Rotavirus A infection in children under five years old with a double health problem: undernutrition and diarrhoea - a cross-sectional study in four provinces of Mozambique.

BACKGROUND: Mozambique has a high burden of group A rotavirus (RVA) infection and chronic undernutrition. This study aimed to determine the frequency and potential risk factors for RVA infection in undernourished children under 5 years old with diarrhoea in Mozambique. METHODS: The analysis was conducted using data from March 2015 to December 2017, regarding children under 5 years old with at least one type of undernutrition. Anthropometric measures were used to calculate indices of weight-for-age, weight-for-height and height-for-age through the Z-Scores. RVA results were extracted from the National Diarrhoea Surveillance database. Descriptive statistics, chi-square test was used for qualitative variables and organized in contingency tables and 95% Confidence Intervals (CI) were considered for the calculation of RVA infection proportion and in the multiple logistic regression models to estimate the adjusted odds ratios (AOR). RESULTS: Of the 842 undernourished children included in the analysis, 27.2% (95% CI: 24.3-30.3%) were positive for RVA. The rate of RVA infection was 42.7% (95% CI: 38.0-47.5%) in the pre-vaccine period, with great reduction to 12.2% (95% CI: 9.4-15.6%) in the post-vaccine period. Most of the RVA undernourished children had severe wasting (33.3%) and severe stunting (32.0%). The risk of infection was significantly high in children from 0 to 11 months (p-value < 0.001) when compared to the age group of 24-59 months. A higher proportion of RVA infection was detected in households with five or more members (p-value = 0.029). Similar proportions of RVA were observed in children fed only by breast milk (34.9%) and breast milk with formula (35.6%). A higher proportion of undernourished HIV-positive children co-infected with RVA (7.4%) was observed. CONCLUSIONS: The frequency of RVA infection in undernourished children declined following the introduction of the vaccine in Mozambique. Beyond the temporal variation, Maputo province, age and crowded households were also associated to RVA infection. A high proportion of RVA infection was observed in children with severe wasting and a triple burden of disease: undernutrition, RVA and HIV, highlighting the need to conduct follow-up studies to understand the long-term impact of these conditions on children's development.

Intestinal protozoa in hospitalized under-five children with diarrhoea in Nampula - a cross-sectional analysis in a low-income setting in northern Mozambique.

BACKGROUND: In Mozambique, infection by intestinal parasites is reported all over the country. However, infection in children with diarrhoea is mostly focused in the southern region of Mozambique. This work aims to determine the frequency and potential risk factors for infection by Cryptosporidium spp., Giardia lamblia, and Entamoeba histolytica in children under-five years hospitalized with diarrhoea in Hospital Central de Nampula, northern Mozambique. METHODS: A cross-sectional hospital-based surveillance was conducted between March 2015 and January 2018 in children admitted with diarrhoea in Hospital Central de Nampula. Sociodemographic information was obtained through semi-structured interviews applied to the children's caregivers. A single stool sample was collected from each child to detect antigens from Cryptosporidium spp., G. lamblia, and E. histolytica using an immune-enzymatic technique. Crude and adjusted odds ratios (with 95% Confidence Intervals) were obtained by logistic regression models to identify factors associated with infection by Cryptosporidium spp. and G. lamblia. RESULTS: The median age and interquartile intervals of our sample population was 12 months (8-20). Intestinal protozoa were detected in 21.4% (59/276). Cryptosporidium spp. was the most common protozoa (13.9% - 38/274), followed by G. lamblia (9.1% - 25/274) and E. histolytica (0.4% - 1/275). Children with illiterate caregiver's (p-value = 0.042) and undernourished (p-value = 0.011) were more likely to be infected by Cryptosporidium spp. G. lamblia was more common in children living in households with more than four members (p-value = 0.039). E. histolytica was detected in an eleven month's child, co-infected with Cryptosporidium spp. and undernourished. CONCLUSION: Cryptosporidium spp. and Giardia lamblia were the most common pathogenic intestinal protozoa detected in children with diarrhoea hospitalized in the Hospital Central de Nampula. Our findings obtained highlight the importance of exploring the caregiver's education level, children's nutritional status for infections with Cryptosporidium spp., and living conditions, namely crowded households for infections with G. lamblia in children younger than five years.

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.

