Microbiological contamination of improved water sources, Mozambique

Objective To assess if water from improved sources are microbiologically safe in Niassa province, Mozambique, by examining the presence of total coliforms in different types of water sources. Methods We conducted a cross-sectional household survey in two rural districts of Niassa province during the dry season, from 21 August to 4 October 2019. We observed water sources and conducted microbiological water quality tests and structured household interviews. Findings We included 1313 households, of which 812 (61.8%) used water from an improved source. There was no significant difference in presence of total coliforms between water sampled at improved and unimproved water sources, 62.7% (509 samples) and 65.7% (329 samples), respectively (P-value=0.267). Households using improved water sources spent significantly longer time collecting water (59.1 minutes; standard deviation, SD: 55.2) than households using unimproved sources (49.8 minutes; SD: 58.0; P-value <0.001). A smaller proportion of households using improved sources had access to water sources available 24 hours per day than that of households using unimproved sources, 71.7% (582 households) versus 94.2% (472 households; P-value <0.001). Of the 240 households treating water collected from improved sources, 204 (85.4%) had total coliforms in their water, while treated water from 77 of 107 (72.0%) households collecting water from an unimproved source were contaminated. Conclusion Current access to an improved water source does not ensure microbiological safety of water and thereby using access as the proxy indicator for safe drinking and cooking water is questionable. Poor quality of water calls for the need for integration of water quality assessment into regular monitoring programmes.

Routine data from prevention of mother-to-child transmission (PMTCT) HIV testing not yet ready for HIV surveillance in Mozambique: a retrospective analysis of matched test results

Background: Opt-out HIV testing is offered at 70% of antenatal care (ANC) clinics in Mozambique through the prevention of mother-to-child transmission (PMTCT) program. If routine data from this program were of sufficient quality, their heightened coverage and continuous availability could complement or even replace biannual sentinel serosurveys that currently serve as the primary HIV surveillance system in Mozambique. Methods: We assessed the efficacy of routine HIV testing data from prevention of mother-to-child transmission programs for estimating the prevalence of HIV infection among pregnant women. The PMTCT program uses sequential point-of-care rapid tests conducted on site while ANC surveillance surveys use dried blood spots tested sequentially for HIV-1/2 antibodies at a central laboratory. We compared matched routine PMTCT and ANC surveillance test results collected during 2007 and 2009 ANC surveillance surveys from 36 sentinel sites. Results: After excluding 659 women without PMTCT data, including 83 who refused rapid testing, test results from a total of 20,563 women were available. Pooling the data from both years indicated HIV prevalence from routine PMTCT testing was 14.4% versus 15.2% from surveillance testing (relative difference -5.1%; absolute difference -0.78%). Positive percent agreement (PPA) of PMTCT versus surveillance tests was 88.5% (95% Confidence Interval [CI]: 85.7-91.3%), with 19 sites having PPA below 90%; Negative percent agreement (NPA) was 98.9% (CI: 98.5- 99.2%). No significant difference was found among three regions (North, Center and South), however both PPA and NPA were significantly higher in 2009 than 2007 (p < 0.05). Conclusions: We found low PPA of PMTCT test results compared to surveillance data which is indicative either of testing errors or data reporting problems. Nonetheless, PPA improved significantly from 2007 to 2009, a possible positive trend that should be investigated further. Although use of PMTCT test results would not dramatically change HIV prevalence estimates among pregnant women, the impact of site-level differences on surveillance models should be evaluated before these data are used to replace or complement ANC surveillance surveys. Keywords: HIV prevalence, HIV program data, HIV surveillance, Prevention of mother-to-child transmission, HIV diagnostic tests, Sentinel surveillance, Mozambique

Evolution of primary HIV drug resistance in a subtype C dominated epidemic in Mozambique

Objective: InMozambique, highly active antiretroviral treatment (HAART) was introduced in 2004 followed by decentralizationandexpansion, resulting inamorethan20-fold increase incoverageby2009. ImplementationofHIV drugresistancethresholdsurveys (HIVDR-TS) iscrucial inorder tomonitor theemergenceof transmittedviral resistance, andtoproduceevidence-basedrecommendationstosupportantiretroviral (ARV)policyinMozambique. Methods: WorldHealthOrganization(WHO)methodologywasusedtoevaluatetransmitteddrugresistance(TDR) innewly diagnosedHIV-1 infectedpregnantwomenattendingante-natal clinics inMaputoandBeira tonon-nucleosidereverse transcriptaseinhibitors(NNRTI),nucleosidereversetranscriptaseinhibitors(NRTI)andproteaseinhibitors(PI).Subtypeswere assignedusingREGAHIV-1subtypingtoolandphylogenetictreesconstructedusingMEGAversion5. Results:Althoughmutations associatedwith resistance toall threedrugweredetected in these surveys, transmitted resistancewasanalyzedandclassifiedas,5%inMaputoinbothsurveysforallthreedrugclasses.Transmittedresistanceto NNRTI inBeira in2009wasclassifiedbetween5­15%, anincreasefrom2007whennoNNRTImutationswerefound.All sequencesclusteredwithsubtypeC. Conclusions: OurresultsshowthattheepidemicisdominatedbysubtypeC,wherethefirst-lineoptionbasedontwoNRTI andoneNNRTI isstilleffectivefor treatmentofHIVinfection,but intermediatelevelsofTDRfoundinBeirareinforcethe needforconstantevaluationwithcontinuingtreatmentexpansioninMozambique.