Measuring Health Literacy Among Adults with HIV Infection in Mozambique: Development and Validation of the HIV Literacy Test.

The role of health literacy on HIV outcomes has not been evaluated widely in Africa, in part because few appropriate literacy measures exist. We developed a 16-item scale, the HIV Literacy Test (HIV-LT) to assess literacy-related tasks needed to participate in HIV care. Items were scored as correct or incorrect; higher scores indicated higher literacy skill (range 0-100 %). We tested internal reliability (Kuder-Richardson coefficient) of the HIV-LT in a convenience sample of 319 Portuguese-speaking, HIV infected adults on antiretroviral treatment in Maputo, Mozambique. Construct validity was assessed by a hypothetical model developed a priori. The HIV-LT was reliable and valid to measure participants' literacy skills. The mean HIV-LT score was 42 %; literacy skills applicable to HIV care were challenging for many participants. The HIV-LT could be used to assess the relationship of literacy and HIV-related outcomes in diverse settings, and evaluate interventions to improve health communication for those in HIV care.

Characteristics associated with viral suppression among HIV-infected children aged 0-14 years in Mozambique, 2019.

The human immunodeficiency virus (HIV) is a global public health problem, disproportionally affecting sub-Saharan African countries including Mozambique. In 2019, of 150,000 estimated HIV-infected children in Mozambique, only 95,080 were on antiretroviral treatment and 73% virally suppressed. The objective of this study was to determine the characteristics associated with viral suppression in children. A cross-sectional study was carried out using records of viral load samples from children aged 0 to 14 years old who underwent viral load tests in 2019 in Mozambique. Secondary analyses were conducted on data obtained from Data Intensive Systems and Applications (DISA) of children enrolled in health facilities who had viral load tests registered. Viral suppression was defined as the presence of less than 1,000 copies/ml of blood. Multivariate logistic regression analysis was used to evaluate the characteristics associated with viral suppression. Of the 33,559 viral load sample records analyzed, 53% (17,794/33,559) were female. The average patient age was 8 (sd ± 4) years old. About 44% (14,888/33,559) of the children had a suppressed viral load, with 55% (8,258/14,888) being female and 16% (2,319/14,888) belonging to the 1-4 years old age group. Characteristics associated with viral suppression were the age groups of 5-9 years [AOR = 1.73; 95% CI 1.34-2.23; p<0.001] and 10-14 years old [AOR = 1.92; 95% CI 1.50-2.48; p<0.001] versus < 1 year. Other factors such as living in Maputo City [AOR = 1.61; 95% CI 1.26-2.05; p <0.001] versus Tete Province were also associated with viral suppression. Factors such as being male [AOR = 0.83; 95% CI 0.80-0.87; p <0.001)], living in the provinces of Niassa [AOR = 0.75; 95% CI 0.56-0.99; p <0.003], Cabo Delgado [AOR = 0.77; 95% CI 0.60-0.99; p <0.045] and Zambezia [AOR = 0.72 (95% CI: 0.56-0.92, p<0.008)] versus Tete Province, or being on ART for 2-5 years [AOR = 0.72 (95% CI: 0.61-0.85, p<0.001)] versus 11-14 years were associated with not being virally suppressed. More than half of children did not achieve viral suppression. The odds of viral suppression were highest among children aged 5-14 years and among children living in Maputo city. Further research is needed to better understand the challenges in achieving viral suppression in children.

Cost-Effectiveness and Budget Impact Analysis of the Implementation of Differentiated Service Delivery Models for HIV Treatment in Mozambique: a Modelling Study.

INTRODUCTION: In 2018, the Mozambique Ministry of Health launched guidelines for implementing differentiated service delivery models (DSDMs) to optimize HIV service delivery, improve retention in care, and ultimately reduce HIV-associated mortality. The models were fast-track, 3-month antiretrovirals dispensing, community antiretroviral therapy groups, adherence clubs, family approach and three one-stop shop models: adolescent-friendly health services, maternal and child health, and tuberculosis. We conducted a cost-effectiveness analysis and budget impact analysis to compare these models to conventional services. METHODS: We constructed a decision tree model based on the percentage of enrolment in each model and the probability of the outcome (12-month retention in treatment) for each year of the study period-three for the cost-effectiveness analysis (2019-2021) and three for the budget impact analysis (2022-2024). Costs for these analyses were primarily estimated per client-year from the health system perspective. A secondary cost-effectiveness analysis was conducted from the societal perspective. Budget impact analysis costs included antiretrovirals, laboratory tests and service provision interactions. Cost-effectiveness analysis additionally included start-up, training and clients' opportunity costs. Effectiveness was estimated using an uncontrolled interrupted time series analysis comparing the outcome before and after the implementation of the differentiated models. A one-way sensitivity analysis was conducted to identify drivers of uncertainty. RESULTS: After implementation of the DSDMs, there was a mean increase of 14.9 percentage points (95% CI: 12.2, 17.8) in 12-month retention, from 47.6% (95% CI, 44.9-50.2) to 62.5% (95% CI, 60.9-64.1). The mean cost difference comparing DSDMs and conventional care was US$ -6 million (173,391,277 vs. 179,461,668) and -32.5 million (394,705,618 vs. 433,232,289) from the health system and the societal perspective, respectively. Therefore, DSDMs dominated conventional care. Results were most sensitive to conventional care interaction costs in the one-way sensitivity analysis. For a population of 1.5 million, the base-case 3-year financial costs associated with the DSDMs was US$550 million, compared with US$564 million for conventional care. CONCLUSIONS: DSDMs were less expensive and more effective in retaining clients 12 months after antiretroviral therapy initiation and were estimated to save approximately US$14 million for the health system from 2022 to 2024.