Epidemiological profile of individuals diagnosed with HIV: results from the preliminary phase of case-based surveillance in Kenya.

Understanding the characteristics of individuals who are newly diagnosed with HIV is critical to controlling the HIV epidemic. Characterizing this population can improve strategies to identify undiagnosed positives and assist in targeting the provision of HIV services to improve health outcomes. We describe the characteristics of newly diagnosed HIV cases in western Kenya from 124 health facilities. The study cohort cases were matched to prevent duplication and patients newly diagnosed between January and June 2015 were identified and descriptive analysis performed. Among 8664 newly identified HIV cases, during the pilot timeframe, 3.1% (n=265) had retested for HIV after initial diagnosis. Linkage to care was recorded for approximately half (45.3%, n = 3930) and 28.0% (n = 2425) had a CD4 count available during the pilot timeframe. The median baseline CD4 count was 332 cells/mL (IQR: 156-544). Among the newly diagnosed age 15 years or older with a CD4 test, 53.0% (n = 1216) were diagnosed late, including 32.9% (n = 755) who had advanced HIV at diagnosis. Factors associated with late diagnosis included being male and in an age group older than 34 years. In western Kenya, continued efforts are needed in the area of testing to enhance early HIV diagnosis and epidemic control.

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.

Characterization of HIV Recent Infection Among High-Risk Men at Public STI Clinics in Mumbai.

We examined associations with HIV recent infection and estimated transmitted drug resistance (TDR) prevalence among 3345 men at sexually transmitted infection clinics in Mumbai (2002-2005). HIV seroincidence was 7.92% by the BED-CEIA and was higher at a clinic located near brothels (12.39%) than at a hospital-based clinic (3.94%). HIV recent infection was associated with a lifetime history of female sex worker (FSW) partners, HSV-2, genital warts, and gonorrhea. TDR prevalence among recent infection cases was 5.7%. HIV testing services near sex venues may enhance case detection among high-risk men who represent a bridging population between FSWs and the men's other sexual partners.

Estimating the Prevalence and Predictors of Incorrect Condom Use Among Sexually Active Adults in Kenya: Results From a Nationally Representative Survey.

BACKGROUND: Condom use continues to be an important primary prevention tool to reduce the acquisition and transmission of HIV and other sexually transmitted infections. However, incorrect use of condoms can reduce their effectiveness. METHODS: Using data from a 2012 nationally representative cross-sectional household survey conducted in Kenya, we analyzed a subpopulation of sexually active adults and estimated the percent that used condoms incorrectly during sex, and the type of condom errors. We used multivariable logistic regression to determine variables to be independently associated with incorrect condom use. RESULTS: Among 13,720 adolescents and adults, 8014 were sexually active in the previous 3 months (60.3%; 95% confidence interval [CI], 59.0-61.7). Among those who used a condom with a sex partner, 20% (95% CI, 17.4-22.6) experienced at least one instance of incorrect condom use in the previous 3 months. Of incorrect condom users, condom breakage or leakage was the most common error (52%; 95% CI, 44.5-59.6). Factors found to be associated with incorrect condom use were multiple sexual partnerships in the past 12 months (2 partners: adjusted odds ratio [aOR], 1.5; 95% CI, 1.0-2.0; P = 0.03; ≥3: aOR, 2.3; 95% CI, 1.5-3.5; P < 0.01) and reporting symptoms of a sexually transmitted infection (aOR, 2.8; 95% CI, 1.8-4.3; P < 0.01). CONCLUSIONS: Incorrect condom use is frequent among sexually active Kenyans and this may translate into substantial HIV transmission. Further understanding of the dynamics of condom use and misuse, in the broader context of other prevention strategies, will aid program planners in the delivery of appropriate interventions aimed at limiting such errors.

Evaluation of Kenya's readiness to transition from sentinel surveillance to routine HIV testing for antenatal clinic-based HIV surveillance.

