Sociocultural and epidemiological aspects of HIV/AIDS in Mozambique

Background: A legacy of colonial rule coupled with a devastating 16-year civil war through 1992 left Mozambique economically impoverished just as the human immunodeficiency virus (HIV) epidemic swept over southern Africa in the late 1980s. The crumbling Mozambican health care system was wholly inadequate to support the need for new chronic disease services for people with the acquired immunodeficiency syndrome (AIDS). Methods: To review the unique challenges faced by Mozambique as they have attempted to stem the HIV epidemic, we undertook a systematic literature review through multiple search engines (PubMed, Google Scholar™, SSRN, AnthropologyPlus, AnthroSource) using Mozambique as a required keyword. We searched for any articles that included the required keyword as well as the terms 'HIV' and/or 'AIDS', 'prevalence', 'behaviors', 'knowledge', 'attitudes', 'perceptions', 'prevention', 'gender', drugs, alcohol, and/or 'health care infrastructure'. Results: UNAIDS 2008 prevalence estimates ranked Mozambique as the 8th most HIV-afflicted nation globally. In 2007, measured HIV prevalence in 36 antenatal clinic sites ranged from 3% to 35%; the national estimate of was 16%. Evidence suggests that the Mozambican HIV epidemic is characterized by a preponderance of heterosexual infections, among the world's most severe health worker shortages, relatively poor knowledge of HIV/AIDS in the general population, and lagging access to HIV preventive and therapeutic services compared to counterpart nations in southern Africa. Poor education systems, high levels of poverty and gender inequality further exacerbate HIV incidence. Conclusions: Recommendations to reduce HIV incidence and AIDS mortality rates in Mozambique include: health system strengthening, rural outreach to increase testing and linkage to care, education about risk reduction and drug adherence, and partnerships with traditional healers and midwives to effect a lessening of stigma.

Challenges to the Scaling of Computer- Based Patient Record System for Antiretroviral Therapy Program in Ethiopia

Drawing upon interpretive paradigm and an action research approach, this study investigated the challenges to the scaling of computer-based health information systems in the public health sector of Ethiopia. The research was situated within a broader action research project by HISP (Health Information System Program) Ethiopia which was aimed at developing and implementing an integrated HIV/AIDS management system in the country. The ART module of the system was developed and implemented in two pilot sites in the capital city, Addis Ababa. The research problem was addressed using this system; specifically through participation in its scaling (both in functionality and geographically). The fieldwork was conducted in two logically connected phases between July 2006 and January 2007. In the first phase, I studied how the computerized system was functioning at the pilot sites with the aim to understand what needs to be done when it is implemented elsewhere; and identify any problems with it which might need to be addressed before its deployment to other sites (geographic scaling). The second phase of the study was the actual deployment of the system to the main case study site, the Southern Nations Nationalities and People's Region. Efforts to deploy the system to other clinics within Addis Ababa; and Amhara, Oromia, and Somali regions were also investigated. Qualitative data collection techniques including interviews, observation, and document review were used to collect the empirical data. The findings were analyzed using qualitative techniques. Analysis of the findings concerning the geographic scaling of the system (through the processes of adoption and implementation) was informed by a theoretical framework which was developed by combining key concepts from the diffusion of innovations and institutional theories; and findings of previous information systems implementation studies. The framework was developed in way that facilitates an integrated analysis of the challenges to the geographic scaling, including the technological factors, organizational issues, and external influences on the public health organizations. The research identified frequent changes in the requirements (information needs) of users, differences in work practices, lack of technical workforce, and the use of complicated pilot sites as the key challenges to the scaling in functionality of the system. A variety of technological, organizational, and environmental factors were found to influence the adoption and implementation of the system by public health organizations. Functionality of the system; and perceived characteristics of the system, specifically perceived benefits, technical compatibility with the existing systems, perceived complexity, trialability (the possibility of trying it before the decision to implement is made), and perceived reliability were the technology-related factors which influenced the adoption and implementation processes. The major organizational factors which affected the processes were inadequate organizational readiness, and the administrative structure of public health organizations. In addition, coercive influences from the NGOs supporting the Antiretroviral Therapy program had significant impact. Analysis of the findings also revealed that the lack of formal rules (such as IS implementation guidelines), which could provide a framework for the actions of iii the decision-makers and the implementers, to be the key problem, and a possible explanation for most of the observed challenges. It is argued that the influences on the adoption and implementation of the system are complex and inter-related; and thus cannot be fully understood in isolation. The research proposes a holistic approach to the investigation and understanding of challenges to computer-based health information systems development and implementation in developing countries. The major implications of the findings for the public health sector in developing countries are also outlined. In the context of the ART program, and the current massive scale-up of the treatment in developing countries, the need to anticipate the information management challenges and strengthen the health information system ­ including the development of clear strategic directions for the adoption of innovative solutions, the strengthening of the manual system and its infrastructure base; and alignment between various stakeholders ­ are emphasized.