Impact of differentiated service delivery models on 12-month retention in HIV treatment in Mozambique: an interrupted time-series analysis.

BACKGROUND: HIV treatment has been available in Mozambique since 2004, but coverage of, and retention in, antiretroviral therapy (ART) remain suboptimal. Therefore, to increase health system efficiency and reduce HIV-associated mortality, in November, 2018, the Ministry of Health launched national guidelines on implementing eight differentiated service delivery models (DSDMs) for HIV treatment. We assessed the effect of this implementation on retention in ART 12 months after initiation, and explored the associated effects of COVID-19. METHODS: In this uncontrolled interrupted time-series analysis, data were extracted from the Mozambique ART database, which contains data on individuals in ART care from 1455 health facilities providing ART in Mozambique. We included individual-level data from facilities that were providing ART at the beginning of the study period (Jan 1, 2016) and at the start of DSDM implementation (Dec 1, 2018). We compared the proportion of individuals retained in ART 12 months after initiation between the periods before (Jan 1, 2017, to Nov 30, 2018) and after (Dec 1, 2019, to June 30, 2021) implementation of the DSDMs, overall and stratified by sex and age. We applied a generalised estimating equation model with a working independence correlation and cluster-robust standard errors to account for clustering at the facility level. In a secondary analysis, we assessed the effect of COVID-19 response measures during the post-intervention period on ART retention. FINDINGS: The study included 613 facilities and 1 131 118 individuals who started ART during the inclusion period up to June 30, 2020, of whom 79 178 (7·0%) were children (age ≤14 years), 226 224 (20·0%) were adolescents and young adults (age 15-24 years), and 825 716 (73·0%) were adults (age ≥25 years). 731 623 (64·7%) were female and 399 495 (35·3%) were male. Introduction of the DSDMs was associated with an estimated increase of 24·5 percentage points (95% CI 21·1 to 28·0) in 12-month ART retention by the end of the study period, compared with the counterfactual scenario without DSDM implementation. By age, the smallest effect was estimated in children (6·1 percentage points, 1·3 to 10·9) and the largest effect in adolescents and young adults (28·8 percentage points, 24·2 to 33·4); by sex, a larger effect was estimated in males (29·7 percentage points, 25·6 to 33·7). Our analysis showed that COVID-19 had an overall negative effect on 12-month retention in ART compared with a counterfactual scenario based on the post-intervention period without COVID-19 (-10·0 percentage points, -18·2 to -1·8). INTERPRETATION: The implementation of eight DSDMs for HIV treatment had a positive impact on 12-month retention in ART. COVID-19 negatively influenced this outcome. FUNDING: None. TRANSLATION: For the Portuguese translation of the abstract see Supplementary Materials section.

Managers' and providers' perspectives on barriers and facilitators for the implementation of differentiated service delivery models for HIV treatment in Mozambique: a qualitative study.