BACKGROUND: Sentinel surveillance for HIV among women attending antenatal clinics using unlinked anonymous testing is a cornerstone of HIV surveillance in sub-Saharan Africa. Increased use of routine antenatal HIV testing allows consideration of using these programmatic data rather than sentinel surveillance data for HIV surveillance. METHODS: To gauge Kenya's readiness to discontinue sentinel surveillance, we evaluated whether recommended World Health Organization standards were fulfilled by conducting data and administrative reviews of antenatal clinics that offered both routine testing and sentinel surveillance in 2010. RESULTS: The proportion of tests that were HIV-positive among women aged 15-49 years was 6.2% (95% confidence interval [CI] 4.6-7.7%] in sentinel surveillance and 6.5% (95% CI 5.1-8.0%) in routine testing. The agreement of HIV test results between sentinel surveillance and routine testing was 98.0%, but 24.1% of specimens that tested positive in sentinel surveillance were recorded as negative in routine testing. Data completeness was moderate, with HIV test results recorded for 87.8% of women who received routine testing. CONCLUSIONS: Additional preparation is required before routine antenatal HIV testing data can supplant sentinel surveillance in Kenya. As the quality of program data has markedly improved since 2010 a repeat evaluation of the use of routine antenatal HIV testing data in lieu of ANC sentinel surveillance is recommended.

Prevalence of HIV, sexually transmitted infections, and risk behaviours among female sex workers in Nairobi, Kenya: results of a respondent driven sampling study.

We conducted a respondent driven sampling survey to estimate HIV prevalence and risk behavior among female sex workers (FSWs) in Nairobi, Kenya. Women aged 18 years and older who reported selling sex to a man at least once in the past 3 months were eligible to participate. Consenting FSWs completed a behavioral questionnaire and were tested for HIV and sexually transmitted infections (STIs). Adjusted population-based prevalence and 95 % confidence intervals (CI) were estimated using RDS analysis tool. Factors significantly associated with HIV infection were assessed using log-binomial regression analysis. A total of 596 eligible participants were included in the analysis. Overall HIV prevalence was 29.5 % (95 % CI 24.7-34.9). Median age was 30 years (IQR 25-38 years); median duration of sex work was 12 years (IQR 8-17 years). The most frequent client-seeking venues were bars (76.6 %) and roadsides (29.3 %). The median number of clients per week was seven (IQR 4-18 clients). HIV testing was high with 86.6 % reported ever been tested for HIV and, of these, 63.1 % testing within the past 12 months. Of all women, 59.7 % perceived themselves at 'great risk' for HIV infection. Of HIV-positive women, 51.0 % were aware of their infection. In multivariable analysis, increasing age, inconsistent condom use with paying clients, and use of a male condom as a method of contraception were independently associated with unrecognized HIV infection. Prevalence among STIs was low, ranging from 0.9 % for syphilis, 1.1 % for gonorrhea, and 3.1 % for Chlamydia. The data suggest high prevalence of HIV among FSWs in Nairobi. Targeted and routine HIV and STI combination prevention strategies need to be scaled up or established to meet the needs of this population.

Comparison of HIV behavioral indicators among men who have sex with men across two survey methodologies, San Francisco, 2004 and 2008.

BACKGROUND: Our goal was to examine whether community-based behavioral surveys can augment data collected for the National HIV Behavioral Surveillance System (NHBS) among men who have sex with men (MSM) in San Francisco. METHODS: We compared estimates of sexual risk behaviors among MSM using data from two cycles of NHBS (2004 and 2008) and outreach surveys conducted by STOP AIDS Project (SAP) during the same years. We compared estimates of unprotected anal intercourse (UAI) and other indicators to assess concordance of estimates across methodologies. RESULTS: Of the 3248 interviews conducted, the NHBS sample included more nonwhite and older MSM, more self-reported HIV positive, and less sexually active men than the SAP sample. Estimates of UAI in the last 6 months were slightly higher in the NHBS survey than in the SAP surveys (2004: 40% vs. 36%, P = 0.03; 2008: 44% vs. 38%, P = 0.08). In 2008, where respondent-partner HIV-discordant status could be measured, estimates of UAI with a potentially discordant partner were similar (12% vs. 12%, P = 0.87). Also, the NHBS and SAP surveys observed similar estimates of UAI by high-risk positioning with potentially discordant partners (HIV-positive men reporting insertive UAI with a potentially HIV-negative partner: 13% vs. 11%, P = 0.45; HIV-negative men reporting receptive UAI with a potentially HIV-positive person: 5% vs. 4%, P = 0.85). CONCLUSIONS: Behavioral estimates drawn from convenience sampling methods can provide informative surveillance estimates of key behavioral indictors that can augment data from more rigorous national HIV behavioral surveillance surveys.

