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.

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.

HIV prevalence and risk behaviors among Mozambicans working in South African mines.

Mineworkers are considered a population at risk for HIV due to risk behaviors associated with migratory work patterns. This was the first study in Mozambique to determine the prevalence of HIV and associated demographic and risk behaviors, and assess use and access to prevention and healthcare services among Mozambicans working in South African mines. Men who had worked in a South African mine in the past 12 months were recruited between February and May 2012 using time location sampling (TLS) at the Ressano Garcia border between Mozambique and South Africa. Demographic and behavioral data were collected through a standardized questionnaire, and HIV prevalence was estimated by testing dried blood spots (DBS) with two enzyme immunoassays. In total, 432 eligible mine workers were recruited. Mean age was 43 years. Most were married or cohabitating; among them, 12.6 % had two or more wives/marital partners in Mozambique. In the 12 months preceding the survey, 24.7 % had an occasional sexual partner, and 6.6 % had at least one partner who was a female sex worker. Only one in five (18.5 %) used a condom during last sex. HIV prevalence among mineworkers was 22.3 %, and 74.6 % of those who tested positive as part of the survey did not know their status. HIV prevalence was significantly higher (p = 0.018) among those that were uncircumcised (31.2 %) than those who were circumcised (18.5 %). Multiple partners (multiple spouses, cross-border relations, and multiple occasional partnerships), inconsistent condom use, and a high proportion of infected mineworkers who do not know their HIV status increases the risk of HIV transmission in this population. Combination strategies involving the promotion of condom use, HIV testing, and male circumcision should be strengthened among mineworkers.

HIV prevalence and TB in migrant miners communities of origin in Gaza Province, Mozambique: The need for increasing awareness and knowledge.

BACKGROUND: As part of ongoing efforts to generate evidence needed on HIV and tuberculosis (TB) to inform policies and programs aimed to improve the health outcomes of migrants and communities affected by migration and mining, a preliminary investigation was conducted through a biological and behavioral (BBS) approach related to HIV and TB in two communities of origin of migrant mineworkers in Gaza Province. The main objective was to determine the prevalence of HIV and the rates of asymptomatic infection by TB, and the social and behavioral risk factors associated. METHODS: A cross-sectional survey was conducted from May to June 2017 using a simple random sampling methodology. Eligible participants were individuals who were living in the community at the time the survey was conducted, which included adult mine workers and members of their families aged 18 and above. A socio-behavioral questionnaire was administered, blood specimens were collected for HIV testing (Determine/Unigold) and sputum for TB (GeneXpert MTB/RIF) was collected. The statistical analysis was performed using the R studio software to produce means, proportion and odds ratio at 95% confidence intervals. RESULTS: A total of 1012 participants were enrolled, 75.2% were females, with a median age of 34. The overall prevalence of HIV found in the two communities was 24.2% (CI: 21.6-27.0) and was higher in the rural community (31.6%; 95% CI: 27.0-35.3). The prevalence of active TB was found to be 0.3% (n = 3) while 7.5% of the participants self-reported to have been previously diagnosed with TB at some point in their life. Only 2.8% of participants had knowledge of the basic principles of TB transmission. Condom use at last sexual intercourse with a regular partner was low among both sexes (17.3% male and 12.6% female). A considerable proportion of participants had not been aware of their HIV positive serostatus(31.1% female and 25.0% male). About 1/3 of the participants had had a history of STIs. CONCLUSION: The results of this survey confirm a high prevalence of HIV in communities of origin of migrant miners in Gaza province. Findings also demonstrated low levels of awareness/ knowledge and prevention of TB and HIV. It is important to strengthen strategies that encourage regular HIV testing and TB screening. Appropriate communication interventions on methods of transmission and prevention of HIV and TB in these communities must be intensified, as well as ensuring ongoing linkage to TB and HIV social and healthcare services.