INTRODUCTION: In 2018, Mozambique's Ministry of Health launched a guideline for a nationwide implementation of eight differentiated service delivery models to optimize HIV service delivery and achieve universal coverage of HIV care and treatment. The models were (1) Fast-track, (2) Three-month Antiretrovirals Dispensing, (3) Community Antiretroviral Therapy Groups, (4) Adherence Clubs, (5) Family-approach, and three one-stop shop models for (6) Tuberculosis, (7) Maternal and Child Health, and (8) Adolescent-friendly Health Services. This study identified drivers of implementation success and failure across these differentiated service delivery models. METHODS: Twenty in-depth individual interviews were conducted with managers and providers from the Ministry of Health and implementing partners from all levels of the health system between July and September 2021. National-level participants were based in the capital city of Maputo, and participants at provincial, district and health facility levels were from Sofala province, a purposively selected setting. The Consolidated Framework for Implementation Research (CFIR) guided data collection and thematic analysis. Deductively selected constructs were assessed while allowing for additional themes to emerge inductively. RESULTS: The CFIR constructs of Relative Advantage, Complexity, Patient Needs and Resources, and Reflecting and Evaluating were identified as drivers of implementation, whereas Available Resources and Access to Knowledge and Information were identified as barriers. Fast-track and Three-month Antiretrovirals Dispensing models were deemed easier to implement and more effective in reducing workload. Adherence Clubs and Community Antiretroviral Therapy Groups were believed to be less preferred by clients in urban settings. COVID-19 (an inductive theme) improved acceptance and uptake of individual differentiated service delivery models that reduced client visits, but it temporarily interrupted the implementation of group models. CONCLUSIONS: This study described important determinants to be addressed or leveraged for the successful implementation of differentiated service delivery models in Mozambique. The models were considered advantageous overall for the health system and clients when compared with the standard of care. However, successful implementation requires resources and ongoing training for frontline providers. COVID-19 expedited individual models by loosening the inclusion criteria; this experience can be leveraged to optimize the design and implementation of differentiated service delivery models in Mozambique and other countries.

Evaluation of the Mozambique Antiretroviral Therapy (MozART) database as an antiretroviral therapy patient surveillance system, 2017-2018.

Introduction: Mozambique antiretroviral therapy is a database used to monitor patients receiving antiretroviral treatment (ART). This study's objective was to evaluate the system for the purpose to monitor patients receiving ART. Methods: data from 287,052 patients who started ART from January to December 2017 were verified, and retention in care was assessed for 2018 in Mozambique. The Centers for Disease Control and Prevention guidelines for evaluating public health surveillance systems were used to conduct the evaluation. Simplicity, flexibility, data quality, representativeness and stability attributes were evaluated. Results: a total of 93% (266,880/287,052) of patients on ART were adults ≥15 years old, and 65% (186,677/287,052) were female. The system was complex, it involved four organisations and its management was online. Data quality was moderate with 19% (1,533,885/8,037,456) of empty variable fields, 0.04% (123/287,052) observations with birth date later than the initial ART date, 0.2% (424/287,052) and 23% (68,039/287,052) with initial ART date and diagnosis date, later than the next ART pickup date. Nationally, 19%(31/161) of the districts did not have data in the information system. MozART cover health facilities with electronic patient tracking systems. Hence did not represent all patients on ART. While it was not possible to add variables of the electronic patient tracking, the system was stable as neither data or server interruptions were reported. Conclusion: the system was useful, stable, with moderate data quality, complex, not flexible and not representative. We recommend to health facilities and partners to develop and distribute procedures for data validation and completeness and report all patient tracking variables in the system.

Health literacy predicts pediatric dosing accuracy for liquid zidovudine.

OBJECTIVES: Little is known about adult caregivers' ability to accurately dose pediatric antiretroviral medications. We aimed to characterize the frequency of dosing errors for liquid zidovudine using two dosing devices and to evaluate the association between HIV literacy and dosing errors in adults living with HIV infection. DESIGN: Cross-sectional study enrolling 316 adults receiving combination antiretroviral therapy (cART) for HIV infection in Maputo Province, Mozambique. METHODS: Participants were administered the HIV Literacy Test (HIV-LT) and asked to measure 2.5 ml of liquid zidovudine using both a cup and syringe. Dosing measurement errors for liquid zidovudine were defined as 'any error' (≥ 20% deviation from reference dose) and 'major error' (≥ 40% deviation from reference dose). RESULTS: Dosing errors were common using the cup (any error: 50%, major error: 28%) and syringe (any error: 48% of participants, major error: 28%). There were no significant differences in proportions of any dosing error (P=0.61) or major dosing errors (P=0.82) between dosing instruments. In multivariable models, associations (P ≤ 0.03) were found between higher HIV-LT score and dosing errors for both the cup [any error adjusted odds ratio, AOR: 0.91 (0.84-0.99), major error AOR: 0.84 (0.75-0.92)] and syringe [any error AOR: 0.82 (0.75-0.90), major error AOR: 0.88 (0.80-0.97)]. CONCLUSION: Liquid antiretroviral medications are critical for prevention and treatment of pediatric HIV infections, yet dosing errors were exceedingly common in this population and were significantly associated with lower HIV literacy levels. Targeted interventions are needed to improve HIV knowledge and skills for pediatric medication dosing, particularly for caregivers with limited literacy.