Male circumcision programmes in Kenya: lessons from the Kenya AIDS Indicator Survey 2007.

OBJECTIVE: To provide guidance for male circumcision programmes in Kenya by estimating the population of uncircumcised men and investigating the association between circumcision and infection with the human immunodeficiency virus (HIV), with particular reference to uncircumcised, HIV-uninfected men. METHODS: Data on men aged 15 to 64 years were derived from the 2007 Kenya AIDS Indicator Survey, which involved interviews and blood collection to test for HIV and herpes simplex virus 2 (HSV-2). The prevalence of HIV infection and circumcision in Kenyan provinces was calculated and the demographic characteristics and sexual behaviour of circumcised and uncircumcised, HIV-infected and HIV-uninfected men were recorded. FINDINGS: The national prevalence of HIV infection in uncircumcised men was 13.2% (95% confidence interval, CI: 10.8-15.7) compared with 3.9% (95% CI: 3.3-4.5) among circumcised men. Nyanza province had the largest estimated number of uncircumcised, HIV-uninfected men (i.e. 601 709), followed by Rift Valley, Nairobi and Western Province, respectively, and most belonged to the Luo ethnic tribe. Of these men, 77.8% did not know their HIV status and 33.2% were HSV-2-positive. In addition, 65.3% had had unprotected sex with a partner of discordant or unknown HIV status in the past 12 months and only 14.7% consistently used condoms with their most recent partner. However, only 21.8% of the uncircumcised, HIV-uninfected men aged 15 to 19 years were sexually active. CONCLUSION: The Kenyan male circumcision strategy should focus on the provinces with the highest number of uncircumcised, HIV-uninfected men and target young men before or shortly after sexual debut.

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.

Beyond sugar daddies: intergenerational sex and AIDS in urban Zimbabwe.

In a survey of 1,313 men reporting on 2,465 partnerships recruited at beer halls in Harare, Zimbabwe, 2.5% met a definition of "sugar daddy": men with a non-marital partner at least 10 years younger and under 20 years old, and exchanged cash or goods for sex. Men engaging in intergenerational sex with a teenage woman had similar HIV prevalence, incomes, and condom use as men in other partnerships. Most men (62.3%) had partners 5 or more years younger, with wider age gaps in longer-term relationships. Condom use was less common within married and steady partnerships compared to casual and more common with younger women. The most common form of intergenerational sex, with the widest age gap and lowest condom use, occurs within marriages and steady partnerships. Such "conventional" intergenerational sex may play the pivotal role in sustaining a generalized epidemic across generations and present the most difficult challenge to prevention.

Evaluation of a peer network-based sexual risk reduction intervention for men in beer halls in Zimbabwe: results from a randomized controlled trial.

While much emphasis has been placed on involving men in AIDS prevention in sub-Saharan Africa, there remain few rigorously evaluated interventions in this area. A particularly appealing point of intervention is the sexual risk behavior associated with men's alcohol consumption. This article reports the outcomes of The Sahwira HIV Prevention Program, a male-focused, peer-based intervention promoting the idea that men can assist their friends in avoiding high-risk sexual encounters associated with alcohol drinking. The intervention was evaluated in a randomized, controlled trial (RCT) implemented in 24 beer halls in Harare, Zimbabwe. A cadre of 413 male beer hall patrons (~20% of the patronage) was trained to assist their male peers within their friendship networks. Activities included one-on-one interactions, small group discussions, and educational events centering on the theme of men helping their male friends avoid risk. Venues were randomized into 12 control versus 12 intervention beer halls with little cross-contamination between study arms. The penetration and impact of the intervention were assessed by pre- and post-intervention cross-sectional surveys of the beer hall patronage. The intervention was implemented with a high degree of fidelity to the protocol, with exposure to the intervention activities significantly higher among intervention patrons compared to control. While we found generally declining levels of risk behavior in both study arms from baseline to post-intervention, we found no evidence of an impact of the intervention on our primary outcome measure: episodes of unprotected sex with non-wife partners in the preceding 6 months (median 5.4 episodes for men at intervention beer halls vs. 5.1 among controls, P = 0.98). There was also no evidence that the intervention reduced other risks for HIV. It remains an imperative to find ways to productively engage men in AIDS prevention, especially in those venues where male bonding, alcohol consumption, and sexual risk behavior are intertwined.

