After the implementation of the first Biological Behavioral Surveillance (BBS) Survey among PWID in Mozambique, the Ministry of Health started the development of a National Harm Reduction Plan. Although the findings from the BBS survey highlighted the specific needs of young PWID, the proposed Harm Reduction Plan does not explicitly focus on reducing high-risk behaviors of young PWID. We outline the importance of the inclusion of age-specific interventions focused on the needs of young PWID in Mozambique, and how a comprehensive Harm Reduction Plan can reduce the HIV epidemic in this population. There is a unique opportunity to advocate for the Harm Reduction Plan to include "youth-friendly" cost-effective and evidence-based interventions that are targeted to this important sub-group within an already vulnerable population.

Spatial Distribution of HIV Prevalence among Young People in Mozambique.

Mozambique has a high burden of HIV and is currently ranked sixth worldwide for adult prevalence. In Mozambique, HIV prevalence is not uniformly distributed geographically and throughout the population. We investigated the spatial distribution of HIV infection among adolescents and young people in Mozambique using the 2009 AIDS Indicator Survey (AIS). Generalized geoadditive modeling, combining kriging and additive modeling, was used to study the geographical variability of HIV risk among young people. The nonlinear spatial effect was assessed through radial basis splines. The estimation process was done using two-stage iterative penalized quasi-likelihood within the framework of a mixed-effects model. Our estimation procedure is an extension of the approach by Vandendijck et al., estimating the range (spatial decay) parameter in a binary context. The results revealed the presence of spatial patterns of HIV infection. After controlling for important covariates, the results showed a greater burden of HIV/AIDS in the central and northern regions of the country. Several socio-demographic, biological, and behavioral factors were found to be significantly associated with HIV infection among young people. The findings are important, as they can help health officials and policy makers to design targeted interventions for responding to the HIV epidemic.

High prevalence of HIV, HBsAg and anti-HCV positivity among people who injected drugs: results of the first bio-behavioral survey using respondent-driven sampling in two urban areas in Mozambique.

BACKGROUND: Few countries in sub-Saharan Africa know the magnitude of their HIV epidemic among people who inject drugs (PWID). This was the first study in Mozambique to measure prevalence of HIV, HBV, and HCV, and to assess demographic characteristics and risk behaviors in this key population. METHODS: We used respondent-driven sampling (RDS) to conduct a cross-sectional behavioral surveillance survey of PWID in two cities of Mozambique lasting six months. Participants were persons who had ever injected drugs without a prescription. Participants completed a behavioral questionnaire and provided blood specimens for HIV, hepatitis B surface antigen (HBsAg) and hepatitis C virus antibody (anti-HCV) testing. We performed RDS-adjusted analysis in R 3.2 using RDSAT 7.1 weights. RESULTS: We enrolled 353 PWID in Maputo and 139 in Nampula/Nacala; approximately 95% of participants were men. Disease prevalence in Maputo and Nampula/Nacala, respectively, was 50.1 and 19.9% for HIV, 32.1 and 36.4% for HBsAg positivity, and 44.6 and 7.0% for anti-HCV positivity. Additionally, 8% (Maputo) and 28.6% (Nampula/Nacala) of PWID reported having a genital sore or ulcer in the 12 months preceding the survey. Among PWID who injected drugs in the last month, 50.3% (Maputo) and 49.6% (Nampula/Nacala) shared a needle at least once that month. Condomless sex in the last 12 months was reported by 52.4% of PWID in Maputo and 29.1% in Nampula/Nacala. Among PWID, 31.6% (Maputo) and 41.0% (Nampula/Nacala) had never tested for HIV. In multivariable analysis, PWID who used heroin had 4.3 (Maputo; 95% confidence interval [CI]: 1.2, 18.2) and 2.3 (Nampula/Nacala; 95% CI: 1.2, 4.9) greater odds of having HIV. CONCLUSION: Unsafe sexual behaviors and injection practices are frequent among PWID in Mozambique, and likely contribute to the disproportionate burden of disease we found. Intensified efforts in prevention, care, and treatment specific for PWID have the potential to limit disease transmission.

Factors influencing risky sexual behaviour among Mozambican miners: a socio-epidemiological contribution for HIV prevention framework in Mozambique.

BACKGROUND: Information dealing with social and behavioural risk factors as well as their mechanisms among Mozambican migrants working in South African mines remains undocumented. This study aims to understand the various factors influencing HIV-related risk behaviours and the resulting HIV positive status of Mozambican miners employed by South African mines. This analysis was undertaken in order to inform a broader and more effective HIV preventive framework in Mozambique. METHOD: This study relied upon data sourced from the first Integrated Biological and Behavioural Survey among Mozambican miners earning their living in South African mines. It employs quantitative techniques using standard statistical tools to substantiate the laid-down objectives. The primary technique applied in this paper is the multivariable statistical method used in the formulation and application of a proximate determinants framework. RESULTS: The odds of reporting one sexual partner were roughly three times higher for miners working as perforators as opposed to other types of occupation. As well, the odds of condom use - always or sometimes - for miners in the 31-40 age group were three times higher than the odds of condom use in the 51+ age group. Miners with lower education levels were less likely to use condoms. The odds of being HIV positive when the miner reports use of alcohol or drugs (sometimes/always) is 0.32 times lower than the odds for those reporting never use of alcohol or drugs. And finally, the odds of HIV positive status for those using condoms were 2.16 times that of miners who never used condoms, controlling for biological and other proximate determinants. CONCLUSION: In Mozambique, behavioural theory emphasising personal behavioural changes is the main strategy to combat HIV among miners. Our findings suggest there is a need to change thinking processes about how to influence safer sexual behaviour. This is viewed to be the result of a person's individual decision, due to of the complexity of social and contextual factors that may also influence sexual behaviours. This only stresses the need for HIV prevention strategies to exclusively transcend individual factors while considering the broader social and contextual phenomena influencing HIV risk among Mozambican miners.