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.

Rotavirus A infection in pre- and post-vaccine period: Risk factors, genotypes distribution by vaccination status and age of children in Nampula Province, Northern Mozambique (2015-2019).

Mozambique introduced the monovalent rotavirus vaccine (Rotarix®, GSK Biologicals, Rixensart, Belgium) in September 2015. Previous analysis, showed that Nampula province continues reporting a high frequency of Rotavirus A (RVA) infection and the emergence of G9P[6], G9P[4] and G3P[4] genotypes. This analysis aimed to determine the RVA frequency; risk factors; genotype distribution by vaccination status and age between pre- and post-vaccine periods in children under-five years old with diarrhea in Nampula. A cross-sectional, hospital-based surveillance study was conducted in the Hospital Central de Nampula in Mozambique. Socio-demographic and clinical data were collected to assess factors related to RVA infection in both periods. Stool specimens were screened to detect RVA by ELISA, and positive samples were genotyped. Between 2015 (pre-vaccine period) and 2016-2019 (post-vaccine period), 614 stool specimens were collected and tested for RVA in which 34.9% (67/192) were positive in pre-vaccine period and 21.8% (92/422) in post-vaccine (p = 0.001). In the post-vaccine period, age, year, and contact with different animal species (chicken, duck, or multiple animals) were associated with RVA infection. RVA infection was higher in children partially vaccinated (40.7%, 11/27) followed by the fully vaccinated (29.3%, 56/191) and the unvaccinated (15.3%, 21/137) (p = 0.002). G1P[8] and G9P[4] were common in vaccinated children less than 12 months. The present analysis showed that RVA infection reduced slightly in the post-vaccine period, with a high proportion of infection and genotype diversity in children, under 12 months of age, vaccinated. Further research on factors associated with RVA infection on vaccinated compared to unvaccinated children and vaccination optimization should be done.

Intestinal protozoan infections among children 0-168 months with diarrhea in Mozambique: June 2014 - January 2018.

BACKGROUND: Intestinal parasites such as Cryptosporidium spp., Giardia lamblia and Entamoeba histolytica can cause severe diarrhea, especially among children in developing countries. This study aims to determine the frequency of Cryptosporidium spp., Giardia lamblia and Entamoeba histolytica in children with diarrhea and identify risk factors for infection. METHODOLOGY: We conducted a cross-sectional study in children aged 0-168 months hospitalized with diarrhea in three regions of Mozambique, from June 2014 to January 2018. Following consent, caretakers were interviewed and a single stool specimen was collected from each child to diagnose Cryptosporidium spp., G. lamblia and E. histolytica using commercial immune-enzymatic assay (TechLab, Inc, Blacksburg, VA, USA). Anthropometric data were collected from the clinical reports. Multivariable logistic regression models were built to identify risk factors for Cryptosporidium spp. and G. lamblia infection. RESULTS: Twenty-one percent of all specimens (212/1008) presented at least one parasitic infection. Cryptosporidium spp. infection was the most common 12.0% (118/985), followed by G. lamblia 9.7% (95/983) and E. histolytica 2.0% (20/1004). Risk factors for infection by Cryptosporidium spp. were: provenience (children from Nampula province showed the highest risk, OR: 8.176; CI: 1.916-34.894; p-value < 0.01); animal contact (children with animal contact had a protective effect OR: 0.627; CI: 0.398-0.986; p-value < 0.05); underweight (children severely underweight showed a risk of 2.309; CI: 1.310-4.069; p-value < 0.05). Risk factors for infection by G. lamblia were: age (group with highest risk, 60-168 months (OR: 2.322; CI: 1.000-5.393, p-value > 0.05)); and living in a household with five or more members (OR: 2.141; CI: 1.286-3.565, p-value < 0.01). CONCLUSIONS: Parasitic infection is common among children with diarrhea. Routine testing, standard treatment, and assessment for risk exposure of children with diarrhea should be implemented at health facilities in Mozambique.

Modes of HIV transmission among adolescents and young adults aged 10-24 years in Kenya.

Understanding how HIV is acquired can inform interventions to prevent infection. We constructed a risk profile of 10-24 year olds participating in the 2012 Kenya AIDS Indicator Survey and classified them as perinatally infected if their biological mother was infected with HIV or had died, or if their father was infected with HIV or had died (for those lacking mother's data). The remaining were classified as sexually infected if they had sex, and the remaining as parenterally infected if they had a blood transfusion. Overall, 84 (1.6%) of the 5298 10-24 year olds tested HIV positive; 9 (11%) were aged 10-14 and 75 (89%) 15-24 years. Five (56%) 10-14 year olds met criteria for perinatal infection; 4 (44%) did not meet perinatal, sexual or parenteral transmission criteria and parental HIV status was not established. Of the 75 HIV-infected, 15 to 24 year olds, 5 (7%) met perinatal transmission, 63 (84%) sexual and 2 (3%) parenteral criteria; 5 (7%) were unclassified. Perinatal transmission likely accounted for 56% and sexual transmission for 84% of infections among 10-14 year olds and 15-24 year olds, respectively. Although our definitions may have introduced some uncertainty, and with the number of infected participants being small, our findings suggest that mixed modes of HIV transmission exist among adolescents and young people.

Where No Universal Health Care Identifier Exists: Comparison and Determination of the Utility of Score-Based Persons Matching Algorithms Using Demographic Data.

BACKGROUND: A universal health care identifier (UHID) facilitates the development of longitudinal medical records in health care settings where follow up and tracking of persons across health care sectors are needed. HIV case-based surveillance (CBS) entails longitudinal follow up of HIV cases from diagnosis, linkage to care and treatment, and is recommended for second generation HIV surveillance. In the absence of a UHID, records matching, linking, and deduplication may be done using score-based persons matching algorithms. We present a stepwise process of score-based persons matching algorithms based on demographic data to improve HIV CBS and other longitudinal data systems. OBJECTIVE: The aim of this study is to compare deterministic and score-based persons matching algorithms in records linkage and matching using demographic data in settings without a UHID. METHODS: We used HIV CBS pilot data from 124 facilities in 2 high HIV-burden counties (Siaya and Kisumu) in western Kenya. For efficient processing, data were grouped into 3 scenarios within (1) HIV testing services (HTS), (2) HTS-care, and (3) within care. In deterministic matching, we directly compared identifiers and pseudo-identifiers from medical records to determine matches. We used R stringdist package for Jaro, Jaro-Winkler score-based matching and Levenshtein, and Damerau-Levenshtein string edit distance calculation methods. For the Jaro-Winkler method, we used a penalty (р)=0.1 and applied 4 weights (ω) to Levenshtein and Damerau-Levenshtein: deletion ω=0.8, insertion ω=0.8, substitutions ω=1, and transposition ω=0.5. RESULTS: We abstracted 12,157 cases of which 4073/12,157 (33.5%) were from HTS, 1091/12,157 (9.0%) from HTS-care, and 6993/12,157 (57.5%) within care. Using the deterministic process 435/12,157 (3.6%) duplicate records were identified, yielding 96.4% (11,722/12,157) unique cases. Overall, of the score-based methods, Jaro-Winkler yielded the most duplicate records (686/12,157, 5.6%) while Jaro yielded the least duplicates (546/12,157, 4.5%), and Levenshtein and Damerau-Levenshtein yielded 4.6% (563/12,157) duplicates. Specifically, duplicate records yielded by method were: (1) Jaro 5.7% (234/4073) within HTS, 0.4% (4/1091) in HTS-care, and 4.4% (308/6993) within care, (2) Jaro-Winkler 7.4% (302/4073) within HTS, 0.5% (6/1091) in HTS-care, and 5.4% (378/6993) within care, (3) Levenshtein 6.4% (262/4073) within HTS, 0.4% (4/1091) in HTS-care, and 4.2% (297/6993) within care, and (4) Damerau-Levenshtein 6.4% (262/4073) within HTS, 0.4% (4/1091) in HTS-care, and 4.2% (297/6993) within care. CONCLUSIONS: Without deduplication, over reporting occurs across the care and treatment cascade. Jaro-Winkler score-based matching performed the best in identifying matches. A pragmatic estimate of duplicates in health care settings can provide a corrective factor for modeled estimates, for targeting and program planning. We propose that even without a UHID, standard national deduplication and persons-matching algorithm that utilizes demographic data would improve accuracy in monitoring HIV care clinical cascades.